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Learning Objectives. Urinary Incontinence: A Hidden Challenge. Urinary Incontinence: Meeting the Clinical Challenge. Urinary Incontinence (UI)

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4 – 4:40pm

Urinary Incontinence:

Meeting the Clinical Challenge

SPEAKER Michelle Eslami, MD

Presenter Disclosure Information

►Michelle Eslami, MD: No financial relationships to disclose.

The following relationships exist related to this presentation:

Off-Label/Investigational Discussion

►In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

Urinary Incontinence: A Hidden

Challenge

Michelle S. Eslami, MD, FACP

Professor of Medicine/Geriatric Medicine David Geffen School of Medicine at UCLA Department of Medicine, Division of Geriatrics

Learning

 

Objectives

Review

 

basic

 

physiology

 

of

 

micturation

Distinguish

 

between

 

potentially

 

treatable

 

and

 

persistent

 

causes

 

of

 

urinary

 

incontinence

Perform

 

a

 

basic

 

evaluation

 

on

 

a

 

patient

 

with

 

urinary

 

incontinence

Identify

 

management

 

strategies

 

appropriate

 

for

 

the

 

individual

 

patient

 

with

 

urinary

 

incontinence

Urinary Incontinence (UI)

 Involuntary loss of urine

 Not normal aging but more common with aging

 3x more common in women than men until age

80yrs when 50% report UI

 50 - 75% of incontinent persons never voluntary

describe their symptoms to physicians

Screening

 AHCQ recommends routine screening all frail

older men and women.

 ACOVE 3 recommends screening all vulnerable

elders at the time of initial evaluation

 3 Incontinence Questions (3IQ)-help distinguish

urge from stress UI with sensitivity of 75% and specificity of 77%

(2)

Case

68 yo woman comes into the office c/o urgency and frequency of urination with occasional

involuntary loss of urine.

What other information would you want to know?

Risk Factors Associated with UI

 Forceps delivery/vaginal delivery> C-section

 Hysterectomy

 Benign Prostatic Hyperplasia (BPH)

 Obesity

 Diabetes, stroke, COPD, CHF, neurologic disorders,

 Estrogen depletion

 Impaired functional, cognitive and/or mobility status

 Medications (eg.,estrogen, diuretics)

 Environmental barriers

Evaluation

 Duration, frequency, severity, timing

 Associated symptoms, precipitants

 Bowel and sexual function, parity, status of other medical conditions, medications, functional status

 GU history (e.g. previous anti-incontinence surgery)

Evaluation

 Bladder record

- timing and volume (drops, small, medium and soaking) of continent and incontinent

episodes

- associated activities (coffee drinking, exercise)

- hours of sleep

Medications that May Affect Continence

Types of Medication  Sedative/hypnotics  Alcohol • Anticholinergics - antipsychotics - antidepressants - antihistamines  Narcotic analgesics

Potential Effects on Continence Sedation, delirium, immobility Frequency, urgency, sedation Urinary retention, overflow incontinence, fecal impaction, delirium Urinary retention, sedation, fecal impaction

Medications that May Affect Continence

Types of Medication

 - Adrenergic antagonists

 - Adrenergic agonists

 Calcium channel blockers

 Potent diuretics

 ACE inhibitors

 Cholinesterase inhibitors

Potential Effects on Continence Urethral relaxation stress UI Urinary retention

Nocturnal incontinence Polyuria, frequency, urgency

Drug-induced cough Urinary urgency and UI

(3)

Case

 She is G3P3, has a BMI 32, and drinks 3 cups

of coffee a day.

 She notes occasional dysuria and has nocturia

x2. She has had loss of urine w/coughing . She denies any constipation.

 She has Type 2 DM and takes metformin and

lisinopril. No pelvic surgeries.

What are some type(s) of urinary incontinence she could have?

Peripheral Nerves in Micturition

Lower Urinary Tract Dysfunction

Failure to store Hyperactive or Overactive bladder Incompetent sphincter Failure to empty Underactive bladder Obstruction

Types of Persistent Incontinence

 Urge

- more common in older women

 Stress

- more common in younger women

 Mixed

- most common overall in women

 Overflow

- most common in men

Potentially Reversible Causes of Incontinence*

 Delirium

 Infection, urinary (symptomatic)

 Atrophic urethritis/vaginitis

 Pharmaceuticals

 Psychological disorders

 Endocrine disorders/excessive urine production

 Restricted mobility

 Stool impaction

*Resnick NM. Med Grand Rounds 1984; 3:281-290.

Urge Incontinence

“I can’t get to the bathroom on time.”

 An abrupt desire to void (urgency) that cannot be suppressed

 Usually thought to be idiopathic

 Other causes - bacterial cystitis, bladder tumor, bladder stones, atrophic vaginitis/urethritis, stroke, Parkinson’s disease, dementia

 Especially in frail elderly, may have detrusor hyperactivity with impaired contractility (DHIC)

(4)

Stress Incontinence

“I leak urine when I cough, laugh, sneeze or when running.”

 Increases in intra-abdominal pressure

overwhelm urethral sphincter

 Hypermobility of bladder neck and urethra (85%

cases) - aging, hormonal changes, multiple childbirths, hysterectomy, pelvic surgery

 Intrinsic sphincter deficiency (15% cases) -previous pelvic/anti-incontinence surgery, pelvic radiation, trauma, neurogenic disorders

Functional Incontinence

 Does not involve lower urinary tract

 Result of physical (e.g. arthritis, stroke) and/or cognitive impairment

Overflow Incontinence

“I dribble urine most of the time.”

 Overdistension of the bladder caused by: - Bladder outlet obstruction –

Stricture, pelvic prolapse, BPH, cystocele, fecal impaction

- Impaired detrusor contractility –

Diabetes, MS, lumbar spinal stenosis, spinal cord injury, medications

Case

 What do you look for on Physical Exam?

Physical Examination

 Mental status  Mobility

 Evidence of volume overload

 Neurologic - evaluation of lumbosacral nerves, focal findings, peripheral neuropathy

 Pelvic exam - atrophic vaginitis, urethral hypermobility, cystocele, uterine prolapse, rectocele, masses

 Rectal - sphincter tone (active/resting) to assess integrity of sacral plexus (S2-S4), perineal sensation, fecal

impaction, masses

Stress Test

 Best done when bladder is relatively full, in standing position with relaxed perineum

 Patient asked to vigorously cough once while a

pad is held underneath perineum or on the floor

 In women, positive test sensitive but not specific for impaired sphincter function

(5)

Post-void Residual Volume (PVR)

 Perform within 5 minutes of voiding

 Catheterization or bladder ultrasound - PVR < 50cc - adequate bladder emptying - PVR < 100cc - adequate bladder emptying >

65 years

- PVR 100-200cc - inadequate emptying vs normal

- PVR > 200cc - refer

Basic Laboratory Evaluation for UI

 Calcium, glucose

 BUN/Cr - especially if PVR > 200cc

 Urinalysis and culture

Urodynamic Testing

Not routinely recommended

Mainly used when surgery is being

considered

Case

 She has no mobility or mental status abnormalities.

 Monofilament testing is normal

 Pelvic exam reveals vaginal atrophy, bulging of the anterior vaginal wall when asked to cough, no leakage

 Rectal sphincter tone is intact

 PVR - 65cc

 Fasting blood sugar level of 87 with HgbA1C

6.5%. Urinalysis was normal. What is your assessment ?

Case

 Overweight

 Vaginal atrophy

 Pelvic prolapse

 Mixed UI-urge>stress

What is your treatment plan?

Management of UI Overview

 Behavioral therapies

 Pharmacological therapies

 Surgery

 Pessaries

 Periurethral bulking agents

 Garments and pads

(6)

Behavioral Interventions

 Reduce amount and timing of fluid intake (e.g. stop at 7pm

 Avoid bladder stimulants such as caffeine, alcohol

 Use diuretics judiciously and not before bedtime

 Elevate legs before bedtime in patients with edema

 Make toilet easier to get to - suggest bedside commode

 Lose weight if obese

Patient Dependent Behavioral Interventions for

Incontinence

Caregiver Dependent Behavioral Interventions

for Incontinence

Anticholinergic Therapy for Urge UI-Overactive

Bladder Syndrome (OAB)

Oxybutynin - Immediate release - Extended release - Transdermal patch - Topical gel Tolterodine - Immediate release - Long acting Trospium Darifenacin Solifenacin Fesoterodine

Potential Adverse Effects of

Antimuscarinic Drugs

Iris/Ciliary Body= Blurred Vision Lacrimal Gland= Dry Eyes

Salivary Glands= Dry Mouth

Heart= Tachycardia Stomach= Dyspepsia Colon= Constipation Bladder= Retention CNS Dizziness Somnolence Impaired Cognition

Adapted from Abrams P et al. The Overactive Bladder- A Widespread and Treatable Condition. 1998.

Beta 3 adrenergic agonist

 Mirabegron improves bladder storage capacity

 25-50mg/day

 Side effects-tachycardia, increased BP, constipation

(7)

Medications to Treat Stress Incontinence

Medication Improvement

Pseudoephedrine * 11% (ARR)

Duloxetine *

Estrogen Up to 25 %

(topical cream, Estring®)

Imipramine ** ?

* not FDA approved for this indication ** dual alpha agonist/anticholinergic activity

Case

 Lifestyle modifications

Wt loss, Reduce/eliminate caffeine

 Behavioral therapies

Kegel exercises, bladder retraining, scheduled toileting

 Pharmacological therapies

Topical estrogen cream, oxybutynin, discontinue lisinopril

Case

 She comes back reporting that she got a dry

mouth from the oxybutynin and stopped it. She is loosing weight and the topical etsrogen cream is helping.

What other options can you give her?

Percutaneous Tibial Nerve Stimulation (PTNS)

 Used for urge incontinence, OAB,

nonobstructive urinary retention

 Electrode placed at medial aspect of ankle leads to neuromodulation thru tibial nerve to S2-S4 plexus

 Cochrane review of 1-3 times/wk x 12wks

- 55% improvement vs 21% sham

Botulinum toxin B

 Direct injection into the urethral and bladder skeletal and smooth muscle results in reversible chemical denervation

 Treatment for overactive bladder due spinal cord injury, MS

 Studies have shown complete continence in

32% to 86% of patients with mean duration of 6 months

InterStim System

(Sacral Neuromodulation)

 Useful for patients with intractable symptoms of urge incontinence, urgency-frequency, or retention.

 Temporary, percutaneous sacral nerve test

stimulation (S 3) and if > 50% improvement over 1-4 weeks--permanent device with implanted lead and neurostimulator, hand held

programmer

(8)

Stress Incontinence

Procedural Interventions

Periurethral Bulking Agents –

Stress Incontinence

 Injection of glutaraldehyde cross-linked bovine collagen or carbon-coated beads under cystoscopic guidance into an incompetent periurethral area

 UTI and transient urethral irritation are most common side effects

 Complications - urgency, UI, urinary retention

Davila GW, et al. Int J Fertility 2004;49(3):101-12

Pessary Use

 Genital prolapse (uterine or vaginal), cystocele

 Stress incontinence

 Older women who are at risk for surgery

 Women who have had previous surgery for

stress incontinence

Criteria for Further Evaluation

 2 or more UTI’s within 12 months

 History of previous anti-incontinence surgery or radical pelvic surgery

 Symptomatic pelvic prolapse, pelvic pain

 Abnormal PVR > 200cc*

 Hematuria in the absence of infection

 Failure to respond to an adequate therapeutic

trial or uncertainty in diagnosis

*except in known BPH and those taking relevant meds

Conclusions

 Urinary incontinence is common, especially with

increasing age

 Usually multifactorial causes

 Persistent types include failure to store (urge/stress) and/or failure to empty (overflow) and mixed

 Once type(s) identified then choose appropriate

intervention(s)

 Improvement rates with intervention are high with nonsurgical management

Resources for Patients

The Simon Foundation

www.simonfoundation.org

National Association for Continence www.nafc.org

The AGS Foundation for Health in Aging

(9)

References

Abrams P, Chapple C, Khoury S, et al. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol 2009; 181:1779.

Alhasso, AA, Glazener, CMA Pickard, R, N'Dow, JMO. Adrenergic drugs for urinary incontinence in adults. Cochrane Database of Systematic Reviews 2007; Issue 1. Art. No.: CD001842. DOI: 10.1002/14651858.CD001842.pub2. Braker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress

incontinence. N Engl J Med 2006; 354:1557.

Chaplet C, Huller V, Gabriel Z, Dooley JA. The effects of antimuscarinic treatments in overactive bladder: a systematic review and meta-analysis. Eur Urol 2005; 48:5.

Dmochowski RR, Blaivas JM, Gormley EA, et al. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol 2010; 183:1906

DuBeau, CE, Kuchel, GA, Johnson, T, et al. Incontinence in the frail elderly. In: Abrams, P, Cardozo, L, Hoary, S, Wien, A. Incontinence, 4th ed. 4th International Consultation on Incontinence. Paris: Editions 21, for Health Publications Ltd, 2009; p.961.

Jones C, Hill J, Chapple C, Guideline Development Group. Management of lower urinary tract symptoms in men: summary of NICE guidance. BMJ 2010; 340:c2354.Management Recommendations. In: Abrams, P, Cardozo, L, Khoury, S, Wein, A. Incontinence, 4th ed. 4th International Consultation on Incontinence. Paris: Editions 21, for Health Publications Ltd, 2009; p.1774.

North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause 2007; 14:355

Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321 Qaseem,A,DallasP,Forciea MA,etalClinical Guideline Committee of American College of PhysicanS.

AnnInternMed.2014:161:429-40.

Steers WD. Pathophysiology of overactive bladder and urge urinary incontinence. Rev Urol 2002; 4 Suppl 4:S7. Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J

References

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