Transcript Impact of Urinary Incontinence

URINARY
INCONTINENCE
An Approach to
Evaluation and Management
Kristen M. Nebel, D.O.
September 29, 2010
Urinary Incontinence
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Goals:
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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
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Definition:
Unintentional
leakage of urine at
inappropriate times
(often leading to social
embarrassment).
Types of Urinary Incontinence
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Stress Urinary Incontinence
Urge Urinary Incontinence
Overflow Urinary Incontinence
Mixed Urinary Incontinence
Functional Urinary Incontinence
Deformity of Urinary Tract
Prevalence
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24 to 64 y/o
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Community-dwelling over
60 y/o
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10-30% of women
1.5-5% of men
25-35% of women
10-15% of men
Nursing home/ home-bound
> 65 y/o
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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?
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Under diagnosed
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Patient - normal aging
process, no help
available,
embarrassment
Physician
Impact of Urinary Incontinence
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Psychosocial- perceived/ actual limitations on
activities, caretaker strain, depression, low selfesteem
Financial- cost of management for those over 65
y/o:
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2000: $20 billion
Urology 1998; 51(3):355-61
Impact of Urinary Incontinence
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Medical- decubitus ulcers, UTI’s, sepsis, renal
failure, falls, dermatoses/ cellulitis
Care-giver:
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Hours per week of informal care in community- dwelling
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Men: 7.4-> 11.3-> 16.6
Women: 5.9->7.6-> 10.7
Strain -> Institutionalization
Normal Micturition
Genito-urinary Age-Related
Changes
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Atrophic vaginitis/
urethritis
BPH
Inability to delay
voiding
Decreased detrusor
contractility
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Increased PVR
Increased UOP later in
day
Detrusor overactivity
Decreased bladder
capacity
Stress Urinary Incontinence
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Urethral sphincter opening without a bladder
contraction during stress maneuvers
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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
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Urethral or bladder neck displacement
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Vaginal deliveries
Pelvic surgeries
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Nerve, muscle, connective tissue injury
Pelvic organ prolapsed- cystocele, rectocele,
uterine prolapse
Etiologies of Stress UI
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Menopause
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Decreased estrogen state  atrophy of urethral
epithelium
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Atrophic urethritis
Decreased urethral mucosal seal/ failure to close
Loss of compliance
Irritation
Insufficient urethral support
ά-adrenergic blocking agents
Urge Urinary Incontinence
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“Detrusor (Bladder) Overactivity”:
uncontrolled bladder contractions or impaired
contractility
Most common form >65y/o
Abrupt sensation of need to void triggered by:
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Running water, hand washing, cold weather,
sights of home
Associated with moderate to severe leakage
Etiologies of Urge UI
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90% idiopathic
Advanced age
Bladder irritation
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Infection, calculi, tumors
Fecal impaction
CNS impairment of inhibitory pathways
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CVA, cervical stenosis, dementia, drugs, MS,
Parkinson’s disease
Risk Factors for UI
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Most common
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Age
Gender
Parity- UI may occur 5 years after first vaginal
delivery
Mixed Urinary Incontinence
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Loss of urine due to both urge and stress
incontinence
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Treatment determined by predominant symptom
Overflow Urinary Incontinence
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Over distension of the bladder due to:
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Lower urinary tract symptomatology
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Bladder outlet obstruction
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BPH
Prostate Cancer
Urethral Stricture
Fecal impaction
Overflow Urinary Incontinence
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Lower urinary tract symptomatology
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Impaired detrusor contractility (5-10%)
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Bladder fibrosis
CNS damage
Anticholinergic drugs
Neuropathic- poor autonomic nerve relay
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DM neuropathy
Overflow Urinary Incontinence
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2nd most common type in men
Accounts for 8% of UI in females
Symptoms:
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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
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Patient- initiated complaint or physician
inquiry regarding incontinence
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Focused H&P and simple office procedures
can lead to initial working diagnosis
Evaluation of UI
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History:
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Onset, frequency, timing, volume
Bowel habits
Sexual function
Medications
How the patient views quality of life
Evaluation of UI
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History continued…
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Triggers
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UI with stress maneuvers has moderate specificity and
high sensitivity for SUI (although no formal studies)
Symptoms
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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
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Past medical history
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CHF
Parity
Surgeries
DM
Physical Examination
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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
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Extremities- edema/ joint mobility/ function
Rectal- mass/ prostate/ impaction
Neuro- examination of lumbosacral nerve
roots: bulbocavernosus reflex
Physical Examination
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Female GU- Atrophy/ vault stenosis/
inflammation/ cystocele/ rectocele/ bladder
distention
Male GU- phimosis/ paraphimosis
Evaluation of UI
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Transient (Acute) vs. Established (i.e. Urge,
Stress, Overflow)
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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 Urination
Drug
Antidepressants, antipsychotics,
sedatives/hypnotics
Side Effect
Sedation, retention (overflow)
Diuretics
Frequency, urgency (OAB)
Caffeine
Frequency, urgency (OAB)
Anticholinergics
Alcohol
Narcotics
Retention (overflow)
Sedation, frequency (OAB)
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
ACE inhibitors
Retention (overflow)
Cough (stress incontinence)
Office Based Studies
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Assess for reversible causes
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UA w/ C+S
PVR- via catheter or ultrasound
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Volume < 50 mL is normal
Volume >200 mL is abnormal
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Associated with OUI
Lab testing
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BMP
B12 level
Office Based Studies
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Clinical Stress Test
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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
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Stress/ Urge Urinary Incontinence
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1st line- Behavioral therapies/ devices
2nd line- Medications
3rd line- Surgery
Overflow Urinary Incontinence
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Catheterization-intermittent/ indwelling
Medications
Behavioral Therapies
for Urge and Stress
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Bladder Training
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2 principles:
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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
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Timed voiding
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Frequency of voids corresponds with shortest
interval between voids (bladder diary)
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Prompted voiding
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After no leakage for 2 days, time is gradually increased
by 30-60 minutes to goal of 3-4 hours
For use in cognitively impaired or Urge UI
Biofeedback
Other Therapies for SUI
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Pelvic floor muscle
exercise
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Weighted vaginal cones
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Botulinum toxin
Sacral neuromodulation
Kegel maneuvers
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3 sets 8-12 CTX held for
6-8 s, 3-4 d/ wk x 1520wks
Pessary
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RCTs on SUI Therapies
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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
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PFME is better than electrical stimulation or
vaginal cones in treating SUI.
BMJ 1999;318:487-93
RCTs on UUI Therapies
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Biofeedback vs. Behavioral training for UUI:
no significant difference
Evidence-based OB/ GYN 2003;5(2)
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Biofeedback-assisted Behavioral Tx vs. drug
therapy vs. placebo in Urge and Mixed UI:
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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
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Dementia patients:
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Success of prompted voids can be predicted if:
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JAGS: 190;38:356.
Patient can state name
Transfer with </=1 assist
Leaks < 4 x/ 12 hours
Voids 75% of time when prompter during 3 day trial
UI in Long-term Care
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Functional Incidental Training: combination of
prompted void with endurance and strength
exercises
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Study of 107 VA pts found FIT reduced wet
checks episodes by ½.
Practical limitations due to staffing, cost, limited
benefits after therapy ended
JAGS 2005: 53(7); 1901-1100.
Pharmacological Therapy
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Stress Incontinence
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Improve urethral sphincter contraction
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ά-adrenergic agents: Imipramine
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Stimulate urethral smooth muscle contraction
Better results if used with estrogen
Not recommended if + orthostatics or at risk for anticholinergic
effects
Pharmacological Therapy
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Stress Incontinence
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Estrogen: vaginal or oral forms
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If used alone has limited effectiveness, some studies indicate
worsening
Increases number /responsiveness of receptors to alphaadrenergic agents
BJOG 1999;106(7):711-8
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Serotonin-Norepinephrine reuptake inhibitor:
Duloxetine
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Approved for Stress UI in England
Am Jnl OB/GYN 2002;187(1):40-8
Pharmacological Therapy
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Urge Incontinence
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Inhibit bladder contractions
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Anticholinergics:
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Oxybutynin (Ditropan, Oxytrol): most common side effect is
dry mouth
 Controlled release form better tolerated
Solifenacin (Vesicare), Darifenacin (Enablex), (Fesoterodine)
Toviaz
Muscarinic Receptor antagonist:
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Tolterodine (Detrol): slightly less efficacious than oxybutynin,
but with less side effects
Trospium (Sanctura)
Pharmacological Therapy
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Efficacy:
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30% continence rate
Reduces UI by ½ + episodes per day
Results may take 4-6 weeks
Trials:
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Vesicare > tolterodine for reducing urgency/
frequency
Oxybutynin > tolterodine for reducing
incontinence
Pharmacological Therapy
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Dementia:
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Combination of cholinesterase inhibitors and
antimuscarinics can cause functional decline
Oxybutynin 5mg ER daily x 4 weeks did not result
in cognitive decline
JAGS 2008 May; 56(5):862-70.
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Case reports of Tolterodine reported increased
hallucinations
Pharmacological Therapy
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Overflow Incontinence
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Relief of obstruction (BPH)
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5-ά-reductase inhibitors: finasteride
ά -1-adrenergic antagonists: flomax
Herbal Symptomatic relief
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Saw Palmetto
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Significant improvement when compared to finasteride
Clinics in Geriatric Medicine 2004;20:3
Lifestyle Modifications for all
Patients
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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)
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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
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In Conclusion:
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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
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70 y/o male with poor stream, straining to
void, and incontinence.
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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