Evaluation & Treatment of Urinary Incontinence

1. Evaluation & Treatment of Urinary Incontinence Andy M. Norman, M.D. Assistant Clinical Professor, Ob-Gyn Vanderbilt University Medical Center

2. Goals • Discuss Urinary Incontinence (UI) • Discuss Incidental Causes of UI • DIAPERS Mnemonic • Discuss Preliminary Diagnostics • Discuss Treatment of Urgency UI • Discuss Treatment of Stress UI • Discuss Overflow Incontinence • Review Some Cases of UI with Emphasis on Medical Management

3. Acknowledgement • Cases designed by: Dr. Patricia Goode, IM/Geriatrics, UAB • Special thanks to: Kathryn Burgio, PhD, UAB • Author of “Staying Dry,” a self help book for patients incontinence.

4. Disclaimer I am a Urogynaecologist. All of my incontinence patients are female. This discussion is, therefore, mostly centered around problems of females. Some of the observations and treatments are also applicable to male patients.

6. Prevalence of Urinary Incontinence • Age 15 to 64 1.5 - 5% men 10-30% women • Noninstitutionalized 15-35%>60 years old Twice as high in women • Homebound elderly 50% • Nursing home residents 50% (two thirds if catheterized population included)

7. In 1995, more than $16.3 billion was spent on urinary incontinence care. More is spent on incontinence care than other chronic diseases such as breast cancer and osteoporosis.

8. ICS DEFINITION OF URINARY INCONTINENCE Complaint of any involuntary leakage of urine International Continence Society.Abrams P, et al. Neurourol Urodyn. 2002;21(2):167-178.

9. Urinary Incontinence Transient Causes of Incontinence Urge Incontinence Stress Urinary Incontinence Mixed Incontinence Both Urgency & Stress Induced Overflow Incontinence

10. URINARY INCONTINENCE 3884 community-dwelling older adult volunteers for a health promotion study Ages 65 – 79 1104 (28.4%) had self-reported incontinence Burgio, et al: JAGS 42: 208, 1994 Treatment Seeking (1)

11. URINARY INCONTINENCE Treatment Seeking (2) % reporting to M.D. Burgio et al: JAGS 42: 208, 1994

12. URINARY INCONTINENCE Personal problem (not medical) Embarrassed Normal after childbearing Normal aging change Fear of nursing home placement Afraid treatment requires surgery Failure to Report UI to Health Care Provider

13. INCONTINENCE YOU GOTTA ASK!!

14. Diagnosis of UI • History • Physical Exam • Pelvic Organ Prolapse Assessment • In & Out Cath for Residual Urine Volume • U/A +/- Urine C & S • Qtip Test for Bladder Neck Hypermobility

15. BLADDER DIARY Fluid intake Time, type, amount Urine output Time, amount Urine leakage Time, amount Precipitating events (cough, sneeze, exercise, etc.) Associated symptoms (urgency, pain, etc.) Pad usage Number, type

16. Transient Causes of UI • Drugs & Diet • Infection • Atrophic Urethritis • Psychological - Depression, Delirium • Endocrine - Diabetes, Hypercalcemia • Restricted Mobility • Stool Impaction

17. Transient Causes of UI • DRUGS • ACE Inhibitors -- cough • Alpha Blockers – relax internal sphincter • Anticholinergics/Antimuscularinics – decrease effective bladder emptying • Diuretics -- timing • Neuroleptics – pseudoparkinsonism • Sedatives – especially in the demented • DIET • Caffeine – provokes detrusor instability • Artificial Sweeteners-bladder irritants

18. Urgency Incontinence(Overactive Bladder) Therapeutic Options

19. Behavioral Treatment: Multi-component Programs Pelvic floor muscle training Home practice and exercise Self-Monitoring Voiding schedules—timed and prompted voiding “Urge” strategies—FREEZE & SQUEEZE

20. Biofeedback Teaching method Facilitates learned control of physiological responses Patients learn by feedback of their attempts to control bladder and sphincter responses.

21. Detrusor Contraction 10 mmHg

22. Urge Wave

23. When the Urge Strikes“Freeze & 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

24. When to Void WorstTime WorstTime BestTime CalmPeriod

25. RCT Comparing Behavior and Drug Therapy 197 older, community-dwelling women with Urge Incontinence Randomized to: Behavioral training (biofeedback) Drug therapy (oxybutynin) Placebo control Burgio et al, JAMA, 1998

26. Biofeedback-Assisted Behavioral Treatment Visit #1: Anorectal BF to teach PFM control. Home exercise instructions. Visit #2: “Urge strategies” and “stress strategies” Visit #3: If not >50% improved, bladder/sphincter biofeedback Visit #4: Individual adjustments and reinforcement

27. Reduction of Incontinencein the Randomized Clinical Trial % Reduction

28. Patient Satisfaction with Treatment for Urge Urinary Incontinence

29. Behavioral Training Tested the same behavioral program with all components minus biofeedback vs. Verbal feedback based on Vaginal Palpation vs. Same program, but Booklet form (Minimal Treatment Control). Is Biofeedback a necessary component? Burgio, Goode, et.al., JAMA, 2002

30. Reduction of Incontinencein a Randomized Clinical Trial % Reduction Burgio, Goode, et.al., JAMA, 2002

31. Stress urinary incontinence is the most common type of incontinence in women Burgio, Matthews and Engel, 1991

32. Stress incontinence = Urethral incompetenceBladder Neck Hypermobility Intrinsic Sphincter Deficiency Pelvic Organ Prolapse

33. Treatments for SUI • Pelvic Floor Physical Therapy • Topical Estrogen Therapy • Urethral Plugs • Incontinence Pessaries • Surgical Therapy

34. Women’s lifetime risk of surgery for SUI or POP is 11% Olsen, Smith and Bergstrom, 1997

35. The Sling is the Thing!

39. TVT – Transvaginal Tape • Relatively new procedure • Large cohort analysis shows cure rate 80%, improvement 94% • Kuuva, 2000

40. CONCLUSIONS regards Surgical Care of SUI • Numerous surgical techniques to treat stress incontinence • Important to know both objective and subjective cure rates as well as side effects of surgical procedures • Thoughtful evaluation of patients with individualization of therapy is advisable

41. Overflow Incontinence • Common Causes • Obstuctive Uropathy such as BPH in men and Pelvic Organ Prolapse in women. • Neurogenic Bladder • Treatments • Relief of the Obstruction • Clean Intermittent Self Catheterization • Indwelling Catheters • Diversion Procedures

42. SUMMARY Incontinence is very common, so question ALL patients Reversible causes of UI D – I – A – P – E – R – S Behavioral Therapy Effective No side effects

43. Transient Causes of UI • Drugs & Diet • Infection • Atrophic Urethritis • Psychological - Depression, Delirium • Endocrine - Diabetes, Hypercalcemia • Restricted Mobility • Stool Impaction Try with Some Case Studies

44. PATIENT CASE 1 48 year old woman Complains that she just can’t get to the bathroom fast enough for the past 3 months 1-2 urge accidents per day (no stress) Nocturia x 2, often with an accident Wears a pad all the time Wants a bladder tack History

45. PATIENT CASE 1 Last menstrual period 6 months ago Having hot flashes Afraid to take hormone replacement therapy Trying to lose weight; drinks 6-8 diet Cokes per day History

46. PATIENT CASE 1 EXAM Vaginal mucosa mildly atrophic Otherwise exam normal URINALYSIS Normal PVR 40 cc

47. PATIENT CASE 1 Drugs & Diet Caffiene Taper off caffeine ½ per week Begin Exercising Infection Atrophic Urethritis Yes Consider HRT Vaginal estrogen cream – ½ gram 3 times/week to vaginal entrance

48. PATIENT CASE 1 Psychological - no Endocrine - no Restricted Mobility – no Stool Impaction – no

49. PATIENT CASE 1 Taper off Caffeine Vaginal Estrogen Drugs? Hold off for now Behavioral Training TREATMENT

50. PATIENT CASE 1 Teach Kegel exercises during her exam Home Exercises 10 paired contractions and relaxations 3 seconds each – build up to 10 seconds TID (standing, sitting, lying) Urge Strategy Freeze/Squeeze to suppress urgency RTC 1 month Behavioral Treatment