2. 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

3. Prevalence of Incontinence
Severity
Hannestad et al., 2000

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

5. 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

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

7. 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?

8. Types of Incontinence
Urge
Stress
Overflow
Functional

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

10. 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.

11. 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.

12. 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.

13. 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)

14. 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.)

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

16. 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?

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

18. 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

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

20. 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

21. 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?

22. 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

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

24. 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

25. 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

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

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

28. 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

29. Reduction of Incontinence

30. Patient Satisfaction with Treatment
Burgio et al. JAMA. 1998; 280:

31. 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?

32. 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.

33. 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?

34. Behavioral Treatment of Post-Prostatectomy Incontinence
20 men; 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

35. 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

36. 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

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

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

39. Pre-Prostatectomy Muscle Training
Median Time to Continence:
Intervention Group 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

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

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

42. 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

43. 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)

44. Contact Information
Patricia Goode, MD
Kathryn Burgio, PhD
Ken Shay, DDS, MS