Urinary Incontinence

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Urinary Incontinence

• ACC Conference
• May 30, 2007
• John Meier

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Definition

• Urinary Incontinence is the involuntary loss of
  urine that is objectively demonstrable and a
  social or hygienic problem.
• International Continence Society
• Overactive Bladder is defined as urinary urgency,
  with or without urge incontinence, usually with
  urinary frequency and nocturia.
• International Continence Society

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Epidemiology

• Prevalence
• By Sex
• Women
• Young Adult 20-30
• Middle Aged 30-40
• Elderly 50
• Men
• Rates are 1/3 of those of women by age group
  until age 80 at which time rates converge
• By Type
• Women
• 50 Stress
• Then Mixed Stress-Urge
• Least common is Urge but becomes more common as
  woman ages
• Men
• No specific delineation, Prostate disease impacts
  assessment

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Epidemiology

• Additional Facts
• 13 million Americans affected, 11 million of whom
  are women
• 1 in 4 women ages 30-59 have experienced an
  episode of urinary incontinence
• 50 or more of the elderly persons living at home
  or in long term-care facilities are incontinent.

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Epidemiology

• Annual Direct Costs in 1995 Dollars
• estimated as 16.3 billion, including 12.4
  billion (76) for women and 3.8 billion (24)
  for men.
• Costs for community-dwelling women (8.6 billion,
  69 of costs for women) were greater than for
  institutionalized women (3.8 billion, 31).
• Costs for women over 65 years of age were more
  than twice the costs for those under 65 years
  (7.6 and 3.6 billion, respectively).
• The largest cost category was routine care (70
  of costs for women), followed by nursing home
  admissions (14), treatment (9), complications
  (6), and diagnosis and evaluations (1).
• Costs were most sensitive to changes in
  incontinence prevalence, routine care costs, and
  institutionalization rates and costs.

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Anatomy and Physiology

• Pontine Micturition Center
• Peripheral Micturition Center Bladder Reflex Arc
  of S2-S4
• Filling (150-200 cc) sympathetic reflex--body
  relaxes, sphincter tightens, detrusor inhibited.
• Further filling(350-500 cc) somatic (voluntary)
  tone increases (external sphincter)
• 5. Voiding detrusor contraction with coordinated
  reflex ? somatic and
  sympathetic tone,
• ? parasympathetic action (M3 receptors)

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Risk Factors

• Women childbearing, vaginal delivery,
  episiotomy, estrogen depletion, GU surgery
• Men Prostate related pathology
• Both Sexes
• Age
• Changes to Detrusor control overactive
• Decreased Bladder capacity
• Decreased Urinary flow rates
• Decreased Renal Clearance
• Changes in Fluid Balance
• More Medications
• Functional and Cognitive Impairment
• Comorbid Diseases CHF, DM, Depression, CNS
  insults

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Categories

• Acute - DRIP
• Urge Detrusor Hyperreflexia, Detrusor
  Instability
• Stress Weakened Sphincter Function
• Overflow Incomplete Bladder Emptying
• Mixed Urge and Stress
• Functional Physical or Cognitive Impairment
• Rare Extraurethral Fistula, Spinal Cord Injury

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Acute Urinary Incontinence

• DRIP
• Drugs, Delirium
• Restricted Mobility, Retention
• Infection, Impaction (fecal), Inflammation
  (atrophic urethritis, vaginitis)
• Polyuric States (CHF, DM, Hypercalcemia)

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Urge

• Definition Involuntary leakage accompanied by or
  immediately preceded by urgency.
• Attributes abrupt urgency with moderate to large
  leakage
• Etiology detrussor over activity (uninhibited
  bladder contractions)
• Sequelae of
• Age
• Interrupted CNS inhibitory pathways
• Bladder irritation
• More common in older adults

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Stress

• Definition involuntary leakage on effort,
  exertion, sneeze or coughing.
• Attributes most common cause in young women,
  second most common in older women and in men
  after TURP or radical prostatectomy
• Etiology Intra-abdominal pressure exceeds the
  muscular strength of the sphincter
• Impaired urethral support
• Intrinsic sphincter deficiency

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Overflow

• Definition dribbling and/or continuous leakage
  associated with incomplete bladder emptying due
  to impaired detrussor contractility and/or
  bladder obstruction.
• Attribute typically small volumes, elevated
  postvoid residual, associated urinary stream
  abnormalities
• Etiology
• Detrusor Under activity 5-10 of elderly,
  detrusor muscle changes, peripheral neuropathy,
  damage to efferents
• Obstruction Men (prostate), Women (s/p
  corrective surgery, cystocele)

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Mixed

• Definition involuntary leakage associated with
  urgency as well as exertion, effort, sneezing or
  coughing
• Attribute most common cause in women
• Etiology overlap of
• Detrusor over activity
• Impaired urethral sphincter function

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Work-Up I

• Screening Question
• Do you ever lose control of your urine and wet
  yourself?
• Not Are you incontinent?

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Work-Up II

• History
• Specific Symptoms
• Acute/Chronic/Recurrent
• Daily Pattern
• Stress or Urge Pattern
• Precipitants
• Polyuria
• Obstructive Symptoms
• Hesitancy
• Decreased Stream
• Dribbling
• Irritative Symptoms
• Dysuria
• Frequency
• Previous Treatment
• Pelvic Surgery or Radiation
• Medications
• Adrenergic or Cholinergic Modulators
• Narcotics

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Work-Up III

• Physical Exam
• General Cognitive and Physical function
• Neurologic sacral dermatomes (S2-4)
• Assess UMN vs. LMN
• Rectal sphincter tone, impaction, prostate
• Pelvic atrophic changes, cystocele, prolapse
• Palpable Bladder

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Work-Up IV

• Laboratories (Initial)
• Chemistries
• Urinalysis Glucose (DM), Hematuria (UTI, Stones,
  etc), Nitrites/LE (UTI)
• Urine Culture
• B12 levels in the elderly

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Work-Up V

• Diagnostic Testing
• Voiding Diary
• Volumes (day and night) with associated
  symptoms/comments
• Post-void Residual
• Agency for Healthcare Research and Quality
  recommend measurement of PVR in all patients
  presenting with UI
• Cut-off is 100 ml
• If greater than 100 ml, evaluate for
  retention/obstruction
• Urodynamic Testing

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Urodynamic Testing

• Urodynamic tests try to measure nerve and muscle
  function, pressures around the bladder, flow
  rates and other factors in an attempt to explain
  the urinary incontinence.
• Cystometry catheter placed in the bladder and
  bladder progressively filled to point of 1) urge
  to void is sensed, 2) volume at which urge is
  uncontrollable and 3) any involuntary contraction
  is sensed
• Multichannel Cystometrogram in a laboratory
  intra-abdominal pressures are measured with
  rectal or vaginal probe which allows more precise
  measurement of detrusor pressure.
• Uroflowmetry measure urine flow rates.
• Pure Stress Incontinence 91 sensitive, 51
  specific
• Pure Urge Incontinence 73 sensitive, 55
  specific

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Urodynamic Testing

• Cochrane Review 2007 Urodynamic investigations
  for management of urinary incontinence in
  children and adults.
• Question does urodynamic testing 1. improve
  clinical outcomes, 2. alter clinical decision
  making and 3. is one urodynamic test better and
  addressing points 1 and 2.
• 52 potential studies but only 3 small trials
  involving 184 met the inclusion criteria and only
  two of the three yielded any useful data.
• Findings of 128 women (no men or children), those
  investigated with urodynamic testing were more
  likely to receive active treatment with drugs or
  surgery
• Recognize the need for a large definitive trial
• At the present time, there are no clear
  guidelines for the role of urodynamic testing.

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Management

• Treatment is based upon the type of incontinence,
  its causes and patient capabilities
• Pelvic Muscle Rehabilitation
• Kegel Exercises younger women, 30-80 times per
  day for 8 weeks
• Biofeedback in conjunction with Kegel Exercises
• Vaginal Weight Training 15 min, bid, 4-6 weeks
• Pelvic Floor Electrical Stimulation in
  conjunction with Kegel Exercises

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Management

• Behavioral Therapies
• Bladder Training resist the urge and gradually
  expand intervals between voiding
• Toileting Assistance routine and schedule
  voiding
• Surgical Therapies
• Bladder Neck suspension
• Sling Procedure
• Minimally invasive Needle Vaginal Suspension
• Bulking injections

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Management

• Medications
• Anticholinergics
• Oxybutynin (Ditropan) not recommended for the
  elderly
• Tolterodine (Detrol) most frequently prescribed
  as extended release 4 mg tablet po qday
• OPERA trial and OBJECT trial favor extended
  release oxybutynin for efficacy and tolterodine
  for fewer side effects
• Side Effects dry mouth, constipation,
  somnolence
• Anti-muscarinic (M3 receptor antagonist)
• Darifenacin (Enablex)
• Solifenacin (Vesicare)
• Side Effects dry mouth and constipation
• Estrogen
• Topical Estrogen 0.5 mg bid for 2 wks then once a
  week
• Estradiol Ring replaced every 90 days
• Estradiol tablet q day for 2 weeks and then one
  tablet q week
• Topical estrogen most likely more effective

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Management

• Urge
• Behavioral Treatment scheduled voids, pelvic MM
• Lifestyle
• Protective Pads
• Bladder MM relaxants (anticholinergics with
  antimuscarinic activity) oxybutynin,
  tolteridine, trospium, solifenacin
• Stress
• Behavioral Treatment
• Estrogen (topical) increase number/responsiveness
  of alpha receptors, potentiates alpha agonists
• Alpha-Agonists imipramine (Mixed UI), duloxetine
• Refer pessary, surgery (highest cure rates
  slings, bladder neck suspension)
• Overflow
• If BPH alpha-1 antagonist (terazosin) , 5-alpha
  reductase inhibitor (finesteride)
• Refer further evaluation, surgery
• Functional
• Treat underlying infection, comorbidity
• Commode, urinal, living space adaptations

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Management

• For those that are chronically incontinent
• Scheduled toileting every 2-4 hours
• Prompted Voiding check for dryness and encourage
  toilet use
• Improved access to toilets mobility aides and
  raise level of toilets
• Managing fluids and diet eliminate caffeine,
  fluid management and fiber for regular bowel
  movements
• Disposable absorbent garments keep people dry

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Overactive Bladder

• Definition includes urinary urgency with or
  without urge incontinence, urinary frequency
  (voiding eight or more times in a 24-hour
  period), and nocturia (awakening two or more
  times at night to void).
• Attributes International Continence Society
  classifies overactive bladder as a syndrome for
  which no precise cause has been identified, with
  local abnormalities ruled out by diagnostic
  evaluation
• Etiology disorders of the lower urinary tract,
  neurologic conditions, behavioral factors such as
  caffeine intake, and a variety of commonly
  prescribed drugs
• Ouslander, JD, Management of Overactive Bladder,
  New England Journal of Medicine, 2004 350786.

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Overactive BladderAssociated Conditions

• Urinary Tract Impairment
• Bladder Abnormalities or inflammation
• Impaired Bladder Contractility
• Obstruction
• Urinary Tract Infection
• Women
• Estrogen Deficiency
• Sphincter Weakness
• Men
• Prostate Enlargement

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Overactive BladderAssociated Conditions

• Neurologic Disorders
• Alzheimers Disease, Multi-infarct Dementia
• Cervical or Lumbar Stenosis or Disk herniation
• Diabetic Neuropathy
• Multiple Sclerosis
• Nerve Injury
• Parkinsons Disease
• Spinal Cord Injury
• Stroke

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Overactive BladderAssociated Conditions

• Systemic Conditions
• Abnormalities of Arginine Vasopressin
• Congestive Heart Failure
• Diabetes
• Sleep Disorders
• Venous Insufficiency
• Functional Behavioral Problems
• Constipation
• Excess intake of Caffeine, Alcohol, Polydipsia
• Impaired Motility
• Psychologcial Disorders

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Overactive BladderAssociated Conditions

• Medications
• Anticholinergic Agents
• Calcium Channel Blockers
• Cholinesterase Inhibitors
• Diuretics
• Narcotics

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Urinary IncontinencePatient Resources

• http//www.niapublications.org/agepages/urinary.as
  p
• Alliance for Aging Research
• Bladder Health Council, c/o American Foundation
  for Urologic Disease
• National Association for Continence
• Simon Foundation for Continence

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Sources

• Annual Direct Cost of Urinary Incontinence,
  Leslie Wilson, PhD, Jeanette S. Brown, MD, Grace
  P. Shin, PharmD, Kim-Oanh Luc, PharmD and Leslee
  L. Subak, MD, Obstetrics Gynecology
  200198398-406
• Incontinence, Urinary Comprehensive Review of
  Medical and Surgical Aspects, Michael
  OShaungnessy, MD, eMedicine, February, 2007.
• Management of Overactive Bladder, Joseph G.
  Ouslander, M.D. N Engl J Med 2004 3502213, May
  20, 2004.
• Overactive Bladder When and How to Treat, David
  Mobley, MD, Neil Baum, MD, Resident and Staff
  Physician, April 2005, 9-20.
• Urinary Incontinence, Thomas Finucane MD, James
  Wright, MD Principles of Ambulatory Medicine
  Sixth Edition, Lippincott, Williams Wilkins,
  2003, pp 727-743.
• Urinary Incontinence, UpToDate,2007.
• Urinary Incontinence in Elderly Women Findings
  From the Health, Aging, and Body Composition
  Study R A. Jackson, MD , E Vittinghoff, PhD,
  Obstetrics Gynecology 2004104301-307
• Urinary Incontinence Guide to Diagnosis and
  Management, National Guideline Clearinghouse,
  http//www.guideline.gov/