URINARY INCONTINENCE

1. URINARY INCONTINENCE For Practicing Physicians

2. 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

3. Definition -- International • Involuntary loss of urine • Generally in an undesirable place • Creating a social, hygienic problem

4. Prevalence. . . • What percentage of YOUR patients present with urinary incontinence? • Mostly men or women? • What age group? • How often do you address this concern?

5. What percentage of community-living older adults have UI? 1. 10% 2. 30% 3. 50% 4. 70% 5. 90%

6. 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%

7. NORMAL MICTURITION • Urine storage is under sympathetic control (T11-L2): • Inhibits detrusor contraction • Increases sphincter control • Voiding is under parasympathetic control (S2-S4): • Induces detrusor contraction • Induces relaxation of sphincter control • Central Nervous System coordinates and integrates these responses

8. What changes occur with the aging process which can contribute to urinary incontinence? 1. Decreased mobility 2. Inability to postpone voiding 3. Prostate hypertrophy 4. Urethral dysfunction 5. Increased night time urine volume 6. All of the above

9. Changes with Normal Agingwhich 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

10. Transient Causes of UI --differential diagnoses • 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)

11. Persistent Types of UI(Duration of at least 2 months) • Stress • Urge • Note: “Overactive bladder” may present as urge w/o urinary losses • Mixed (often Stress and Urge) • Overflow • Functional

12. Prevalence of Types (Women) How does this compare to your experience? 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

13. 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

14. 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

15. Case 1 Mrs. Leeky • 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

16. Case 1 continued • 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.

17. What are the type(s) of UI manifested by Mrs. Leeky? 1. Urge 2. Urge and stress (mixed) 3. Functional 4. Overflow 5. Drug induced

18. 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

19. What percent of patients with urge/stress UI are said to be cured or helped by behavioral interventions? 1. 100% 2. 70% 3. 50% 4. 25% 5. 15%

20. 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

21. 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)

22. 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

23. 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 intra-abdominal pressure changes

24. Urge (continued) Signs and Symptoms Losses of variable (often large) amounts Little or no warning time Associated frequency Occurs both day and night

25. Urge – Behavioral Treatment • Bladder training • Kegel exercises • Prompted voiding; scheduled voiding • Biofeedback • Electrical stimulation

26. Urge – Drug Treatment • Nonspecific anticholinergics: • Oxybutynin (Ditropan or Oxytrol) • Tolterodine (Detrol) • Trospium (Sanctura)

27. Urge – Drug Treatment • Selective drugs for M3 (? added value): • Darifenacin (Enablex) • Solifenacin (Vesicare) • There are 5 muscarinic receptors: • 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

28. Systematic Summary Use of Non-specific Anticholinergics in Urge Incontinence 32 trials of 6800 patients, double-blind: • 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

29. Urge - Treatment Options Surgical: Sacral nerve neuromodulation Augmentation cystoplasty Palliative: Appropriate products

30. Product--example

31. Case 2 Mr. Holdner • 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

32. 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

33. Which of the following tests is the most appropriate next step in evaluating Mr. Holdner? 1. Urine cytology 2. Serum prostate-specific antigen (PSA) 3. Postvoid residual volume (PVR) 4. Cystometry 5. Voiding diary

34. Case 2 continued Mr. Holder is found to have a post void residual of 350 ml.

35. What factors are contributing to Mr. Holder’s urinary incontinence? 1. Urge symptoms 2. Overflow UI 3. Functional UI 4. All of the above

36. Which of the following interventions would be most appropriate at this time? 1. Start on tamsulosin (Flomax) 2. Refer to urologist 3. Start on ditropan 4. Start on levodopa/carbidopa 5. Arrange to have urinal at bedside and chair side at all times

37. Performing PVR • 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

38. How much residual urine is considered abnormal after a spontaneous void? 1. 0 ml 2. >50 ml 3. >100 ml 4. >150 ml 5. >200 ml

39. 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)

40. 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: • Cholinergic drugs, e.g., bethanechol (Urecholine) – Rarely effective • Intermittent catheterization

41. Functional Incontinence • Definition Inappropriate urination despite normally functioning bladder and sphincter • Causes Cognitive or emotional: dementia, behavioral Musculoskeletal limitations: strokes, arthritis Environmental barriers: restraints

42. Functional (continued) • Treatment options for • 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

43. Overview of Managementfor Urinary Incontinence • 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

44. 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

45. URINARY INCONTINENCE For Practicing Physicians: Part 2 Variables and Pitfalls

46. 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

47. Reprise: Persistent Types • Stress • Urge • Note: “Overactive bladder” may present as urge w/o urinary losses • Mixed (often Stress and Urge) • Overflow • Functional

48. Transient Causes of UI • History • Drugs • Delirium • Recent prostatectomy • Excessive fluid intake • Physical exam • Atrophic vaginitis • Fecal impaction • Impaired mobility • Urinalysis • Urinary infection • Glycosuria

49. Which of the following medications can contribute to UI? 1. Tamsulosin (Flomax) 2. Diphenhydramine (Benadryl) 3. Pseudoephedrine (Sudafed) 4. Benztropine (Cogentin) 5. All of the above (See accompanying list)

50. Implications of Incontinence • Medical Pressure ulcers Urinary infections Sepsis Renal failure Increased mortality • Social Loss of self-esteem Dependence on caregivers Depression Restriction of social and sexual activities Nursing home placement • Financial $32 billion annually