URINARY INCONTINENCE

An Approach to Evaluation and Management

Kristen M. Nebel, D.O.September 29, 2010

Urinary Incontinence

Goals: Define urinary incontinence (UI) Epidemiology Types of UI Risk factors Brief pathophysiology Office based assessment and diagnosis UI in Long- term care Therapies

Urinary Incontinence

Definition:

Unintentional leakage of urine at inappropriate times (often leading to social embarrassment).

Types of Urinary Incontinence

Stress Urinary Incontinence Urge Urinary Incontinence Overflow Urinary Incontinence Mixed Urinary Incontinence Functional Urinary Incontinence Deformity of Urinary Tract

Prevalence 24 to 64 y/o

10-30% of women 1.5-5% of men

Community-dwelling over 60 y/o

25-35% of women 10-15% of men

Nursing home/ home-bound > 65 y/o

60-78% of women 45-72% of men

AFP 1998;57:11

What Percentage are Treated?

Less than 50% of those with urinary incontinence

Why? Under diagnosed

Patient - normal aging process, no help available, embarrassment

Physician

Impact of Urinary Incontinence

Psychosocial- perceived/ actual limitations on activities, caretaker strain, depression, low self-esteem

Financial- cost of management for those over 65 y/o:

2000: $20 billionUrology 1998; 51(3):355-61

Impact of Urinary Incontinence

Medical- decubitus ulcers, UTI’s, sepsis, renal failure, falls, dermatoses/ cellulitis

Care-giver: Hours per week of informal care in community- dwelling

Men: 7.4-> 11.3-> 16.6 Women: 5.9->7.6-> 10.7

Strain -> Institutionalization

Normal Micturition

Genito-urinary Age-Related Changes

Atrophic vaginitis/ urethritis BPH Inability to delay voiding Decreased detrusor contractility

Increased PVR Increased UOP later in day Detrusor overactivity Decreased bladder capacity

Stress Urinary Incontinence

Urethral sphincter opening without a bladder contraction during stress maneuvers Stress maneuvers: cough, laugh, running, bending

over, changing position Most common in young women and in men

s/p TURP 2nd most common form in ages >65 y/o

Etiologies of Stress UI

Urethral or bladder neck displacement Vaginal deliveries Pelvic surgeries

Nerve, muscle, connective tissue injury

Pelvic organ prolapsed- cystocele, rectocele, uterine prolapse

Etiologies of Stress UI

Menopause Decreased estrogen state atrophy of urethral

epithelium Atrophic urethritis Decreased urethral mucosal seal/ failure to close Loss of compliance Irritation Insufficient urethral support

ά-adrenergic blocking agents

Urge Urinary Incontinence

“Detrusor (Bladder) Overactivity”: uncontrolled bladder contractions or impaired contractility

Most common form >65y/o Abrupt sensation of need to void triggered by:

Running water, hand washing, cold weather, sights of home

Associated with moderate to severe leakage

Etiologies of Urge UI

90% idiopathic Advanced age Bladder irritation

Infection, calculi, tumors Fecal impaction CNS impairment of inhibitory pathways

CVA, cervical stenosis, dementia, drugs, MS, Parkinson’s disease

Risk Factors for UI

Most common Age Gender Parity- UI may occur 5 years after first vaginal

delivery

Mixed Urinary Incontinence

Loss of urine due to both urge and stress incontinence Treatment determined by predominant symptom

Overflow Urinary Incontinence

Over distension of the bladder due to: Lower urinary tract symptomatology

Bladder outlet obstruction BPH Prostate Cancer Urethral Stricture Fecal impaction

Overflow Urinary Incontinence

Lower urinary tract symptomatology Impaired detrusor contractility (5-10%)

Bladder fibrosis CNS damage Anticholinergic drugs

Neuropathic- poor autonomic nerve relay DM neuropathy

Overflow Urinary Incontinence

2nd most common type in men Accounts for 8% of UI in females Symptoms:

Continuous dribbling Loss of small amount of urine Weak stream Hesitancy Nocturia Frequency

Clinics in Geriatric Medicine 2004; 20:4

Functional UI

Evaluation of UI

Patient- initiated complaint or physician inquiry regarding incontinence

Focused H&P and simple office procedures can lead to initial working diagnosis

Evaluation of UI

History: Onset, frequency, timing, volume Bowel habits Sexual function Medications How the patient views quality of life

Evaluation of UI

History continued… Triggers

UI with stress maneuvers has moderate specificity and high sensitivity for SUI (although no formal studies)

Symptoms Obstructive- dribbling, hesitancy, intermittency,

impaired flow, incomplete void Irritating- nocturia, frequency, urgency, dysuria

J Am Geriatric Soc 1990 Mar;38(3):300-5

Questions to Guide you

Do you leak urine when you cough, laugh, lift something or sneeze? How often?

Do you ever leak urine when you have a strong urge on the way to the bathroom? How often?

How frequently do you empty your bladder during the day?

How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?

Do you ever leak urine during sex?

Questions continued…

Do you wear pads that protect you from leaking urine? How often do you have to change them?

Do you ever find urine on your pads or clothes and were unaware of when the leakage occurred?

Does it hurt when you urinate?

Do you ever feel that you are unable to completely empty your bladder?

Bladder Diary

Evaluation of UI

Past medical history CHF Parity Surgeries DM

Physical Examination

Assess memory impairment Functional status Dehydration – possible sign of immobility CV- volume overload? Abdomen- mass/ ascites/ organomegaly which

may increase intra-abdominal pressure

Physical Examination

Extremities- edema/ joint mobility/ function Rectal- mass/ prostate/ impaction Neuro- examination of lumbosacral nerve

roots: bulbocavernosus reflex

Physical Examination

Female GU- Atrophy/ vault stenosis/ inflammation/ cystocele/ rectocele/ bladder distention

Male GU- phimosis/ paraphimosis

Evaluation of UI

Transient (Acute) vs. Established (i.e. Urge, Stress, Overflow) Assess for reversible causes and treat

Delirium/ Drugs Retention/ Restricted mobility Infection/ Impaction Polyuria/ Prostatism

Up to 50% of UI in hospitalized patients and 33% of UI in community-dwelling patients may be due to reversible etiologies

Drug Effects on UrinationDrug Side Effect

Antidepressants, antipsychotics, sedatives/hypnotics

Sedation, retention (overflow)

Diuretics Frequency, urgency (OAB)

Caffeine Frequency, urgency (OAB)

Anticholinergics Retention (overflow)

Alcohol Sedation, frequency (OAB)

Narcotics Retention, constipation, sedation (OAB and overflow)

α-Adrenergic blockers Decreased urethral tone (stress incontinence)

α-Adrenergic agonists Increased urethral tone, retention (overflow)

α-Adrenergic agonists Inhibited detrusor function, retention (overflow)

Calcium channel blockers Retention (overflow)

ACE inhibitors Cough (stress incontinence)

Office Based Studies

Assess for reversible causes UA w/ C+S

PVR- via catheter or ultrasound Volume < 50 mL is normal Volume >200 mL is abnormal

Associated with OUI

Lab testing BMP B12 level

Office Based Studies

Clinical Stress Test Performed with full bladder Recumbent or standing position Response to stress maneuver If elevation of urethra prevents loss, most likely

SUI “Cough test”

Algorithm to Determine Treatment

Treatment options

Stress/ Urge Urinary Incontinence 1st line- Behavioral therapies/ devices 2nd line- Medications 3rd line- Surgery

Overflow Urinary Incontinence Catheterization-intermittent/ indwelling Medications

Behavioral Therapies for Urge and Stress

Bladder Training 2 principles:

Frequent voiding to keep urine volume low Retraining CNS and pelvic mechanisms to inhibit

detrusor contractions Conscious suppression/ resistance of urge to void

(often only helpful for 6 months)

Behavioral Therapies for Urge and Stress

Timed voiding Frequency of voids corresponds with shortest

interval between voids (bladder diary) After no leakage for 2 days, time is gradually increased

by 30-60 minutes to goal of 3-4 hours

Prompted voiding For use in cognitively impaired or Urge UI

Biofeedback

Other Therapies for SUI

Pelvic floor muscle exercise Kegel maneuvers

3 sets 8-12 CTX held for 6-8 s, 3-4 d/ wk x 15-20wks

Pessary

Weighted vaginal cones

Botulinum toxin Sacral neuromodulation

RCTs on SUI Therapies

Short term improvement in group with PFME + biofeedback compared to PFME only. However, no change in groups after 3 months.

Am Jnl OB/GYN 1998;179(4):999-1007

PFME is better than electrical stimulation or vaginal cones in treating SUI.

BMJ 1999;318:487-93

RCTs on UUI Therapies

Biofeedback vs. Behavioral training for UUI: no significant difference

Evidence-based OB/ GYN 2003;5(2)

Biofeedback-assisted Behavioral Tx vs. drug therapy vs. placebo in Urge and Mixed UI: Behavioral 80.7% reduction of incont. episodes Drug therapy 68.5% reduction Placebo 39.4% reduction

JAMA 1998;280(23):1995-2000

UI in Long-term Care

Dementia patients: Success of prompted voids can be predicted if:

Patient can state name Transfer with </=1 assist Leaks < 4 x/ 12 hours Voids 75% of time when prompter during 3 day trial

JAGS: 190;38:356.

UI in Long-term Care

Functional Incidental Training: combination of prompted void with endurance and strength exercises Study of 107 VA pts found FIT reduced wet checks

episodes by ½. Practical limitations due to staffing, cost, limited

benefits after therapy endedJAGS 2005: 53(7); 1901-1100.

Pharmacological Therapy

Stress Incontinence Improve urethral sphincter contraction

ά-adrenergic agents: Imipramine Stimulate urethral smooth muscle contraction Better results if used with estrogen Not recommended if + orthostatics or at risk for

anticholinergic effects

Pharmacological Therapy

Stress Incontinence Estrogen: vaginal or oral forms

If used alone has limited effectiveness, some studies indicate worsening

Increases number /responsiveness of receptors to alpha-adrenergic agents

BJOG 1999;106(7):711-8

Serotonin-Norepinephrine reuptake inhibitor: Duloxetine

Approved for Stress UI in England

Am Jnl OB/GYN 2002;187(1):40-8

Pharmacological Therapy

Urge Incontinence Inhibit bladder contractions

Anticholinergics: Oxybutynin (Ditropan, Oxytrol): most common side effect is

dry mouth Controlled release form better tolerated

Solifenacin (Vesicare), Darifenacin (Enablex), (Fesoterodine) Toviaz

Muscarinic Receptor antagonist: Tolterodine (Detrol): slightly less efficacious than oxybutynin,

but with less side effects Trospium (Sanctura)

Pharmacological Therapy

Efficacy: 30% continence rate Reduces UI by ½ + episodes per day Results may take 4-6 weeks

Trials: Vesicare > tolterodine for reducing urgency/

frequency Oxybutynin > tolterodine for reducing

incontinence

Pharmacological Therapy

Dementia: Combination of cholinesterase inhibitors and

antimuscarinics can cause functional decline Oxybutynin 5mg ER daily x 4 weeks did not result

in cognitive declineJAGS 2008 May; 56(5):862-70.

Case reports of Tolterodine reported increased hallucinations

Pharmacological Therapy

Overflow Incontinence Relief of obstruction (BPH)

5-ά-reductase inhibitors: finasteride ά -1-adrenergic antagonists: flomax

Herbal Symptomatic relief Saw Palmetto

Significant improvement when compared to finasteride

Clinics in Geriatric Medicine 2004;20:3

Lifestyle Modifications for all Patients

Frequent toileting No fluids 3-4 hrs. before bed or leaving home Limit fluid to 1 L/ day Treat constipation with sorbitol D/C tobacco use (cut down on coughing) Protective garments

Clinics in Geriatric Medicine 2004;20(3)

Stay warm in cold weather Avoid ETOH and tobacco Elevate legs 2 hours before bed (re-circulate

extra-vascular fluid) Avoid caffeine Weight loss in morbidly obese

Urinary Incontinence

In Conclusion: Be aware and ask Follow algorithm and assess for reversible vs.

established causes Implement therapy Refer if warranted by history, exam, or refractory

incontinence

Case

70 y/o male with poor stream, straining to void, and incontinence. PMHx: TIA, HTN, DM II w/ neuropathy, OA Meds: Plavix, Notriptyline (dose doubled),

glipizide, naproxen, Ace-I UA: neg.

What is most likely diagnosis, what are contributing factors, what should be done next?

The End