Assessment and Management of Urinary Incontinence in the Clinic Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate Director for GRECC Clinical Programs Birmingham/Atlanta Geriatric Research Education and Clinical Center – July 27, 2006

Prevalence of Incontinence Severity Hannestad et al., 2000

UI - Treatment Seeking 1,104 Community Dwelling Older Adults with Urinary Incontinence on interview 38% 62% Burgio, et al: JAGS 42: 208, 1994

Reasons for Not Reporting Incontinence to Provider Not aware that can be treated Normal part of aging Personal problem (not medical) Embarrassed Fear of nursing home placement Afraid treatment requires surgery

Include Incontinence in the Review of Systems for all geriatric patients.

Patient Case 75 year old man Goes to the bathroom every 1-2 hours daytime and 3 times at night. About once a week, on the way to the bathroom, he can’t make it and wets his clothes. Evaluation? Diagnosis? Appropriate treatment?

Types of Incontinence Urge Stress Overflow Functional

Work-up of Incontinence History Physical Urinalysis Post-void Residual Volume

Incontinence History Type Do you leak urine during physical activity such as coughing, sneezing, lifting, or exercising? Do you get the urge to go and can’t make it without leaking? Onset Severity Frequency of leakage Need for absorbent products KEY POINT: The clinician should question the patient about these factors and identify those that may be causing incontinence symptoms.

Incontinence History Lower urinary tract symptoms Urgency, frequency, nocturia, dysuria, weak stream, straining to void, etc. Fluid intake – volume and type Previous treatments and effects on incontinence KEY POINT: The clinician should question the patient about these factors and identify those that may be causing incontinence symptoms.

Medical History Medical, neurological, history Surgical history Prostatectomy Review medications including OTC Habits (caffeine, tobacco, alcohol use) KEY POINT: The history should focus on activities that aggravate or worsen the urine loss along with gynecological and urological events from childbirth to surgery.

Physical Exam Brief Neurologic Exam Rectal (and Pelvic for women) Gait Lower extremity strength Cogwheel rigidity Sphincter tone and voluntary contraction Rectal (and Pelvic for women)

Urinalysis Bacteriuria Pyuria Glycosuria Hematuria KEY POINT: A urinalysis will rule out infection and can be done by dipstick or microscope. A urinalysis often includes tests to detect nitrates and leukocyte esterase. ADDITIONAL INFORMATION: (Glycosuria is also called glucosuria.)

Post-Void Residual Volume Measure amount of urine left in bladder after voiding. Ultrasound or catheter Normal: < 50 ml

Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation. Physical: hard stool in vault UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) PVR: 200 mL Diagnosis? Treatment Options?

Contributors to UI to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

Contributors to UI to Treat First Drugs Sedatives including alcohol ACE inhibitors (cough) Antipsychotics (pseudoparkinsonism) Diuretics (bad timing) Alpha Blockers – worsen stress UI Anticholinergics – incomplete emptying

Contributors to UI to Treat First Drugs and Diet – Caffeine & Fluids Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation. Physical: hard stool in vault UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) PVR: 200 mL

Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up Hx: Otherwise negative Physical: unremarkable UA: normal PVR: 45 mL Diagnosis? Treatment options?

First Line Treatments Medications Other treatments Anticholinergics Oxybutynin – generic, Ditropan XL, Oxytrol patch Tolterodine - Detrol Solifenacin - VESIcare Trospium - Sanctura Darifenacin - Enablex Alpha blocker for BPH Other treatments Behavioral training – try BEFORE or with drug

Least Invasive – Use First !! Behavioral Strategies Diet & Fluid Management PFM Training and Exercise Behavioral Approaches Bladder Training Biofeedback Weight Loss Bladder Diaries

Behavioral Treatment: Multi-component Program Pelvic floor muscle training Home practice of exercises Increase duration of contraction/relaxation over time Bladder Control Techniques Self-Monitoring w/ bladder diaries

When the Urge Strikes – Freeze and Squeeze Stop and stay still Squeeze pelvic floor muscles Relax rest of body Concentrate on suppressing urge Wait until the urge subsides Walk to bathroom at normal pace Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

When to Void Worst Time Best Time Worst Time Calm Period Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

Other Behavioral Strategies Stress Strategy Squeeze before you sneeze (or cough or lift) Post Void Dribbling Strategy Squeeze after voiding

RCT Comparing Behavior and Drug Therapy 197 older women with urge incontinence Randomized to 8 weeks of: Behavioral training (biofeedback) Drug therapy (oxybutynin) Placebo control Burgio et al, JAMA, 1998

Reduction of Incontinence

Patient Satisfaction with Treatment Burgio et al. JAMA. 1998; 280:1995-2000

Patient Case 85 year old woman Frequently leaks on the way to the bathroom Work up Hx: Aricept for dementia Physical: Frail, walks slowly, uses a walker UA: normal PVR: 85 mL Diagnosis? Treatment Options?

The Patient with Functional Limitations Avoid anticholinergic drugs in pts with dementia Facilitate functional status Mobility devices Physical therapy Bedside commode Urinal for men Prompted voiding – VERY effective Consider assistive devices.

Post-Prostatectomy Incontinence 65 yo had radical prostatectomy 1 year ago Leaks when he coughs, sneezes or lifts something heavy Wears a pad in the daytime, dry at night No problem making it to the bathroom Diagnosis? Treatment Options?

Behavioral Treatment of Post-Prostatectomy Incontinence 20 men; 55-87 years old Average 2 ½ years since surgery 8 weeks of biofeedback-assisted behavioral training 78.3% decrease in accidents (range of -12 – 100%) Burgio, et.al., J Urology, 1989

Behavioral Training for Post-Prostatectomy Incontinence Case Series of 27 men with persistent post-prostatectomy UI Taught pelvic floor muscle exercises without using biofeedback 56.6% reduction in leakage Meaglia et al. J Urol. 1990;144:674

Post-Prostatectomy Incontinence 65 yo considering radical prostatectomy Continent Read that 72% of patients reported incontinence persisting 1 year after surgery and 40% wearing pads What can he do to help prevent incontinence? Stanford, et.al. JAMA, 2000

Pre-Prostatectomy Muscle Training Burgio, Goode, et al, J Urol, 175:196; 2006

Reduction of Incontinence p=.090 p=.045 % Burgio, Goode, et.al., J Urology, 2006

Pre-Prostatectomy Muscle Training Median Time to Continence: Intervention Group - 3.5 months Control Group - > 6 month Number Needed to Treat to get 1 additional man out of pads at 6 months = 5 Burgio, Goode, et al, J Urol, 175:196; 2006

Summary - Work-up of Incontinence History Physical Urinalysis Post-void Residual Volume

Summary: Contributors to Incontinence to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

Urinary Incontinence Treatments Behavioral Treatments Pelvic Floor Muscle Exercises (Kegel) Bladder training Timed/Prompted voiding Bladder Control Techniques Biofeedback Medications Pessary Pelvic Floor Electrical Stimulation Magnetic Chair Urethral Bulking Agents Surgery

Current Studies at Bham/ATL GRECC MOTIVE - Combined medication and behavioral therapy for overactive bladder in men (VA Rehab R&D) ProsTech – Behavioral therapy with and without biofeedback and electrical stimulation for persistent incontinence in men after radical prostatectomy (NIH) COMBO - Combined medication and behavioral therapy for urge incontinence in women (VA Rehab R&D) ATLAS – Behavioral therapy or pessary or combined for stress incontinence in women (NIH) RUBI - Botox injections for refractory urge incontinence in women (NIH)

Contact Information Patricia Goode, MD pgoode@aging.uab.edu 205-934-3249 Kathryn Burgio, PhD kburgio@aging.uab.edu 205-558-7067 Ken Shay, DDS, MS kenneth.shay@va.gov 734-222-4325 http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=22318