Urinary incontinence
Urinary incontinence is a common condition especially affecting elderly females. It is still
considered to be a “geriatric giant”, posing challenges in management. This article describes
how an accurate assessment and categorisation into different types of incontinence can guide
the clinician towards various management options available.
Dr Rajeev Mammachan Trust Registrar, West Wales Hospital, Carmarthen, SA31 2AF Dr Abhaya Gupta* Consultant Elderly Care, West Wales Hospital, Carmarthen, SA31 2AF Dr Kiran AgarwalConsultant Gynaecologist, Rohilkhand Medical College, Bareilly, India
*email guptaabhaya@hotmail.com
Urinary incontinence affects around 3⋅5 million people in the UK.1 Prevalence of urinary incontinence ranges from 15% among relatively healthy community dwelling older adults to 65% among frail older adults.2 The prevalence is twice as high in women as in men. Urinary incontinence is an under-reported problem with many sufferers coping in silence. Potential consequences of urinary incontinence include significant functional decline, impaired quality of life, frailty and institutionalisation.3 Older people with incontinence are more likely than continent people to have a fall or a fracture4 and more likely to be admitted to hospital or a nursing home.5
Unmet needs
Despite the high prevalence, few women seek help from health-care professionals. Moreover the treatment provision in both primary and secondary care is variable. In a cross-sectional survey of adult females attending a primary care practice in the UK, nearly
half had urinary incontinence but only a minority sought help.6 Even amongst the nearly 1 in 10 women with moderate/severe urinary incontinence, only half had sought help.6 The National Service Framework for Older People 20017 required the establishment of continence services for older people by April 2004. However, the UK National Audit of Continence care for Older People8 across England, Wales and Northern Ireland showed deficiencies in organisation of services, assessment and management of urinary incontinence.
Classification
Urinary incontinence can be categorised into three major groups:
• Urge incontinence is involuntary leakage often associated with urgency. Overactive Bladder Syndrome (OAB) is urgency, frequency with or without incontinence
• Stress incontinence results from poor urethral sphincter function (primary urethral incompetence)
• Overflow incontinence
• Mixed incontinence is both urge and stress incontinence.
Urge incontinence
Urge incontinence occurs in one in four adults over the age of 65 years. In about one third of women sufferers, and around a half of all men with incontinence, the cause is urge incontinence.
Common causes are
inflammation or irritation within the bladder or when the brain centres that inhibit bladder contractions are impaired by neurological conditions, drugs, or metabolic disorders.
Urge incontinence can occur when mobility is impaired making it difficult for patients to get to the toilet in time. This condition is sometimes referred to as “functional incontinence”.
Stress incontinence
Stress incontinence presents with involuntary urine loss in the presence of a relatively incompetent urethral sphincter. (eg. when the patient laughs, coughs or sneezes). Causes include vaginal child birth and pelvic surgery such as
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hysterectomy in women or prostate surgery in men.
Overflow incontinence
Overflow incontinence occurs because of urine retention with bladder distension related to bladder outlet obstruction that results in progressive bladder distension. It usually manifests as dribbling. Common causes include prostatic enlargement in men, and uterine fibroids or cystocele in women.
Assessment
Assessment begins with a detailed history of the patients’ symptoms including any provoking factors.
It is also important to ask how the condition is affecting their life. An accurate voiding diary facilitates quantification, classification and characterisation of urinary incontinence. Short voiding diaries of 48–72 hours have been shown to be just as reliable and valid as traditional seven-day diaries. NICE recommends a diary for a minimum of 3 days.9
General examination should assess mobility and mental status. The abdomen should be examined for palpable bladder or other masses. Rectal examination, to assess for constipation and in men, prostatic hypertrophy. In women, vulva and vagina should be examined for atrophic vaginitis or prolapse. Urethral sphincter response to cough reflex should be evaluated during pelvic examination to enable exclusion of stress incontinence.
Perineal sensation and reflexes, and neurological examination of the lower limbs, should be performed. People who have stress incontinence may lose urine during coughing, whereas patients who have intact perineal reflexes exhibit tightening of the anal sphincter during coughing.
Bedside measurement of post void residual volumes is helpful in the clinical diagnosis of overflow incontinence. Volumes >150 ml in older adults suggest inadequate bladder emptying and volumes >200 ml indicate urinary retention. Investigations are shown in Box 1. Box 2 shows drugs causing incontinence.
Always rule out transient causes such as delirium, infection, medication, psychological, endocrine, metabolic, poor mobility and stool impaction.
Referral to a specialist may be needed in certain circumstances.10 (Box 3).
Management
Urge incontinence
First line management is general and includes lifestyle measures as well as bladder retraining. Second line would be treatment with antimuscarinic drugs such as oxybutynin and tolterodine. Third line management would include surgical procedures such as sacral nerve stimulation (rarely used).
Stress incontinence
First line management is again bladder retraining as well as pelvic floor exercises. Second line is treatment with medications such as duloxetine, alpha-adrenergic agonists and/or oestrogen. Third line would be surgical procedures (most effective).
Overflow incontinence
First line management is treatment with medications such as alpha blockers and 5-alpha reductase inhibitors. Second line is surgical procedures (eg. surgery for benign
Urology
GM | Midlife and Beyond | March 2010
Box 1:
Investigations
Urine dipstick, culture, sugar, red blood countBlood urea, creatinine, electrolytes, glucose, calcium Ultrasound abdomen (if obstruction or incomplete emptying)
Cystometry and urodynamic studies—not routine.
Box 2:
Medications
affecting continence
Anticholinergics Narcotics Sedatives DiureticsCalcium channel blockers Antidepressants
Anti-parkinsonian drugs Antipsychotics.
Box 3:
Indications of
referral to specialist
Complex history with pain or recurrent infection
Neurological deficit Pelvic masses Haematuria Urinary retention
Stress incontinence where surgery contemplated.
The first line of therapy in all cases should be non-pharmacological management. In patients with urge incontinence the mainstay is behaviour modification, to suit the individual patient. Caregiver dependent toileting protocols are more appropriate in dependent or cognitively impaired patients. Adaptive equipment and assistive appliances may help efficient toileting and reduce incontinent episodes.
Limiting fluid intake to 1⋅5 litre daily may reduce symptoms. Caffeine should be avoided as it can act as a mild diuretic. Referral to a continence advisor is useful to ensure provision of the most suitable form of daytime and night time protection (pads and garments).
Bladder retraining
Bladder retraining aims to suppress urinary urge and to increase the intervals between voiding. The retraining regimen sets target voiding intervals, initially around 1⋅5–2 hours. It is recommended by NICE for a minimum of 6 weeks as first line treatment to patients with urge or mixed incontinence.9 Clinical studies have reported incontinence cure rates of 44– 90% using bladder retraining alone.11,12 However, the main
Pelvic floor exercises
This appears to be an effective treatment for women with genuine stress incontinence or mixed urge and stress incontinence.13 Bladder retraining is often combined with exercises to strengthen the pelvic floor muscles as this can help urinary urgency.14 A wide range of pelvic muscle exercise regimens have been reported but programmes need to be tailored to the needs of patients.
Pharmacotherapy
Common drugs and the level of evidence is shown in Table 4. Antimuscarinic drugs can reduce detrusor muscle contractions and increase bladder capacity. Side effects such as delirium, cognitive impairment, orthostatic hypotension, falls and cardiac arrhythmias mandate caution in the use of these agents in older adults.15 SIGN guidelines16 recommend a trial of treatment to patients with significant urgency or urge incontinence having excluded urinary retention. Large meta-analysis of the most commonly used antimuscarinic drugs have clearly shown these drugs provide significant clinical benefits.17 More research is needed to decide the best drug for first, second orwww.gerimed.co.uk
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GM | Midlife and Beyond | March 2010
third line treatment.17 Optimal treatment needs to be individualised considering patients comorbidities, concomitant medications and the pharmacological profile of drugs. Treatment should be reviewed to ascertain continuing need.
Oxybutynin is recommended by NICE9 as a first-line therapy in urge incontinence. Side effects such as dry mouth, constipation, blurred vision cause a limited tolerability especially in elderly patients. The modified release oxybutynin XL retains efficacy of standard release preparation with 40% fewer side effects.18 A transdermal patch is also available.
T o l t e r o d i n e i s a n antimuscarinic drug with more selective action on bladder muscle with less side effects.19 Although more expensive than oxybutynin, it has fewer withdrawal rates allowing treatment of a greater number of patients. It is also available as an extended release preparation.
The antidepressant imipramine is not licenced for OAB mainly due to side effects but has shown to improve symptoms.
Trospium is an effective drug in several randomised trials with improvements in clinical as well as quality of life.20 Compared with oxybutynin, withdrawal rates are lower.21 Moreover oxybutynin is most likely to cause deterioration in cognition especially in the elderly.
Newer antimuscarinic drugs include solifenacin,22 darifenacin, fesoterodine and propiverine. Results from the STAR22 and VENUS23 trials showed solifenacin improved symptoms and quality of life in OAB patients.
Other drug treatments include: flavoxate, desmopressin and oestrogens. Intravaginal oestrogens are useful in postpartum females with vaginal atrophy. Local oestrogen ointments may alleviate OAB symptoms. Desmopressin is helpful in reducing nocturia and can improve quality of life but hyponatraemia is one of the main clinically important side effects.24
Duloxetine, a selective serotonin and noradrenaline reuptake inhibitor, increases sphincter contractility via the stimulation of pudendal motor neuron
alpha1 adrenergic and serotonin2 receptors. It can be used for the treatment of moderate to severe stress incontinence in women; it may be more effective when used as an adjunct to pelvic floor exercises. NICE9 does not recommend its routine use in stress incontinence. SIGN guidelines16 recommend a 4 week trial in moderate/severe cases.
The selective alpha blockers like alfuzosin, doxazosin, indoramin, prazosin, tamsulosin and terazosin relax smooth muscle in benign prostatic hyperplasia producing an improvement in obstructive symptoms in overflow incontinence. The side effects are orthostatic hypotension, dizziness, tiredness, nasal congestion and erectile dysfunction. There is a lack of good quality evidence for use of drugs for overflow incontinence.
The 5-alpha reductase inhibitors—finasteride and dutasteride—are effective treatments for prostatic enlargement. Patients who have overflow incontinence resulting from a hypotonic or atonic bladder may benefit from medications with cholinergic agonist activity such as bethanechol.
Conclusion
Urinary incontinence is frustrating for the patient and physician. It is common, under-reported and a significant cause of disability in the elderly population. Urge incontinence can be treated successfully in some patients, but the low therapeutic index and frequent side effects limit patient compliance. Stress incontinence can be improved but not eliminated by pharmacological treatment. Overflow incontinence resulting from bladder outlet obstruction
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Box 4:
Common drugs and level of evidence
Drugs in OAB Level of evidence Grade of
recomendation Oxybutynin 1 A Tolterodine 1 A Trospium 1 A Solifenacin 1 A Darifenacin 1 A Desmopressin 1 A
Drugs in stress incontinence
Duloxetine 1 B
Level 1–Evidence from randomised trails Grade A–Based on at least one randomised trial Grade B–Based on well conducted clinical studies)
can be managed successfully. In a nursing home population due to polypharmacy and comorbidity, drugs may be contraindicated and behavioural strategies more beneficial than drug treatment.
We have no conflict of interest References
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