Urinary Incontinence

1. Urinary Incontinence Stephen J. Titus MD

3. Objectives Define the main causes of urinary incontinence. Formulate an approach to their diagnosis. Identify the treatment strategies for each. Remind each of us to not eat Yellow Snow

4. Impact Direct cost of treatment in 1995 was $26.3 billion More common in women then men >1/3 women >65 have some degree of incontinence Fewer than 50% will raise complaint to physician Routine examinations should address screening for urinary incontinence

5. Types of Urinary Incontinence Urge Incontinence �Overactive Bladder�, Detrusor overactivity A strong sense to void followed by involuntary loss of urine Usually idiopathic, but can be due to infection, bladder stones, bladder cancer

7. Types of Urinary Incontinence Stress Incontinence Involuntary loss of urine due to increased intra-abdominal pressure Coughing Sneezing Laughing Most common type in young women Due to pelvic floor muscle weakening resulting in urethral hypermobility

8. Types of Urinary Incontinence Mixed Incontinence Most common in women overall Exact mechanism not well understood Characteristics of both Urge and Stress Incontinence

9. Types of Urinary Incontinence Overflow Incontinence Due to overdistension of the bladder Frequent or constant �dribbling� Either due to an outlet obstruction (prostate) or detrusor underactivity (medications, spinal chord injury, diabetic neuropathy, MS) Post void residual is often elevated

10. Types of Urinary Incontinence Functional Incontinence Especially in the elderly Cognitive or Physical limitations Diagnosis of exclusion as other types might be present in functionally limited individuals

11. Types of Urinary Incontinence Incontinence due to secondary causes Medications Urinary Tract Infections Stool Impaction Hyperglycemia Heart Failure Interstitial Cystitis Bladder Malignancies

12. Medications Diuretics Caffeine Alcohol Anticholinergics Alpha agonists Beta agonists Sedatives/Antidepressants/Antipsychotics Urge Urge Urge Overflow Overflow Overflow Overflow

13. Medications Narcotics Alpha blockers ACE inhibitors(cough) Mixed Stress Stress

15. Evaluation History Screen patients �Have you leaked urine in the last 3 months?� �What preciptants led to leakage?� �Which precipitant caused leakage most often� Comorbid conditions DM2, Stroke, Dementia, Spinal Stenosis Constipation

16. Evaluation History GYN history Surgical history Medication list Bladder Diary

17. Evaluation Physical �above the waist� CV exam: signs of volume overload Abd exam: masses, tenderness Neuro exam Genital Exam Atrophy, cystocele, rectocele, pelvic masses Rectal Exam Prostate enlargement, rectal mass, stool impaction

18. Evaluation Post Void Residual Controversial in primary care setting at first presentation Catheter or Ultrasound <50mls complete voiding >200mls suggests obstruction/detrusor underactivity

19. Evaluation Laboratory Urinalysis (with culture if infection suspected) Renal function Fasting Glucose

20. Evaluation Urodynamic Testing Routine testing is not recommended �Gold Standard� Expensive, Invasive, specialized equipment

22. Treatment Urge Incontinence Behavior therapies are recommended first-line and more effective than medications alone However, a combination of the 2 is most successful Behavior therapy depends on patient adherence and motivation

23. Treatment Urge Incontinence Bladder training (holding urine longer between voids) Kegel Excercises to strengthen pelvic floor 81% reduction in episodes vs 69% reduction in oxybutynin treated patients 3 sets of 8-12 contractions x 6sec, 3x/week, x 15wks

24. Treatment Urge Incontinence Medications Anticholinergics Oxybutynin (short acting, long acting, transdermal) Tolteradine (short acting, long acting) Oxybutynin slightly more effective, but higher side effects (Dry Mouth)

25. Treatment Stress Incontinence Kegel Excercises No difference shown between Kegel�s alone vs. Kegel�s + Biofeedback/Weighted Vaginal Cones Devices Pessaries (short or long term uses) Urethral occlusion plugs (short term)

26. Treatment Stress Incontinence Medications Likely not on test as none currently FDA approved Alpha adrenergic agonists (Duloxetine) DO NOT use Estrogen replacement Only consider for atrophic vaginitis Invasive Treatments Surgery Bulking agent injections

27. Treatment Mixed Incontinence Target therapy at most prominent component Overflow Incontinence Identify and relieve obstruction Men usually due to the prostate (BPH medication, Surgery, catheterizaton) Women usually with history of previous surgery and referral is warranted

28. Treatment Functional Incontinence What are the physical/mental function limitations? Improve mobility Improve access Decrease evening fluid intake Schedule voidings

30. Practice A 70 y.o. white female complains of two episodes of urinary incontinence. On both occasions she was unable to reach a bathroom in time to prevent loss of urine. The first episode occurred when she was in her car and the second while she was in a shopping mall. She is reluctant to go out because of this problem. The most likley cause of her problem is:

31. Practice Overflow incontinence Stress incontinence Urge incontinence Functional incontinence

32. Practice Overflow incontinence Stress incontinence Urge incontinence Functional incontinence

33. Practice A 56 yo male presents to your clinic with a chief complaint of: �Leaking Urine�. The most appropriate next step in the evaluation of this patient is to: A) Obtain a post void residual B) Conduct urodynamic testing C) History and Physical Exam D) Obtain a urinalysis

34. Practice A 56 yo male presents to your clinic with a chief complaint of: �Leaking Urine�. The most appropriate next step in the evaluation of this patient is to: A) Obtain a post void residual B) Conduct urodynamic testing C) History and Physical Exam D) Obtain a urinalysis

35. Practice A 42 yo otherwise healthyAfrican American female states she has had several episodes of leaking urine. She has noticed it mostly with coughing or sneezing and has had to begin wearing absorbent undergarments. She has 2 children, both of which were vaginal deliveries. The best first-line treatment option for this patient is:

36. Practice Tolterodine ER 4mg daily Pessary Placement Oxybutynin 5mg tid Kegel Excercises

37. Practice Tolterodine ER 4mg daily Pessary Placement Oxybutynin 5mg tid Kegel Excercises

38. Practice A 62 yo otherwise healthy female states she has had several episodes of leaking urine. She has noticed it mostly at night when she awakens with an intense desire to void. The best first-line treatment option for this patient is: Tolterodine ER 4mg daily Pessary Placement Oxybutynin 5mg tid Kegel Excercises

39. Practice A 62 yo otherwise healthy female states she has had several episodes of leaking urine. She has noticed it mostly at night when she awakens with an intense desire to void. The best first-line treatment option for this patient is: Tolterodine ER 4mg daily Pessary Placement Oxybutynin 5mg tid Kegel Excercises

40. Summary Most cases of urinary incontinence can be diagnosed and initially treated with an H&P and routine labwork First line treatment for Urge, Stress and Mixed incontinence is behavioral and centered around Kegels Overflow: Think prostate in men, scar tissue /previous surgery in women.

41. Questions?

42. Resources Culligan PJ, Heit M. Urinary Incontinence in Women: Evalauation and Management. Am Fam Phys 2000;62:2433-44. Brown JS, Choi SC, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715. Association of Women�s Health, Obstetric and Neonatal Nurses (AWHONN). Continence for women-evidence based practice guideline. Washington (DC). AWHONN; 2000. Fantl JA, Newman DK, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update, AHCPR Publication No. 96-0682, Public Health Service, Agency for Health Care Policy and Research, Rockville, MD. Griffiths D, Kondo, et al. Dynamic testing. In: Incontinence, 3rd ed. Abrams P, Cardozo L, Khoury S, Wein A (Eds), Health Publications, Plymouth, 2005. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology 1998;51:355-61. Resnick NM. Improving treatment of urinary incontinence. JAMA 1998;280:2034-5. Weiss B. Selecting Medications for the Treatment of Urinary Incontinence. Am Fam Physician 2005;71:315-22. Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998;280:1995-2000.