Sindhura Manubolu PGY2 Family Medicine Urinary Incontinence in Men
Epidemiology • Definition : At least one urinary incontinence episode in the preceding 12 months among community-dwelling men. PREVALENCE : • COMMUNITY : (General) Ever : 22 % in men older than 65 years Daily : 5% in men older than 65 years COMMUNITY : (Frail, and those with mobility and cognitive disorders ) 40% overall in both men and women older than 65 yrs NURSING HOMES: 50% to 70% overall both men and women older than 65 yrs old
Geriatric Urinary Incontinence Prevalence Women Men Community (Frail)/ Acute Hospital N H Community (General)
Facts Despite the important burden of urinary incontinence in men : • Only one in five men with symptoms are likely to seek care • Men are half as likely as women to seek care for UI (22 versus 45 percent, respectively) • As per evidence, presence of UI in men may have a greater emotional and social impact on quality of life compared to women.
Types 5 major types: • Urge • Stress • Mixed • Overflow (Incomplete emptying) • Functional
Lower Urinary Tract Cholinergic and Adrenergic Receptors Μ=muscarinic =1-adrenergic Detrusor muscle(M) Trigone() Bladder neck() Urethra ()
Motor Innervation of the Bladder Neurotransmitter:Acetylcholine Receptors: Muscarinic Contraction Pelvic Nerve
Physiology Of Bladder Innervation • Detrusor Mechanism • The cholinergic action of the pelvic nerves : - Causes the detrusor muscle to contract and the bladder to empty. • Sphincter Mechanism • Alpha-adrenergic activity : causes the urethral sphincter to contract. • Anatomic relationship of the urethra to the bladder and the abdominal cavity. Continent sphincter mechanism requires proper angulation between the urethra and the bladder.
Reversible Causes (“DRIP”) D elirium R estricted mobility, R etention I nfection, I nflammation, I mpaction P olyuria : glycosuria, excess fluid intake Pharmaceuticals
Screening • Recommendations: - All women should be screened for UI - No specific evidence-based guidelines in men • Questions: • Do you ever leak urine/water when you don't want to? • Do you ever leak urine when you cough, laugh, or exercise? • Do you ever leak urine on the way to the bathroom?
Diagnostic Evaluation • History • Physical exam • UA • Post void residual • Identify reversible causes • Initiate treatment
History The key components of the history include: • Onset and temporal course of incontinence • Severity • Associated symptoms • Precipitants • Bowel function • Sexual function • History of prostate disease • Comorbidities
Physical exam • CVS : Volume overload • GI: Masses and tenderness, bladder distention. • LE: Joint mobility, function, and peripheral edema. • Neuro : • Sacral root integrity: perineal sensation, resting tone of the anal sphincter • Peripheral neuropathy: vibration and peripheral sensation • Screening : • Depression, assessment of functional status, and evaluation of cognitive function. • Digital rectal exam : Prostate size and detect any abnormalities suggestive of prostate cancer.
Tests : Recommended in initial evaluation • UA and culture (Infection, sterile hematurea, glucosuria) • Serum calcium, glucose, B12 and folate (If needed based on history and PE) • Post Void Residual: Recommendations: is a part of initial evaluation as per guidelines. No high quality evidence from RCT ,but is based on expert opinion. - PVR of < 50 mL : adequate emptying - PVR of > 250 mL: inadequate and suggestive of either detrusor weakness or obstruction .
Further testing to diff b/w stress and urge Stress Test • Stress test : stress incontinence • Ask the patient, with a full bladder, to stand, relax, and give a single vigorous cough. Hold chux or pad is held underneath the perineum or on the floor and the clinician observes directly whether there is leakage from the urethra.
Office cytometry : A nonballooned catheter is placed in the patient's bladder 50-mL syringe is inserted into open end of the catheter. Syringe is held 15 cm above the symphysis pubis. Sterile water is instilled into the bladder until patient reports feeling a strong urge to void or until bladder contractions occur. Contractions detected by observing movement of the fluid level in the syringe. Severe urgency or bladder contractions at less than 300 mL of bladder volume constitute a presumptive diagnosis of urge incontinence.
Specialist referral Inability to arrive at a presumptive diagnosis or treatment plan Failure to respond to treatment of presumptive diagnosis Consideration of surgical intervention Immediate specialist referral : • Recent onset (within two months) of urge incontinence or irritative bladder symptoms • Previous anti-incontinence surgery or radical pelvic surgery • Incontinence with abdominal pain • Hematuria in the absence of a UTI • Suspected fistula • Complex neurological conditions (eg Parkinson disease, spinal cord injury, possible normal pressure hydrocephalus [cognitive impairment, wide-based gait,incontinence])
Urodynamics and Urine flow rate: Specialist setting • Urine flow rate: -Measurement of the peak urine flow rate with a flowmeter • Urodynamics : -Urodynamics are the physiological diagnostic "gold standard“ Invasive, expensive, require special equipment and training, and do not affect outcome. The precise diagnosis offered by urodynamic testing is most important when invasive therapy is planned.
Bladder Diary • When is a Bladder Diary Used? Can point to any dietary or behavioral factors • How to Complete the Diary: • 1. Begin and end the diary at the same times each day (example: begin when you wake (6 am) and end (6 am the following day). • 2. Record the fluid intake to the nearest ounce. • 3. Measure urine output with either a scaled collection device or by urinating into a large disposable cup . • 4. It is requested that you collect 3 days of information; however, they do not need to be consecutive days.
Urge Incontinence Urge incontinence is involuntary leakage accompanied by urgency. • Urgency is the complaint of a sudden and compelling desire to pass urine that is difficult to defer. • Associated with frequency and nocturia • Commonly-reported precipitants include running water, hand washing, and going out in the cold.
Geriatric Urinary Incontinence & OAB Detrusor Overactivity 100 Involuntarybladder contractions Normal voluntary void Bladder pressure 0 0 100 200 300 400 Volume
Geriatric Urinary Incontinence & OAB DHIC 100 80 60 % bladder emptying 40 20 0 DHIC DH Resnick, Yalla JAMA 1987;148:3076
Pathophysiology of DetrusorOveractivity • Neurogenic • Myogenic • Combination • Unknown
Treatment :Urge incontinence • First-line treatment - Behavioral therapies such as bladder training and bladder drill • Second-line treatment: -Medications • Third-line treatment: -Surgical procedures (rarely used)
Drug Therapy for Urge UI • Darifenacin (“Enablex”) • Oxybutynin(“Ditropan”) • IR • ER (“ XL”) • Patch (“Oxytrol”) • Solifenacin(“Vesicare”) • Tolterodine (“Detrol”) • IR • Long-acting (“LA”) • Trospium (“Sanctura”)
Potential Side Effects of Antimuscarinic Drugs Iris/Ciliary Body = Blurred Vision Somnolence Impaired Cognition CNS Lacrimal Gland = Dry Eyes Salivary Glands = Dry Mouth Heart = Tachycardia Stomach = GERD Colon = Constipation Bladder = Retention
Antimuscarinics and Cognition • Antimuscarinic drugs used for the bladder can theoretically cause cognitive impairment • ACh is a pivotal mediator of short-term memory and cognition • Cholinergic system involvement in Alzheimer’s disease has been clearly established • Of the 5 muscarinic receptors M1 appears most involved in memory and learning
Antimuscarinic Drugs and Cognition Vasculature CNS BBB • Low lipophilicity • Charged • Relatively “bulky” Tolterodine + + + + + + + + + + • High lipophilicity, • Neutral • Relatively “small” Oxybutynin, Solifenacin Trospium ++ ++ ++ ++ ++ • Relatively “bulky” • Highly polar ++ ++ ++ ++ Darifenacin • Lipophilic, small • “M3 selective”
Failure of Medical Treatment- Surgical • Electrical stimulation • Injection of botulinum toxin via cystoscopy • Augmentation cystoplasty. • Most common surgical treatment for urge incontinence : sacral nerve stimulation, which is effective for long-term
STRESS INCONTINENCE - Transurethral resection of the prostate (TURP) -2/2 damage to the external urethral sphincter - Uncommon in contemporary series, reported rates of urinary incontinence following TURP are <1 percent. - Radical prostatectomy.: - external urethral sphincter is closely approximated to the prostatic apex, and is at risk for damage.
Stress -Treatment First line treatment : - Pelvic floor training, biofeedback, electrostimulation, magnetic field stimulation Second line treatment : -Alpha adrenergic treatments : Non FDA approved -Serotonin and noradrenaline reuptake inhibitor: Duloxetine is a new treatment option. (Relaxation of the detrusor muscle and simultaneous contraction of urethral smooth muscle).
Failure of medical therapy: Surgical Third line: Surgical: For male stress incontinence - Transurethral bulking agents - Perineal slings - Artificial urinary sphincter. S/p radical prostatectomy: Recommendation: - Watchful waiting - Supplemented with conservative measures for a period of at least 6 to 12 months
Overflow incontinence 2/2 urine retention with bladder distention. Urine accumulates in the bladder until maximum bladder capacity is reached and then leaks through the urethra by “overflow”
Overflow Treatment:Rx Cause 1. BPH • Alpha-1-adrenergic blocking agents : relax sphincter, decreasing urethral resistance and relieving symptoms. • 5 alpha reductase - : slower onset of action, decrease prostate size and alter the disease course • Recommendations: • Alpha blockers provide symptomatic relief of moderate to severe BPH symptoms. A • In men with a prostate volume greater than 40 mL, 5-alpha reductase inhibitors should be considered for the treatment of BPH. 2.Neurogenic bladder : Catheterization - intermittent catheterization – most recommended - indwelling catheterization - suprapubic catheterization
Indications:Catheterisation Long-term : • Bladder outlet obstruction not correctable medically or surgically • Intractable skin breakdown caused or exacerbated by incontinence • Some patients with neurogenic bladder + retention • Palliative care for terminally ill or severely impaired incontinent patients • Patient preference who has not responded to specific incontinence treatments
Short term : catheterisation • Urologic surgery • Surgery on contiguous structures • Critically ill patients requiring accurate measure of urinary output • Acute urinary retention
Catheter choices • EXTERNAL CATHETERS: condom catheter Considered in incontinent men without urinary retention who have severe functional disabilities. • more comfortable • lower incidence of bacteriuria than indwelling catheters. • Skin breakdown is common, whereas urethral diverticuli and penile ischemia occur occasionally. • Minimize sleep disruption and limit bacteriuria, can be used only at night.
URETHRAL VS.SUPRAPUBIC CATHETERS • Suprapubic catheters are recommended by some physicians for short-term use when a catheter is needed for gynecologic, urologic and other surgeries. • 1Theoretically, there are fewer microbes on the abdominal wall than on the perineum, creating less risk for infection. Another advantage is easier catheter changes. Suprapubic catheters can also be clamped to test for adequate voiding. Some patients might also prefer a suprapubic catheter to enhance self-image and sexual functioning. Other patients prefer its comfort and convenience.1 Disadvantages of suprapubic catheters include the risk of cellulitis, leakage, hematoma at the puncture site, prolapse through the urethra1 and the psychologic barrier of insertion through the abdominal wall.
Lifestyle Changes (Weight loss , Dietary ) • Weight loss • Dietary changes — Some foods and beverages are thought to contribute to bladder leakage Alcoholic beverages Carbonated beverages (with or without caffeine) Coffee or tea (with or without caffeine) Other food groups mentioned in the literature but without supporting evidence include: citrus juice and fruits, tomatoes and tomato-based products, spicy foods, artificial sweetener, chocolate, corn syrup, sugar or honey
BEHAVIORAL THERAPY Behavioral treatments are effective for urge, stress, and mixed urinary incontinence; should be the initial treatment for patients with mild to moderate leakage. Behavioral treatments include : - Bladder training - Pelvic muscle exercises (PME)
Bladder training • Used for urge and mixed incontinence and is based upon two general principles: - Frequent voluntary voiding to keep the bladder volume low - Training of central nervous system and pelvic mechanisms to inhibit urgency
Pelvic muscle exercises — (Kegel) exercises • - Used for urge, stress, and mixed incontinence. - Strengthen the muscular components of the urethral closure mechanism and are based on principles of strength - The basic recommended regimen is three sets of 8 to 12 slow velocity contractions sustained for six to eight seconds each, performed three or four times a week and continued for at least 15 to 20 weeks
BIOFEEDBACK • Biofeedback - supplement to bladder training or PMA - Randomized studies have shown their effects comparable to self-help booklets and verbal feedback
ADJUNCTIVE MEASURES • Scheduled toileting—take people to the toilet every 2 to 4 hours or according to their toilet habits. • Prompted voiding—check for dryness and encourage use of the toilet. • Improved access to toilets—use equipment such as canes, walkers, wheelchairs, and devices that raise the seating level of toilets to make toileting easier. • Managing fluids and diet—eliminate dietary caffeine (for those with urge incontinence) and encourage adequate fiber in the diet. • Disposable absorbent garments—use to keep people dry. • Urinary bladder catheters
Case 1 • 66 yr old male comes to your clinic complaining of chronic incontinence. He says he is so frustrated that he is nearly always wet. When he does go the bathroom, he has difficulty initiating the stream, and has some dribbling afterwards. His PMH is consistent with HTN, BPH and UTIs. He has no h/o prostate cancer or prostate procedures. He is taking OTC benadryl for cold and cough for 2 weeks.