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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 Community-dwelling over 60 y/o 10-30% of women 1.5-5% of men 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 selfesteem Financial- cost of management for those over 65 y/o: 2000: $20 billion Urology 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 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 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) Prompted voiding 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 Pelvic floor muscle exercise Weighted vaginal cones Botulinum toxin Sacral neuromodulation Kegel maneuvers 3 sets 8-12 CTX held for 6-8 s, 3-4 d/ wk x 1520wks Pessary 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: 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 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 ended JAGS 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 alphaadrenergic 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 decline JAGS 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