Urinary Incontinence Ben Blaine Dec 3, 2015

Definition • involuntary loss of urine that represents a hygienic or social problem to the individual

• A symptom/sign, not a disease (i.e. diverse etiologies) • Common in the elderly, but not part of “normal aging” • 20% of home-care patients • 25% of older hospitalized patients • 50% of nursing home residents

• Estimated that 50-70% of women with urinary incontinence fail to seek medical evaluation and treatment because of social stigma

• 2009 survey of women in a managed care population found that the prevalence of undiagnosed urinary incontinence was 53% in the preceding year

Neuronal Control of Micturition • Distention of the bladder relays information to the pontine storage center in the brain, which triggers efferent impulses to enhance urine storage: • Sympathetic input via hypogastric nerve to:

Loading... • B3 (inhibitory) receptors in detrusor

• A1 (stimulatory) receptors in bladder neck • Parasympathetic input via somatic, pudendal, and sacral nerves to nicotinic AChR (stimulatory) in striated muscle of distal urethra and pelvic floor

• When signalling to the brain exceeds a certain

threshold, the pathways above are inhibited and parasympathetic outflow via pelvic nerves is

• Stress

4 types

• Urge • Mixed • Overflow • (some add functional as 5th type)

Stress Incontinence • Leakage (usually small amount) with increased intraabdominal pressure (e.g. exertion, coughing, laughing)

• 2 mechanisms:

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• Urethral hypermobility (due to insufficient support from

pelvic floor musculature and vaginal CT) • Chronic pressure (e.g. chronic cough, obesity) • Trauma (e.g. vaginal deliveries) • Intrinsic sphincteric deficiency (usually more severe and challenging to treat) • Caused by neuromuscular damage (e.g. multiple pelvic surgeries)

Urge Incontinence • Urge to void accompanied by leakage (variable amounts)

• Usually caused by detrusor overactivity (i.e. unhibited contraction during bladder filling) from: • Central neurologic disorders (e.g. spinal cord injury, stroke, NPH) • Autonomic dysfunction (e.g. Parkinson’s) • Detrusor instability/irritation (e.g. bladder cancer, atrophic vaginitis) • Idiopathic

Overflow Incontinence • Constant dribbling in the setting of incomplete bladder emptying • Symptoms include weak stream, hesitancy, frequency, nocturia • May or may not sense bladder fullness

• When bladder is very full can have stress leakage or trigger bladder contractions, causing symptoms of stress or urge incontinence

• Causes: • Detrusor underactivity (anticholinergics, age, fibrosis, peripheral neuropathy (e.g. DM)) • Outlet obstruction (fecal impaction, fibroids, BPH, advanced pelvic organ prolapse, overcorrection in pelvic floor surgery)

Functional Incontinence • Causes include: • Impaired mobility (including barriers like

bedrails) • Inability to recognize need to void or how to use toilet (e.g. dementia)

• Timed voiding can be helpful (q2H is generally recommended)

• Lifestyle modifications such as decreasing caffeine intake are also important

Acute Urinary Incontinence: DIAPERS • Delirium • Infection • Atrophic vaginitis • Pharmaceuticals or Psychological

• Excessive urine output (eg, hyperglycemia, hypercalcemia)

• Reduced mobility or Retention • Stool impaction

History Timeline vs of chronic) • • Severity and (acute quantity urine lost and frequency of incontinence • episodes Context (urge vs stress vs constant) • UTI symptoms • • Duration of the complaint and whether problems have been Concomitant fecal incontinence, constipation, or pelvic worsening organ prolapse • Caffeine, alcohol, and overall fluid consumption • • Triggering factors or events (eg, cough, sneeze, lifting, Obstetrical history (grand-multiparity, forceps, largebending, feeling of urgency, sound of running water, sexual babies) • activity/orgasm) PMHx/PSHx • Medications • • Constant intermittent Effect versus on quality of life urine loss and provocation by minimal increases in intra-abdominal pressure, such as movement, changes in position, and incontinence with an empty bladder

• Associated frequency, urgency, dysuria, pain with a full bladder,

PMHx • Chronic cough • Chronic obstructive pulmonary disease (COPD) • Congestive heart failure • Diabetes mellitus

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• Obesity • Connective tissue disorders • Postmenopausal hypoestrogenism • CNS or spinal cord disorders • Chronic UTIs

PSHx • Pelvic procedures,

particularly incontinence correction, pelvic floor reconstruction, or hysterectomy

• Urologic procedures • Spinal and CNS surgery

Medications • Cholinergic or anticholinergic drugs • Alpha-blockers and alpha-agonists • Estrogen replacement • Beta-mimetics • Sedatives • Antidepressants and antipsychotics • Muscle relaxants • Diuretics

Physical Exam • Assess cognitive/functional status if functional incontinence is suspected

• Abdo exam for distended bladder or hernia • Focused Neuro exam (lower extremity sensory and motor; ideally also perineal/perianal sensation and rectal tone)

• Pelvic floor exam • At minimum, visually check for prolapse to rule out severe case • Ideally do full speculum and bimanual exam

Investigations • Bladder diary • Urinalysis to check for blood and WBCs • Avoid urine culture unless patient has UTI symptoms (treating otherwise asymptomatic bacturia is ineffective at improving incontinence)

• PVR by bladder scanner (or post-void catheterization) • PVR < 200 makes overflow incontinence very unlikely If concerned or inadequate response to initial therapy specialists may do:

• Bladder stress test (directly visualize whether urine is expelled

Treatment • Aim is improved quality of life so carefully weigh risk/benefits of each treatment option

• When pads are used, ensure they’re changed regularly to avoid contact dermatitis

• Always address contributing factors first (medication, fecal impaction, etc)

• Options: • • • • •

Lifestyle modifications Pelvic floor (Kegal) exercises Bladder training Topical vaginal estrogen Pessaries

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Initial Treatments

Lifestyle Modification • Weight loss (especially for stress incontinence) • Dietary changes • Reduce alcohol and caffeine • Limit fluid to 2L/day • Reduce qHS fluid consumption if patient has nocturia

• Smoking cessation: smoking increases risk of UI, but no studies have evaluated whether smoking cessation decreases UI

Pelvic Floor Muscle Exercises (Kegal Exercises) • Useful for both stress and urge incontinence • Basic regimen = 10 contractions x 10 seconds x TID x 15-20 weeks

• Patients with poor motivation or poor muscle isolation can be helped by: • Pelvic PT • Vaginal weighted cones • Biofeedback

• Cochrane systematic review showed women performing Kegal exercises are significantly more likely to report cure than those with no treatment or inactive control

Bladder Training • Best for urge incontinence • Method: • Patient voids at regular intervals corresponding to the shortest

voiding interval identified using a voiding diary • Urgency between voids is controlled with distraction or relaxation techniques • Once patient can go 2 days without leakage, the time between voids is increased • The interval is gradually increased until patient voids q3-4 hrs without leakage

• Be sure to let patients know that success can take up to 6

weeks so they don’t lose motivation due to initial lack of

Topical Vaginal Estrogen • Useful for stress or urge incontinence • Acts by reducing vaginal atrophy • Options include creams, rings, and tablets • Can take up to 3 months to observe benefit • Systemic estrogen absorption is low. • Cochrane systematic review of 4 RCTs showed: (Cody et al. 2012)

RR 0.74, 95% CI 0.64-0.86

Stress Incontinence Treatments

Stress Incontinence: Pessaries • Improve urethral angle and support

• ATLAS randomized trial divided 446 women with stress incontinence into 3 treatment groups: • Pessary • Behavioral therapy (Kegal exercises and other strategies) • Combination of the above

• Main outcome was complete absence of incontinence symptoms • At 3 months pessary was significantly worse (33, 49, 44%)

Stress Incontinence: Pharmacotherapy • Duloxetine (SNRI) • Showed promise in early studies, but recent systematic review found no difference from placebo (Shamiliyan et al. 2012)

• Alpha-adrenergic agonists (e.g. phenylpropanolamine) act by stimulating urethral

contraction • No longer recommended because only mildly efficacious compared to placebo and high rate of adverse effects (Malallah and Al-Shaiji, 2015)

• Imipramine (TCA) • Not recommended due to insufficient evidence and significant side effects (Zinner et al. 2004)

Stress Incontinence: Surgery • E.g. sling procedure, Burch procedure • High success rates, but given invasiveness, surgery should only be used if initial therapies fail

Urge Incontinence Treatments

Urge Incontinence: Pharmacotherapy • 2 main types: • Antimuscarinics (first line) • Beta-adrenergics

• Combination of medication and behavioural therapy is more effective than either alone (Burgio et al. 2000)

Anti-Muscarinics • darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium • They have similar efficacy (about 10% success rate), but slightly different sideeffect profiles (Shamliyan et al. 2012)

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• In general, S/E include: dry mouth, constipation, blurred vision for near objects,

tachycardia, drowsiness, and decreased cognitive function (watch out in patients with dementia!)

• Improvement may take up to 4 weeks, and it may take up to 12 weeks to reach full efficacy

• Monitor for evidence of urinary retention and check PVR if needed

Beta-Agonists (Mirabegron) • Activates B3 receptors in detrusor muscle, leading to relaxation

• Similar clinical efficacy to anti-muscarinics • Must monitor for urinary retention • May cause hypertension • Meta-analysis found a non-significant trend towards

cardiac arrhythmia (OR 1.67, 95% CI 0.95-2.92) (Cui et al. 2014)

Mixed Incontinence Treatments

Mixed Incontinence Treatment • Initial therapies are lifestyle modifications, Kegal exercises, and bladder training • If these fail determine whether stress or urge symptoms predominate • For urge-predominant treat like urge incontinence • For stress predominant treat surgically, typically with mid-urethral sling • But success rates are lower than for pure stress incontinence

Overflow Incontinence Treatments

Overflow Incontinence Treatments

• Depends on etiology:

• Bladder outlet obstruction: • Generally surgical management • Pessary can help obstruction caused by cystocele

• Detrusor underactivity: • Discontinue all medications that relax detrusor • Some success with sacral nerve stimulation • Otherwise manage with clean intermittent catheterization

Indications for Referral to a Specialist • Associated abdominal or pelvic pain in the absence of UTI

• Gross or microscopic hematuria with risk factors for malignancy in the absence of UTI

• Abnormal physical exam findings (e.g., pelvic mass,

pelvic organ prolapse beyond the hymen, vesicovaginal fistula, urethral diverticula)

• New neurologic symptoms in addition to incontinence • History of pelvic reconstructive surgery or pelvic irradiation

• Persistently elevated postvoid residual volume, after

Urinary Incontinence in Men • Rate approximately half that of women • Men less likely to seek care • History, P/E, and U/A are generally sufficient to guide initial therapy • Most common etiologies are BPH and prostate surgery (e.g. TURP, radical prostatectomy)

• Initial therapy consists of addressing contributing factors (e.g. medications), lifestyle modifications, and Kegal exercises

• If these fail: • Urge incontinence: alpha-blocker or anti-muscarinic • Stress incontinence: duloxetine (only 1 RCT in men and it shows only mild efficacy) (Filocamo et al. 2007)

Key points • UI can be divided into stress, urge, mixed, overflow (and functional)

• Important historical elements include surgical and obstetrical history, cognitive/functional status, lifestyle factors, and concurrent conditions

• Initial therapy consists of addressing

contributing factors, lifestyle modification, and pelvic floor exercises

• Bladder training, topical vaginal estrogen,

pessaries, systemic pharmacotherapy, and surgery can be attempted in more difficult

SAMPS 1.

Name the 4 types of incontinence

2.

What is the innervation for bladder contraction?

3.

What are the two most common causes for urinary incontinence in men?

4.

Contraindications for use of anti-cholinergics for incontinence?

• Tariq, S. H., and M. M. Wilson. "Geriatric incontinence--selected questions."Missouri medicine 104.5 (2006): 440-445.

References

• Parker, William P., and Tomas Lindor Griebling. "Nonsurgical

Treatment of Urinary Incontinence in Elderly Women." Clinics in geriatric medicine 31.4 (2015): 471-485.

• Thirugnanasothy, Subashini. "Managing urinary incontinence in older people."Bmj 341 (2010).

• Frank, Christopher, and Agata Szlanta. "Office management of urinary incontinence among older patients." Canadian Family Physician 56.11 (2010): 1115-1120.

• Lee, S. Y., D. Phanumus, and S. D. Fields. "Urinary incontinence. A

primary care guide to managing acute and chronic symptoms in older adults." Geriatrics55.11 (2000): 65-71.