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Assessment and Management of Urinary Incontinence in the Clinic

Assessment and Management of Urinary Incontinence in the Clinic. Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate Director for GRECC Clinical Programs Birmingham/Atlanta Geriatric Research Education and Clinical Center – July 27, 2006.

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Assessment and Management of Urinary Incontinence in the Clinic

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  1. Assessment and Management of Urinary Incontinence in the Clinic Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate Director for GRECC Clinical Programs Birmingham/Atlanta Geriatric Research Education and Clinical Center – July 27, 2006

  2. Prevalence of Incontinence Severity Hannestad et al., 2000

  3. UI - Treatment Seeking 1,104 Community Dwelling Older Adults with Urinary Incontinence on interview 38% 62% Burgio, et al: JAGS 42: 208, 1994

  4. Reasons for Not Reporting Incontinence to Provider Not aware that can be treated Normal part of aging Personal problem (not medical) Embarrassed Fear of nursing home placement Afraid treatment requires surgery

  5. Include Incontinence in the Review of Systems for allgeriatricpatients.

  6. Patient Case • 75 year old man • Goes to the bathroom every 1-2 hours daytime and 3 times at night. • About once a week, on the way to the bathroom, he can’t make it and wets his clothes. Evaluation? Diagnosis? Appropriate treatment?

  7. Types of Incontinence Stress Urge Functional Overflow

  8. Work-up of Incontinence • History • Physical • Urinalysis • Post-void Residual Volume

  9. Incontinence History Type • Do you leak urine during physical activity such as coughing, sneezing, lifting, or exercising? • Do you get the urge to go and can’t make it without leaking? Onset Severity • Frequency of leakage • Need for absorbent products

  10. Incontinence History • Lower urinary tract symptoms • Urgency, frequency, nocturia, dysuria, weak stream, straining to void, etc. • Fluid intake – volume and type • Previous treatments and effects on incontinence

  11. Medical History • Medical, neurological, history • Surgical history • Prostatectomy • Review medications including OTC • Habits (caffeine, tobacco, alcohol use)

  12. Physical Exam • Brief Neurologic Exam • Gait • Lower extremity strength • Cogwheel rigidity • Sphincter tone and voluntary contraction • Rectal (and Pelvic for women)

  13. Urinalysis • Bacteriuria • Pyuria • Glycosuria • Hematuria

  14. Post-Void Residual Volume • Measure amount of urine left in bladder after voiding. • Ultrasound or catheter • Normal: < 50 ml

  15. Patient Case • 75 year old man • Frequent voiding and weekly urge incontinence • Work up • Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation. • Physical: hard stool in vault • UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) • PVR: 200 mL • Diagnosis? • Treatment Options?

  16. Contributors to UIto Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

  17. Contributors to UIto Treat First Drugs Sedatives including alcohol ACE inhibitors (cough) Antipsychotics (pseudoparkinsonism) Diuretics (bad timing) Alpha Blockers – worsen stress UI Anticholinergics – incomplete emptying

  18. Contributors to UIto Treat First Drugs and Diet – Caffeine & Fluids Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

  19. Patient Case • 75 year old man • Frequent voiding and weekly urge incontinence • Work up • Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation. • Physical: hard stool in vault • UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) • PVR: 200 mL

  20. Patient Case • 75 year old man • Frequent voiding and weekly urge incontinence • Work up • Hx: Otherwise negative • Physical: unremarkable • UA: normal • PVR: 45 mL • Diagnosis? • Treatment options?

  21. First Line Treatments • Medications • Anticholinergics • Oxybutynin – generic, Ditropan XL, Oxytrol patch • Tolterodine - Detrol • Solifenacin - VESIcare • Trospium - Sanctura • Darifenacin - Enablex • Alpha blocker for BPH • Other treatments • Behavioral training – try BEFORE or with drug

  22. Least Invasive – Use First !! Behavioral Strategies Diet & Fluid Management PFM Training and Exercise Behavioral Approaches Bladder Training Biofeedback Weight Loss Bladder Diaries

  23. Behavioral Treatment: Multi-component Program Pelvic floor muscle training Home practice of exercises Increase duration of contraction/relaxation over time Bladder Control Techniques Self-Monitoring w/ bladder diaries

  24. When the Urge Strikes –Freeze and Squeeze Stop and stay still Squeeze pelvic floor muscles Relax rest of body Concentrate on suppressing urge Wait until the urge subsides Walk to bathroom at normal pace Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

  25. When to Void WorstTime BestTime WorstTime CalmPeriod Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

  26. Other Behavioral Strategies • Stress Strategy • Squeeze before you sneeze (or cough or lift) • Post Void Dribbling Strategy • Squeeze after voiding

  27. RCT Comparing Behavior and Drug Therapy 197 older women with urge incontinence Randomized to 8 weeks of: Behavioral training (biofeedback) Drug therapy (oxybutynin) Placebo control Burgio et al, JAMA, 1998

  28. Reduction of Incontinence % Reduction

  29. Patient Satisfaction with Treatment Burgio et al. JAMA. 1998; 280:1995-2000

  30. Patient Case • 85 year old woman • Frequently leaks on the way to the bathroom • Work up • Hx: Aricept for dementia • Physical: Frail, walks slowly, uses a walker • UA: normal • PVR: 85 mL • Diagnosis? • Treatment Options?

  31. The Patient with Functional Limitations Avoid anticholinergic drugs in pts with dementia Facilitate functional status Mobility devices Physical therapy Bedside commode Urinal for men Prompted voiding – VERY effective

  32. Post-Prostatectomy Incontinence • 65 yo had radical prostatectomy 1 year ago • Leaks when he coughs, sneezes or lifts something heavy • Wears a pad in the daytime, dry at night • No problem making it to the bathroom • Diagnosis? • Treatment Options?

  33. Behavioral Treatment of Post-Prostatectomy Incontinence 20 men; 55-87 years old Average 2 ½ years since surgery 8 weeks of biofeedback-assisted behavioral training 78.3% decrease in accidents (range of -12 – 100%) Burgio, et.al., J Urology, 1989

  34. Behavioral Training for Post-Prostatectomy Incontinence Case Series of 27 men with persistent post-prostatectomy UI Taught pelvic floor muscle exercises without using biofeedback 56.6% reduction in leakage Meaglia et al. J Urol. 1990;144:674

  35. Post-Prostatectomy Incontinence • 65 yo considering radical prostatectomy • Continent • Read that 72% of patients reported incontinence persisting 1 year after surgery and 40% wearing pads • What can he do to help prevent incontinence? Stanford, et.al. JAMA, 2000

  36. Pre-Prostatectomy Muscle Training N=125 (p = .032) Burgio, Goode, et al, J Urol, 175:196; 2006

  37. Reduction of Incontinence p=.090 p=.045 % Burgio, Goode, et.al., J Urology, 2006

  38. Pre-Prostatectomy Muscle Training • Median Time to Continence: • Intervention Group - 3.5 months • Control Group - > 6 month • Number Needed to Treat to get 1 additional man out of pads at 6 months = 5 Burgio, Goode, et al, J Urol, 175:196; 2006

  39. Summary - Work-up of Incontinence • History • Physical • Urinalysis • Post-void Residual Volume

  40. Summary: Contributors to Incontinence to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

  41. Behavioral Treatments Pelvic Floor Muscle Exercises (Kegel) Bladder training Timed/Prompted voiding Bladder Control Techniques Biofeedback Medications Pessary Pelvic Floor Electrical Stimulation Magnetic Chair Urethral Bulking Agents Surgery Urinary Incontinence Treatments

  42. Current Studies at Bham/ATL GRECC • MOTIVE- Combined medication and behavioral therapy for overactive bladder in men (VA Rehab R&D) • ProsTech– Behavioral therapy with and without biofeedback and electrical stimulation for persistent incontinence in men after radical prostatectomy (NIH) • COMBO - Combined medication and behavioral therapy for urge incontinence in women (VA Rehab R&D) • ATLAS– Behavioral therapy or pessary or combined for stress incontinence in women (NIH) • RUBI- Botox injections for refractory urge incontinence in women (NIH)

  43. Contact Information • Patricia Goode, MD pgoode@aging.uab.edu 205-934-3249 • Kathryn Burgio, PhD kburgio@aging.uab.edu 205-558-7067 • Ken Shay, DDS, MS kenneth.shay@va.gov 734-222-4325 • http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=22318

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