Urinary Incontinence

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Urinary Incontinence

• By Karen Hanisch, Mary Ann Jakowicz, Stephanie
  Orth, and Heather Tietjen

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Definition

• Urinary incontinence is the unintentional leakage
  of urine at inappropriate times. What does a
  person with UI look like?

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Vulnerable Populations

• Is a problem across the lifespan, including
  persons above age 5 years.
• Women have a higher incidence than men
• 41 ratio ages below 60 years
• 21 ratio ages above 60 years
• Incidence increases with age

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Vulnerable Population

• Co-morbid diseases
• Medications
• Obesity

• Status post hysterectomy
• Pregnancy and Child birth
• Physical disability two times more likely
• Increases 50 with sleep disturbances
• Men-Post-prostatectomy

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Co-Morbidity

• COPD-increased intra-abdominal pressure with
  coughing
• Hip fracture-limited mobility
• Parkinsons-limited mobility and neurological
  impairment
• Fecal impaction-pressure/irritation to bladder

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UI and Chronic Illness

• CVA
• Dementia
• Multiple Sclerosis
• Various Tumors
• Spinal Cord injuries

• Peripheral Vascular Insufficiency
• Prostate Enlargement
• Heart Failure
• Diabetes

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Medications

• Anticholinergics
• Antidepressants
• Antipsychotics
• Sedative/hypnotics
• Antihistamines
• Nervous system depressants
• Narcotics

• Alcohol
• Ca channel blockers
• a- and ß-adrenergics
• Diuretics
• Caffeine

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Classifications of UI

• Stress
• Urge
• Mixed
• Overflow
• Functional

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Stress Incontinence

• Failure to store urine due to urethral sphincter
  incompetence and hypermobility of bladder neck
• Risk factors
• Increased parity
• Difficult vaginal birth/prolonged labor
• Chronic cough
• Chronic straining at stool
• History of heavy lifting
• Pelvic surgery
• Obesity
• Estrogen deficiency

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Urge Incontinence (Overactive Bladder)

• Associated with strong urge to void
  characterized by urgency, frequency, nocturia,
  urge/leakage with hearing running water/cold
  air/clothing removal at toilet/rushing to get to
  bathroom

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Mixed Incontinence

• Symptoms of two or more forms of UI, most
  commonly stress and urge.

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Overflow Incontinence

• Failure of bladder to empty completely R/T
  urethral obstruction or impaired bladder
  contractility
• Bladder overdistention
• Dribbling
• Frequency
• Diminished urinary stream
• Sensation of incomplete voiding

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Functional Incontinence

• Loss associated with factors that interfere with
  access to a toilet such as physical, cognitive,
  or motivational impairment

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Prevalence

• Studies yield various results
• used different populations
• different criteria to define incontinence

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Prevalence of Types of Incontinence

• Stress incontinence proportionately more
  incontinence among younger women
• Over active bladder (OAB) more common in women
  after age 60

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Prevalence in Geriatrics

• Overall about one half of the homebound and
  institutionalized elderly are incontinent
• 25-30 of community-dwelling, ambulatory,
  non-homebound women over 60 years
• 10-15 of community-dwelling, ambulatory,
  non-homebound men over 60 years.
• Over 40 of postmenopausal women

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Prevalence in Younger Women

• 10-30 of women aged 15-64 years
• One study reported 47 for women between 20-49
  years
• Prevalence in pregnancy 23-67, postpartum
  prevalence ranges from 6-31

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Prevalence in Younger Men

• 1-5 of men aged 15-64 years
• 10 of children (especially boys) over age 5
  years experience bedwetting
• 1 of adolescents over age 16 years

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Prevalence of Those Seeking Medical Care

• Fewer than 50 percent seek medical care
• Over 80 can be cured or improved with treatment
• Myths
• Incontinence is a normal result of aging or
  having children
• Nothing can be done about it
• I dont want surgery

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Implications of Urinary Incontinence

• Medical, Psychosocial, and Economic implications
• associated with decubitus ulcers, urinary tract
  infections, sepsis, renal failure, and increased
  mortality
• loss of self-esteem, restricted social and sexual
  activities, depression, and dependence on
  caregivers
• Often a key factor in Nursing Home placement
• Associated with increased risk of falls

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Cost of Urinary Incontinence

• Overall economic burden of Urinary Incontinence
  is estimated at 17.5 billion annually
• 2 of health care costs in the U.S.
• Over 1,000 per person per year for pads

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Costs of Urinary Incontinence

• Treatments
• medications
• surgery
• mechanical devices
• Associated Morbidity hospitalizations and
  treatment
• Supplies
• absorbant pads
• foley catheters

• Supplementary costs
• laundry costs
• caregiver time
• social isolation, dependency, institutionalization
  
• social stigma
• hygienic problems

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Theoretical Model-Health Belief Model

• Perceived Susceptiblity-opinion of getting
  condition
• Perceived Severity-Opinion of seriousness of
  condition
• Perceived Benefits-opinion of efficacy of action
  to reduce seriousness
• Perceived Barriers-opinion of costs of action
• Cues to Action-strategies to implement action
• Self-Efficacy-confidence in ability to take action

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Pathophysiology

• Occurs when the urethra is not able to maintain
  closure against the force of pressure transmitted
  from the bladder
• Causes not yet totally understood
• ? Incompetent Detrusor Muscle or Urethral
  Sphincter Mechanism
• Transient causes account for 1/3 of cases among
  community dwelling patients and 1/2 of
  hospitalized
• Vaginal delivery R/T neuropathy, connective
  tissue damage, muscle injury

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Pathophysiology

• Detrusor Mechanism-detrusor muscle, pelvic
  nerves, spinal cord, cerebral centers
• Subcortical centers-bladder relaxation to
  fill-Medications or disease may diminish ability
  to postpone urination
• Neural impulses transmitted through the spinal
  cord and pelvic nerves to the detrusor muscle
  when urination desired-cholinergic activity
  causes detrusor contraction and bladder emptying
• Prostaglandin receptors-prostaglandin inhibitors
  impair detrusor contractions

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Pathophysiology of Detrusor Mechanism

• Prostaglandin receptors-prostaglandin inhibitors
  impair detrusor contractions
• Calcium channel dependent-calcium channel
  blockers impair contractions

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Pathophysiology of the Sphincter Mechanism

• Requires proper angulation and positioning
  between the urethra and the bladder
• Alpha-adrenergic activity causes urethral
  sphincter contraction
• alpha-adrenergic agonists can strengthen
  sphincter contractions
• alpha-blocking agents impair sphincter closure
• Beta-adrenergic agents cause sphincter relaxation
• Beta-adrenergic blocking agents interphere with
  relaxation

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Purpose of the Assessment

• To determine the cause of the incontinence
• To detect related urinary tract and nervous
  system pathology
• To evaluate the patient comprehensively with
  regard to mental and physical status,
  comorbidity, medications, environment, quality of
  life, and availability of resources
• Simple measures are often effective and some
  conditions may not be curable

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Assessment Goals

• Identify transient (easily reversible) causes of
  incontinence to implement effective treatment
• Identify conditions that require special
  evaluation or referral
• Classify UI based on symptoms to initiate proper
  treatment

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Holistic Evaluation

• Cognitive/Functional
• Psychological
• Medical/Surgical history and ROS
• Voiding History
• Physical Examination
• Evaluation of Bladder Function (testing)
• Quick Assessment (DIAPPERS)

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DIAPPERS Assessment in the Elderly

• D-delirium
• I-infection
• A-atrophic urethritis/vaginitis
• P-Psychiatric disorders
• P-Pharmaceuticals
• E-excess urine output
• R-restricted mobility
• S-Stool impaction

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Interventions for UI

• Medications (Ditropan, Detrol, collagen injection
  therapy)
• Behavioral Therapy
• Diet Modification
• Pelvic Muscle Rehabilitation
• Mechanical Devices
• Hormone replacement therapy
• Surgery
• Supportive Interventions (Absorbent products)

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Goals

• Correcting faulty habits of frequent urination
• Improving ability to control bladder urgency
• Prolonging of voiding intervals
• Increasing bladder capacity
• Reducing episodes of incontinence
• Building patient confidence

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Medications

• Ditropan-(oxybutynin)
• FDA approved in 1972 for OBD
• 2.5-5 mg TID-QID-49 for 60 tabs
• Available in syrup-55 for 300 mL
• High adverse event profile
• Pregnancy Risk Category B
• Transdermal patch
• Ditropan XL
• FDA approved 2002
• 5-15 mg QD-74-88 for 30 tabs

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Medications

• Detrol (tolterodine tartrate)
• FDA approved in 1998
• 1-2 mg BID-84-89 for 60 tabs
• Pregnancy risk category C
• Lower adverse event profile than Ditropan
• Detrol LA
• FDA approved in 2001
• 2-4 mg QD-75-78 for 30 caps

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Behavioral Therapy

• Bladder Diary
• Bladder training-Requires cognitively intact and
  motivated patient capable of toileting and
  adhering to voiding regimen
• Habit training and prompted voiding
• Urinary schedules
• Toileting programs
• Smoking cessation
• Maintain normal bowel movements

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Diet Modification

• Fluids and foods that function as bladder
  irritants and precipitate urgency and bladder
  contractions
• Caffeine
• Chocolate
• Soft drinks
• Alcohol
• Artificial Sweetener
• Hot Spicy foods
• Orange Juice
• Watermelon
• Tomatoes
• Restricted Fluid Intake in evenings
• Maintain Normal BMI

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Pelvic Muscle Rehabilitation

• Kegel exercises-exercises to strengthen pelvic
  muscles and involve tightening and relaxing
  vaginal and rectal muscles
• Expected short-term cure/improvement rate may
  reach 70

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Mechanical Devices

• Pessaries
• Clean Intermittent Catheterization
• Electrical Stimulation
• Silicone Sheath Drainage System-Transfix
• Artificial Urinary Sphincter-treatment of choice
  for post-prostatectomy
• Male bulbourethral sling

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Hormone Replacement

• Reduces symptoms of urinary incontinence for
  post-menopausal women

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Surgery

• Consideration and trial of all non-surgical
  options first.
• Pubovaginal slings
• Endoscopic bladder neck suspensions
• Bladder neck suspensions using bolsters
• Periurethral injections
• Artificial sphincter implants
• Artificial bladder grafts
• Studer Pouch-for bladder cancer
• Clam ileocystoplasy-bladder augmentation for
  bladder instability

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Application of Theory

• Define and personalize risk
• Specify personal consequences of risk and
  condition
• Define action to take (how, where, when) and
  positive effects to be expected
• Identify and reduce barriers through reassurance,
  incentives and assistance
• Provide how-to information and reminders
• Provide training and guidance for action

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Outcome Measures

• Complete absence of UI or decreased incidence
  (times or amount) of UI
• Absence of nocturia
• Improved social activity and self-esteem
• Improved sexual relations
• Increased productivity-work and home
• Reassessment within 30 days with follow-up PRN
  and yearly

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Further Research

• Improved public awareness of treatment options
• Incorporation of routine screening, assessment,
  and diagnosis of patients across the lifespan
• Further studies in prevention, physiology, and
  treatments
• ???

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Resources and Services

• Healthcare Providers
• US Agency for Health Care Policy and Research
  (AHCPR)
• International Continence Society
• Association of Womens Health Obstetric and
  Neonatal Nurses (AWHONN)
• www.overactivebladder.com (Detrol LA)
• Local incontinence support groups (New
  Beginnings-Avera McKennan)