Transcript urinary incontinence

URINARY
INCONTINENCE
For Practicing Physicians
Take Away Points




UI is a common and a serious problem among
your patients
A careful history and a brief exam can help
identify the type(s) of UI
Behavioral treatments are underutilized
Anticholinergic drugs are indicated only for urge
incontinence
Definition -- International

Involuntary loss of urine

Generally in an undesirable place

Creating a social, hygienic problem
Prevalence. . .
What percentage of YOUR patients
present with urinary incontinence?
 Mostly men or women?
 What age group?
 How often do you address this
concern?

What percentage of communityliving older adults have UI?
1.
2.
3.
4.
5.
10%
30%
50%
70%
90%
Reported Prevalence
in Elderly in US

Community dwelling
10-30%
These are the patients in your office!

Hospitalized
30-50%

Long-term care
50-70%
NORMAL MICTURITION

Urine storage is under sympathetic control
(T11-L2):



Voiding is under parasympathetic control
(S2-S4):
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
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Inhibits detrusor contraction
Increases sphincter control
Induces detrusor contraction
Induces relaxation of sphincter control
Central Nervous System coordinates and
integrates these responses
What changes occur with the aging
process which can contribute to urinary
incontinence?
1.
2.
3.
4.
5.
6.
Decreased mobility
Inability to postpone voiding
Prostate hypertrophy
Urethral dysfunction
Increased night time urine volume
All of the above
Changes with Normal Aging
which can contribute to incontinence
GENERAL--potential decline in mentation, mobility,
motivation, manual dexterity, and sensory input
BLADDER-- decrease in contractility, capacity, and ability to
postpone voiding. Increase in involuntary contractions. Increase
in post-void residual volume
PROSTATE--hypertrophy
URETHRA--decrease in maximum closure pressure and length
in women
FLUID MANAGEMENT--increase in urinary volume at night
Transient Causes of UI
--differential diagnoses
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D elirium
I nfection
A trophic urethritis or vaginitis
P harmaceuticals
P sychological
E xcessive urine production
R estricted mobility
S tool impaction
(For discussion in part 2)
Persistent Types of UI
(Duration of at least 2 months)
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
Stress
Urge
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

Note: “Overactive bladder” may present as urge
w/o urinary losses
Mixed (often Stress and Urge)
Overflow
Functional
Prevalence of Types (Women)
How does this compare to your experience?
Symptom Types Reported
Ages
Reporting UI
Urge
Stress
Mixed
30-49
33%
10%
44%
33%
70-90
55%
20%
19%
54%
Melville JL Urinary Incontinence in US Women A population based study
Arch Int Med 2005;165:537-542 Mail survey of 6000 – 57% response rate
Prevalence Data from JH
Incontinence Program
403 patients, 85% female, age 78.4+/-8.22
Urge 254 total (35 urge alone)
Stress 185 total (42 stress alone)
Urge and Stress together 138 total
Overflow 34 total (17 overflow alone)
Functional 160 total (10 functional alone)
Most cases had 2 or 3 types of incontinence
Workup in Primary Care
--Persistent incontinence

History—including medications, supplemented
by bladder records or voiding diaries. Quality of
life concerns.
 Focused physical—mental and neurologic,
abdomen, pelvic and rectal
 Office Testing—Urinalysis, routine lab tests,
postvoid residual
Case 1 Mrs. Leeky
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A 78 year old woman with urinary incontinence:
urgency, nocturia and leakage enroute to BR
Duration >2mos. Also losses with coughing. Wears
pads. No significant GU history.
The pt has CHF, GERD, glaucoma, and
osteoporosis.
Meds: enalapril, furosemide, K+, timolol eyedrops,
calcium, ranitidine.
More
Case 1 continued
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
PE: Ambulatory, cognitively intact. Normal
CV and neurologic findings. 2+ ankle
edema. Abd neg. Pelvic--no inflammation,
grade 2 cystocele, no masses. Rectal nl.
Coughing produces drops of urine at the
meatus.
The patient voids 325 ml of urine when she
develops a normal sense of micturition and
is then catheterized for 60 ml. Urinalysis is
normal.
What are the type(s) of UI
manifested by Mrs. Leeky?
1.
2.
3.
4.
5.
Urge
Urge and stress (mixed)
Functional
Overflow
Drug induced
Select the preferred next step
in management:
1. Prescribe anticholinergics
2. Order estrogen vaginal cream and sudafed
3. Teach pelvic muscle exercises/bladder
training techniques
4. Arrange for urodynamic studies
5. Refer to Gyn for correction of cystocele
What percent of patients with urge/stress
UI are said to be cured or helped by
behavioral interventions?
1.
2.
3.
4.
5.
100%
70%
50%
25%
15%
Stress Incontinence

Definition
Loss of urine due to pressure on the bladder
exceeding ability of sphincter to control

Causes
Relative incompetence of sphincter
Weakness of supporting structures
Malposition of bladder/urethra
Stress (continued)

Symptoms
Leakage of small amounts of urine with laughing,
coughing, sneezing, lifting, etc
Rarely occurs (or recognized) at night
In men only after urethral manipulations (e.g.,
prostate surgery)
Stress (continued)

Treatment options




Behavioral: Same as Urge
Pharmacological: Alpha agonists, such as
pseudoephedrine. Low dose Tricyclics, e.g.,
imipramine. Estrogens (postmenopausal).
Surgical: Pessaries. Bladder neck suspension.
Injections of collagen.
Products—usually small padding only
Urge Incontinence
Definition
Involuntary loss of urine due to uncontrollable
contraction of bladder, with and without
warning
Causes
GU changes of aging
Irritative/neurologic condition,such as infections,
diabetes mellitus, bladder stones, tumors,
stroke or dementia, and increased intraabdominal pressure changes
Urge (continued)
Signs and Symptoms
Losses of variable (often large) amounts
Little or no warning time
Associated frequency
Occurs both day and night
Urge – Behavioral Treatment
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Bladder training
Kegel exercises
Prompted voiding; scheduled voiding
Biofeedback
Electrical stimulation
Urge – Drug Treatment

Nonspecific anticholinergics:
 Oxybutynin (Ditropan or Oxytrol)
 Tolterodine (Detrol)
 Trospium (Sanctura)
Urge – Drug Treatment

Selective drugs for M3 (? added value):



Darifenacin (Enablex)
Solifenacin (Vesicare)
There are 5 muscarinic receptors:


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M1: Cognitive, Salivary glands
M2: Smooth muscle, Heart Rate, Hindbrain
M3: Smooth muscle, Salivary gland, Eye
M4: Brain, Salivary gland
M5: Substantia nigra, Eye
Bladder
Systematic Summary
Use of Non-specific Anticholinergics in
Urge Incontinence
32 trials of 6800 patients, double-blind:
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Cure or improvement (subjective) RR = 1.41
Decrease episodes/24 hrs = 0.6
Decrease voids/24 hrs = 0.6
Increase max capacity = 54 ml
Increase volume at 1st contraction = 52 ml
Increase rate of dry mouth RR = 2.56
Herbison et al BMJ 2003;326:841
Urge - Treatment Options
Surgical:
Sacral nerve neuromodulation
Augmentation cystoplasty
Palliative:
Appropriate products
Product--example
Super Brief
Medium (34"-47")
packaged 28/bag - 56/case
Capacity 5.6 cups
Large (48"-59")
packaged 28/bag - 56/case
Capacity: 7.6 cups
Costs: 45 to 70 cents each
Case 2 Mr. Holdner
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A 78-year-old man has longstanding urinary
frequency and urgency that has worsened in past
month.
He often cannot reach the toilet in time and must
change clothes once or twice a day.
A tremor of the left hand has worsened in the past
2 months.
His wife reports that he is lazy and “hardly moves
around any more.”
His medical history includes hypertension,
hyperlipidemia and coronary artery disease.
More
Case 2 continued
He has masked facies, diminished arm swing,
normal gait, and increased muscle tone and resting
tremor on left side
 Abdomen and genitalia are normal
 Rectal exam shows brown stool in the vault and no
evidence of impaction. The prostate seems slightly
large, with partial obliteration of the median sulcus,
but without nodules or masses
 Urinalysis is normal
 Plasma glucose and serum calcium levels are
normal; serum creatinine is 1.2 mg/dl

Which of the following tests is the most
appropriate next step in evaluating Mr. Holdner?
1.
2.
3.
4.
5.
Urine cytology
Serum prostate-specific antigen (PSA)
Postvoid residual volume (PVR)
Cystometry
Voiding diary
Case 2 continued
Mr. Holder is found to have a post void
residual of 350 ml.
What factors are contributing to Mr.
Holder’s urinary incontinence?
1.
2.
3.
4.
Urge symptoms
Overflow UI
Functional UI
All of the above
Which of the following interventions would
be most appropriate at this time?
1.
2.
3.
4.
5.
Start on tamsulosin (Flomax)
Refer to urologist
Start on ditropan
Start on levodopa/carbidopa
Arrange to have urinal at bedside and
chair side at all times
Performing PVR
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Be certain the patient voids spontaneously
before measuring, not void-on-command
If catheter is used, be sure to empty bladder
completely to obtain accurate measurement
If ultrasound is used, be certain that
technician has been trained—and checked by
catheter drainage confirmation
How much residual urine is considered
abnormal after a spontaneous void?
1.
2.
3.
4.
5.
0 ml
>50 ml
>100 ml
>150 ml
>200 ml
Overflow Incontinence
Definition
Unpredictable involuntary losses of urine due to
overdistention of the bladder
Causes
Obstructive

Prostatic hypertrophy; urethral stenosis
Neurogenic

Spinal cord injury; neuropathy (e.g., diabetes)
Overflow (continued)
Signs and Symptoms


Involuntary losses of urine, including dribbling,
urge and stress symptoms
Palpable bladder; large residual volume
Treatment

Obstructive:


Surgical intervention
Neurogenic:
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
Cholinergic drugs, e.g., bethanechol
(Urecholine) – Rarely effective
Intermittent catheterization
Functional Incontinence

Definition
Inappropriate urination despite normally
functioning bladder and sphincter
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Causes
Cognitive or emotional: dementia, behavioral
Musculoskeletal limitations: strokes, arthritis
Environmental barriers: restraints
Functional (continued)
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Treatment options for
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Cognitive: routine toileting, habit retraining,
behavior modification
Non-motivated/depressed: reinforcers, rewards
Musculoskeletal: assistance, assistive devices,
commode placement
Environmental: removal of barriers and
restraints, lighting, commode placement
Overview of Management
for Urinary Incontinence
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Goal: relieve the most bothersome aspect(s)
Correct underlying medical illnesses and medications
that may contribute to UI
Manage fluid intake: avoid caffeine, alcohol; minimize
evening intake
Reduce constipation
Start with least invasive treatments:
behavior - medications - palliation - surgery
Take Away Points




UI is a common and a serious problem
among your patients
A careful history and a brief exam can help
identify the cause
Behavioral treatments are underutilized
Anticholinergic drugs are indicated only for
urge incontinence
URINARY
INCONTINENCE
For Practicing Physicians:
Part 2
Variables and Pitfalls
Take Away Points





Inquiring about incontinence should be
included in the review of systems
Overactive Bladder Syndrome is common
even in the absence of incontinence
Drugs used for other purposes may affect
the voiding mechanisms
Transient causes of incontinence can be
distinguished from established types
Only selected cases of UI require referral
to specialists
Reprise: Persistent Types


Stress
Urge
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
Note: “Overactive bladder” may present as urge
w/o urinary losses
Mixed (often Stress and Urge)
Overflow
Functional
Transient Causes of UI

History




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Physical exam

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Drugs
Delirium
Recent prostatectomy
Excessive fluid intake
Atrophic vaginitis
Fecal impaction
Impaired mobility
Urinalysis


Urinary infection
Glycosuria
Which of the following
medications can contribute to UI?
1.
2.
3.
4.
5.
Tamsulosin (Flomax)
Diphenhydramine (Benadryl)
Pseudoephedrine (Sudafed)
Benztropine (Cogentin)
All of the above
(See accompanying list)
Implications of Incontinence

Medical
Pressure ulcers Urinary infections
Renal failure
Increased mortality

Sepsis
Social
Loss of self-esteem
Dependence on caregivers
Depression Restriction of social and sexual
activities Nursing home placement

Financial
$32 billion annually
Case 1 Mrs. Roth
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75 year old woman, cognitively intact, enjoys her
Tuesday afternoon bridge games with her 3 best
friends.
Her friends are expressing concern, as Mrs. R. goes
running from the bridge table to the bathroom about
every 45 minutes. “Gotta go! Gotta go!”
She never seems to wet herself; she does not smell
of urine. When she returns to the table, she goes on
with her game as though nothing happened.
What is Mrs. Roth’s problem?
1.
2.
3.
4.
5.
Urge incontinence
Overactive bladder
Stress incontinence
Psychological problem
Excessive fluid ingestion
Overactive Bladder (OAB)
Symptoms
 Urgency, Frequency, and Incontinence which can
affect lifestyle and quality of life.
 Urgency—sudden and compelling desire to pass
urine
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
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High urinary frequency, e.g., >8 voids/24 hours
Nocturia, e.g., >2 times per night
Overlap with urge incontinence
Overactive Bladder
Your experiences:
Are you having many complaints regarding this
issue, especially since the direct-to-consumer
advertisements have made it so apparent?
How do you manage these cases?
What kind of results are you having?
Prevalence (OAB)
Overall prevalence
 Age 40+
Men 16%

Ages 40-44
Men 3%

Women 17%
Women 9%
Ages 75+
Men 42%
Women 31%
Survey of 16,776 individuals in general population of France,
Germany, Italy, Spain, Sweden and United Kingdom
Overactive Bladder (OAB)

1/3 of people with OAB also have UI

Even without incontinence, OAB is a
bothersome condition
Management is the same as Urge
Incontinence


Primarily behavioral and pharmacological
Case 2 Mrs. Lekson





A 92 yr old woman is found “down”, confused
and soiled.
In ER she is dehydrated, confused and
lethargic with LLL pneumonia.
Before admission she was living alone,
continent, and capable of self-care.
After hydration and antibiotics, she remains
incontinent of urine and feces.
Nurses want to place a Foley catheter.
Which of the following would be considered
the most likely cause of Mrs. Lekson’s UI?
1.
2.
3.
4.
5.
Delirium
Urinary tract infection
Vaginitis
Fecal impaction
Urinary retention with overflow
Treating Delirium and
Incontinence
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Pursue medical treatments
Avoid catheterization
Encourage use of incontinence products
Reduce stimulating activities
Avoid sedatives, if possible
Assist patient to the bathroom
Encourage involvement of family
Case 3 Mrs. Moore
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A 78 yr old woman has urinary frequency, urgency,
leakage of urine on the way to the bathroom, and
episodes of nocturia.
History of bipolar disease, peripheral neuropathy,
and CHF.
Meds: digoxin, furosemide, potassium, amitriptyline,
olanzapine.
PX: No evidence of CHF. Pelvic-grade 2 cystocele,
No vaginitis.
Urinalysis is negative.
What is the first step in the
management of Mrs. Moore’s urinary
complaints?
1.
2.
3.
4.
5.
Low dose oxybutynin
Pelvic muscle exercises/bladder training
D/C amitriptyline and olanzapine
Perform a post-void residual
Urodynamic testing
Case 3 Discussion



The differential here is between urge and
overflow, not easily distinguished by history.
Since Mrs. Moore is on 2 drugs that could
cause retention, determining PVR would be
the first step in her care.
Alternatively, discontinue the meds and
follow-up.
Case 4 Mr. Downey
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

82 yr old man with 3 year history of
Alzheimer’s on Aricept 5 mg hs for 2 months.
Pt is ambulatory and able to care for self with
some assistance.
Detrol is prescribed for urinary incontinence.
He comes back to your office 2 weeks later
manifesting severe aggressiveness and
delusional behavior.
What might account for
Mr. Downey’s change in behavior?
1.
2.
3.
4.
5.
Urinary sepsis
Influenza
Meningitis
Reduction of acetylcholine in brain
Undiagnosed pain syndrome
Case 4 Discussion



Cholinesterase inhibitors may reduce the rate
of breakdown of acetylcholine in the brain of
the Alzheimer patients
Anti-cholinergic medications prevent
production of acetylcholine
Aricept and Detrol (or other drugs of these
two classes) are antagonistic and may cause
adverse effects in some patients
Case 5 Mrs. Lewis




An 83 year old woman, widowed and living alone,
has become increasingly isolated, losing interest in
appearance, socialization, and nutrition.
Her granddaughter brings her to your office.
You note she is cognitively intact, complaining
vaguely about bowels and sleep, and sighing
frequently.
She does not offer a complaint of incontinence.
More
Case 5 continued

In the review of systems you learn that Mrs.
Lewis has:




Frequent episodes of loss of urine
Inability to get to the bathroom in a timely fashion
Nocturia 3 times/night
Need for frequent change of clothing because of
wetness
What factors have kept Mrs. Lewis
from telling you about her
incontinence?
1.
2.
3.
4.
5.
She considers incontinence normal with age
She is too embarrassed to talk about it
She believes that it is untreatable
She is depressed
All of the above
How would you manage her isolation
and depression?
1.
2.
3.
4.
5.
Offer antidepressants
Offer drug treatment for incontinence
Encourage use of urinary products
Explain that UI is common and treatable
All of the above
Case 6 Mr. Burton
An 83 year old man who has:
Frequency, urgency, urge incontinence and
nocturia persisting two months after
transurethral resection of the prostate for
benign prostatic hypertrophy.
Which of these drugs should
be offered?
1.
2.
3.
4.
5.
Pseudoephedrine
Imipramine
Oxybutynin
Bethanechol
Tamsulosin (Flomax)
Mr. Burton Discussion




The aging bladder, in both genders, becomes
more irritable
The prostate, with its “irritative” symptoms,
adds a second reason for urgency
In this case, the “obstructive” concerns have
been relieved, but the urgency persists
Treat with appropriate anticholinergics for
symptom control
Referral to Specialists?
Indications in appropriate patients:







Recurrent urinary infections
Recent pelvic surgery
Severe pelvic prolapse
Prostatic enlargement or nodules
Sterile hematuria
Urinary retention (PVR >200 ml)
Failure to respond to initial therapy
Take Away Points





Inquiring about incontinence should be
included in the review of systems
Overactive Bladder Syndrome is a frequent
issue, even in the absence of incontinence
Drugs used for other purposes may affect the
voiding mechanisms
Transient causes of incontinence can be
distinguished from established types
Only selected cases of UI require referral to
specialists
Future considerations in UI



Improved diagnostic techniques
Better understanding of cellular, myogenic
and neurogenic mechanisms
Evaluation of newer bladder-specific drugs:


M3 specific blockers
Resiniferitoxin (RTX)--ultrapotent capsaicin
analog for direct instillation into bladder
URINARY INCONTINENCE
IS NOT A DIAGNOSIS...
BUT RATHER IS A SYMPTOM
OF AN UNDERLYING PROBLEM.
THE TERMS DEFINING
TYPES OF PERSISTENT
INCONTINENCE...
ARE DESCRIPTIVE,
AND NOT DIAGNOSTIC
URINARY INCONTINENCE
IS NOT SIMPLY A PART
OF NORMAL AGING...
…BUT AGE-RELATED CHANGES
PREDISPOSE TO ITS
OCCURRENCE.