Urinary Incontinence Donald R. Noll DO FACOI Edited by Edward Warren, MD, Chair Geriatrics Carolinas Campus, March 2012

GOAL To understand urinary incontinence, its types, its evaluation, and its treatment.

Learning Objectives Define urinary incontinence and how to uncover it. (slides 5 - 7) Discuss the neurology of urinary function. (slides 8 – 11) List the types of urinary incontinence. (slide 12) List causes of transient urinary incontinence. (slide 13) Discuss urge incontinence. (slides 14 – 16) Discuss stress incontinence. (slides 17 – 20) Discuss overflow incontinence. (slides 21 – 23) Discuss functional incontinence. (slides 24 – 25) Describe mixed urinary incontinence. (slides 26 – 27)

Learning Objectives Describe the elements of the H&PE related to urinary incontinence evaluation. (slides 28 – 31) Describe the use of a bladder diary. (slides 32 – 33) Discuss the use of post voiding residual urine volume and urodynamic testing. (slides 34 – 35) Describe nonpharmacological treatment of urinary incontinence and Kegel exercises. (slides 36 – 40) List and explain the medications useful for urinary incontinence. (slides 41 – 43) Discuss surgical treatment of urinary incontinence. (slide 44) Explain the use of vaginal pessaries for urinary incontinence. (slide 45) Discuss the use and risks of Foley catheters in urinary incontinence. (slide 46)

Urinary Incontinence Involuntary leakage of urine Under diagnosed and under-treated Ask about it. Patients often don’t mention it. ~ ⅓ community dwelling elders ~ ½ of hospitalized patients.

Risky Medications Loop diuretics – urgency Calcium channel blockers – detrusor contractility impairment, nocturnal diuresis NSAIDS – noctural diuresis Anticholinergics – bladder retention

Questions Do you ever leak urine when you don’t want to? Do you ever leak urine when you cough, laugh or exercise? Do you leak urine on the way to the bathroom? Do you wear pads in your underwear to catch urine?

Neurologic Input

Neurologic Input Beta 2 - Relaxes Detrusor Parasympathetic Response Stimulates Detrusor Contractions Relaxes the trigone and urinary sphincter Sympathetic Response Beta 2 - Relaxes Detrusor Alpha 1 - Contracts the trigone and urinary sphincter

During Urine Storage Bladder distention stimulates: Sympathetic outflow to the bladder Pudendal outflow to the urinary sphincter The above two functions are spinal reflexes. A region in the pons allows conscious increase in urinary sphincter activity.

During Voiding The pontine micturition center is stimulated. Parasympathetic outflow then leads to: Bladder contraction Sphincter relaxation

Types of Urinary Incontinence Transient Urge Stress Overflow Functional Mixed

Transient Incontinence Mnemonic: DIAPPERS D elirium I nfection A trophic urethritis / vaginitis P harmaceuticals P sychological (severe depression, psychosis) E xcessive Fluid output (diuretics, caffeine) R estrictive Mobility S tool Impaction

Urge Incontinence Abrupt onset or overwhelming desire to void. Can be precipitated by running water, going out in the cold or even trying to unlock the door to get into the house. Is characterized by leakage of moderate to large amounts of urine leakage.

Urge Incontinence The etiology: Uninhibited bladder contractions or detrusor overactivity Contributing factors or causes of this include: Age-related changes Disruption of CNS inhibitory pathways Bladder irritation by infection, inflammation, stones

Urge Incontinence Urge incontinence is often due to a combination of detrusor hyperactivity and impaired contractility These patients have urgency as well as an elevated post void residual volume.

Stress Incontinence Leakage of small amounts of urine when there is increased intra-abdominal pressure. This pressure overcomes the sphincter tone. The leakage occurs immediately. If delayed, it might be stress-maneuver-induced urge incontinence.

Stress Incontinence Caused by impaired urethral support from the pelvic musculature in women Worse in Multi-parous women Overweight women

Stress Incontinence Less commonly, can be due to sphincter incompetence from: Trauma and scarring or Mucosal atrophy in post-menopausal women With sphincter incompetence, the leakage is continuous and not solely with increased intra-abdominal pressure.

Stress Incontinence Stress incontinence does not generally respond well to drug treatment and is usually treated with muscle training or surgical approaches.

Overflow Incontinence This is continual leakage of urine or dribbling associated with incomplete bladder emptying. Due to Impaired detrusor contractility bladder outlet obstruction (BPH) Or both

Overflow Incontinence Post-void residuals (urine remaining in the bladder following micturition) are elevated. There are often stress incontinence type of symptoms when an intact sphincter is overwhelmed by the large bladder volume.

Overflow Incontinence Detrusor underactivity is the most common cause of overflow incontinence. Outlet obstruction from prostatic disease is the second most common cause of overflow incontinence in older men. Patient are in danger of renal failure due to back pressure into the kidneys harming glomerular function.

Functional Incontinence Due to functional or situational issues and often involves both urinary and fecal incontinence. Not an organic or anatomic cause Examples Limited mobility from arthritis Limited cognition from dementia

Functional Incontinence Treatment is pragmatic. If the bathroom is too far away, consider a bedside commode. Timed voidings, especially at night, helps avoid urgent situations.

Mixed Urinary Incontinence Often, an individual patient, especially older patients, have multiple factors contributing to their problem. An elderly man might have a functional impairment from a previous CVA, outlet obstruction from prostatic hypertrophy, detrusor overactivity and be on a diuretic which contributes to urinary urgency.

Mixed Urinary Incontinence Many patients have a MIXED picture Examples: Stress + Urge in women Functional + Urge in Dementia

Approach to a Patient: History Ask about volume and circumstances of urine loss. Does your entire bladder empty at once? Is your urine leaking continuously? Does your urine only leak when you cough or exercise? Do you feel as though you do not empty your bladder completely or have to go to the bathroom a second time to finish? Do you ever loose stool?

Approach to a Patient: History History questions Do you have a history of Prostate problems? Are you post-menopausal? How many children have you had? How big was your largest baby delivered vaginally? Did you tear or have to have an episiotomy with your deliveries?

Approach to a Patient Review Medical and Surgical History Have you ever had bladder or prostate surgery? Have you ever had a significant injury to your private area? Have you ever had low back problems or spinal surgery? Have you ever had a stroke?

Approach to a Patient Review drugs Physical exam-includes pelvic in woman A rectal in both men and woman Lab work based on symptoms but nearly also includes at least a urinalysis Bladder diary-helps to clarify details of the incontinence if not clear.

Instructions on Keeping a Bladder Diary Things to record The time Amount of urine you pass Whether you leaked urine Any special circumstances that may have made you leak

Example of a Bladder Diary

Approach to a Patient Post void residual urine volume Very helpful test Can be done with a bladder scan (ultrasound) in many places or with an in and out catheterization. Less than 50 ml of urine is considered normal but many feel the normal range for older patients should be up to 200 ml.

Approach to a Patient Urodynamic Testing Measure the volume and pressure in the bladder during filling and voiding Done by a urologist in office or hospital outpatient setting Not needed for all, do in Men considering an prostatectomy Women considering surgery Failed empiric medical treatment Considered the gold standard - invasive and costly.

Treatment: General Avoid Ethanol Weight loss Limit fluid intake at bedtime or when a bathroom will be inconvenient Control constipation

Treatment: Physical strengthening Kegel’s exercises Vaginal Weights Biofeedback Best in women with to strengthen pelvic floor muscles. These are especially beneficial in women with stress incontinence.

KEGEL Exercises FINDING THE RIGHT MUSCLES TO EXERCISE Squeeze muscles to try to stop the flow of urine when you are sitting on the toilet. If you can do it, you are probably using the right muscles. This is just a technique to FIND the muscles. Do not do your exercises regularly while you are urinating. Squeeze the muscles you would use if you were trying to stop passing gas. If you sense a "pulling" feeling, those are the right muscles for pelvic exercises. Don't tighten your abdominal muscles, or push down. Pretend you are sitting on a marble, and gently use your vaginal muscles (or, if you are a man, use your bowel muscles) to "lift" that marble up. It is more important to do the exercise correctly, than to use a lot of force.

KEGEL Exercises EXERCISES — After you have identified the correct muscles to squeeze, you can begin performing pelvic muscle exercises. Squeeze the muscles and hold for a count of 3, then relax for a count of 3. Perform a set of 10 to 15 repetitions each time you exercise and do a set of exercises three times each day.

Treatment: Behavioral therapy Toileting regimens for cognitively impaired Bladder training for cognitively intact: This involves timed voiding while awake based upon smallest time intervals in a bladder diary and relaxation techniques to suppress urge in between times. Biofeedback may help with bladder training: sometimes done by occupational therapists.

Drug Therapy Anticholinergics-inhibit action of acetylcholine and reduce bladder spasms. Oxybutynin (Ditropan)* Tolterodine (Detrol)* Trospium (Santura) Solifenacin (Vesicare) Darifencin (Enablex) Anticholinergics can lead to urinary retention and must be used with care, especially if the patient also has outlet obstruction. * These can lead to confusion in the elderly.

Drug Therapy Alpha 1 receptors in the trigone area promote contraction. Imipramine has a dual alpha agonist and anticholinergic properties and might be useful in some patients with mixed incontinence (Urge, Stress). Alpha 1 blockers are often used with prostate disease in an effort to help relax the urinary sphincter (Overflow) -- tamsulosin

Drug Therapy Bethanechol stimulates cholinergic receptors and increases detrusor tone. It is useful in urinary retention. Oral Estrogen-increases the number and responsiveness of alpha receptors: beneficial. Oral estrogen/progesterone regimens have been shown to worsen incontinence. Intravaginal / Topical products are useful in some studies, not in others.

Surgical Treatments Multiple surgical approaches are available depending on the type of incontinence. Surgery works best for stress incontinence or to repair outlet obstruction. Procedures range from peri-urethral collagen injections to bladder suspension.

Other Treatments: Vaginal Pessaries Help in women with stress incontinence, vaginal prolapse, weak pelvic floor. Patients must understand the need for removal and cleaning of a pessary and they need to be fitted by an experienced health care provider. Fitted exactly like a diaphragm.

Other Treatments Indwelling catheters (Foleys): These carry a high risk of infection and are best used for short term only. Intermittent catheterization is theoretically safer but requires a motivated patient and caregivers. Men needing long term Foleys should have a suprapubic cystostomy. Otherwise, the catheter will eventually cut through the length of the penile shaft on the dorsum.

References Bladder Diary. National Kidney and Urologic Disease Information Clearinghouse. 3 Information Way Bethesda, MD 20892–3580. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/diary.pdf