URINARY INCONTINENCE

URINARY INCONTINENCE - Pamela I. Ellsworth, MD
BASICS
DESCRIPTION
Involuntary loss of urine from the bladder
• May occur while asleep or awake
• Amount of urine lost may vary greatly.
• Condition comes to medical attention when it is perceived to be a social and/or hygiene problem by the patient or caregiver
• System(s) Affected: Renal/Urologic; Skin/Exocrine
• Synonym(s): Transient incontinence; Urge incontinence; Overflow incontinence; Stress incontinence; Overactive bladder
GENERAL PREVENTION
• Routine Kegel exercises after childbirth
• Regular pelvic examination of female patients to detect pelvic pathology
EPIDEMIOLOGY
• Predominant age: Elderly
• Predominant sex: Female > Male
Prevalence
• 1 in 20 people in the US
• Women (community dwelling)
- Aged 65 years: 10%
- Aged >65 years: 35%
• Men (community-dwelling)
- Aged 65 years: 1.5%
- Aged 65: 1.5%
• Institutionalized men and women aged >65 years: 30-50%
ALERT
Geriatric Considerations
This problem is most commonly seen in older patients.
Pediatric Considerations
Neurogenic, congenital, and idiopathic overactive bladder also occurs in children.
RISK FACTORS
• Increasing age
• Female sex/estrogen deficiency
• Prostatic hypertrophy (males)
• Multiparity (females)
• Dementia
• Stroke
• Diabetes
• Spinal cord injury
• Multiple sclerosis
• Obesity
• Hysterectomy
• Vaginal childbirth
• Functional impairment
Genetics
Unknown
ETIOLOGY
• Urgency urinary incontinence (UUI)
- Idiopathic
- Neurogenic (stroke, dementia, Parkinson disease, multiple sclerosis)
- Inflammatory (infection, tumors, stones, diverticula)
• Stress urinary incontinence (SUI)
- Genuine (types 0, 1, 2): pelvic floor muscle weakness, urethral hypermobility
- Intrinsic sphincteric deficiency (type 3): Post transurethral resection of the prostate (TURP), post radical prostatectomy, prior urethral/pelvic surgery
- May occur during pregnancy
• Mixed (MUI): Stress plus urge incontinence
• Overflow incontinence
- Bladder outlet obstruction (benign prostatic hyperplasia, urethral stricture, pelvic prolapse)
- Neurogenic bladder (diabetes, spinal cord injury, multiple sclerosis)
• Transient/reversible: Delirium, infection, atrophic urethritis/vaginitis, excessive urine output, restricted mobility, stool impaction (DIAPPERS)


DIAGNOSIS
SIGNS AND SYMPTOMS
• Involuntary loss of urine
• May be associated with urinary urgency, or exertion
History
The diagnosis is often made by history.
Physical Exam
• Men: Palpate abdomen (for distended bladder), digital rectal exam (for prostatic hypertrophy/cancer/fecal impaction), and neurologic exam
• Women: Palpate abdomen (for distended bladder), pelvic exam (for gynecologic pathology), rectal exam (for fecal impaction), and neurologic exam
• Assess lower extremities for edema.
• Helpful to ask the patient to reproduce the activities (e.g., coughing, sneezing, laughing) that result in loss of urine
• Urinary diaries over 2-3 days
TESTS
Urodynamic evaluation may be indicated in select patients.
• Uroflowmetry: Poor flow rate may be indicative of obstruction or poor detrusor contractility.
• Cystometrogram: May show abnormal sphincter pressure or bladder function
• Pressure flow: High pressure with low flow may indicate obstruction.
• Video: Visualization to rule out diverticulum, reflux
• Electromyogram: Assesses sphincteric activity
Lab
• Urinalysis: R/0 glycosuria (diabetes), proteinuria (glomerular disease), white blood cells (infection), red blood cells (tumor), or bacteria (infection)
• Urine culture: Positive if urinary tract infection
• Drugs that may alter lab results
- Diuretics (low urine specific gravity)
- Antibiotics (negative urine culture)
• Disorders producing abnormal lab results generally contribute to the problem of incontinence.
Imaging
May be indicated in some patients
• Renal ultrasound to rule out hydronephrosis
• Bladder scan or ultrasound postvoid residual: May show increased residual urine (normally 50 mL); ultrasound can assess bladder wall thickness and rule out bladder stones
• Voiding cystourethrogram: May show bladder and/or urethral pathology
Pathological Findings
• Relate to the primary cause of incontinence
• Intrinsic urinary sphincter disorder
• Prostatic hypertrophy
• Neurogenic bladder
• Bladder tumors
DIFFERENTIAL DIAGNOSIS
• Urinary tract infection
• Vaginal discharge (women)
• Urethral discharge (men)
• Medication effect (diuretics, alcohol, caffeine, anticholinergics, -agonists, calcium channel blockers, -adrenergic blockers, antiparkinson drugs, angiotensin-converting enzyme inhibitors)
• Polyuria (diabetes, excessive water intake)
• Bladder tumor
TREATMENT
STABILIZATION
Outpatient evaluation and management
GENERAL MEASURES
Identification and specific treatment of all primary conditions relating to urinary incontinence (e.g., urinary tract infection, bladder tumors, prostatic hypertrophy, diabetes)
• Pelvic floor muscle therapy (PFMT) should be offered as 1st line therapy to all women with SUI, UUI, or MUI.
• Females with SUI or MUI combination of PFMT/bladder training may be more effective than PFMT alone in the short term.
• PFMT in men with post RRPX incontinence
• Biofeedback/behavioral training
• Behavioral therapy in men with incontinence
• Intermittent catherization if overflow incontinence
• Incontinence pads
• Indwelling catheterization (selected patients); rarely
• Condom catheters (male patients)
• Treatment for fecal impaction
• Weighted vaginal cones and electrical stimulation appear to be equally effective for women with SUI, but these may have side effects.
Diet
• In situations in which access to bathroom facilities is limited, patients should avoid high-volume fluid intake.
• Caffeine may aggravate overactive bladder symptoms by increasing urine volume and by having an irritant effect on the bladder.
• Weight loss: Obesity is an independent risk factor for urinary incontinence.
Activity
Encourage full activity.
MEDICATION (DRUGS)
First Line
• UUI (A, level of evidence 1)
- Oxybutynin (Ditropan XL): 5-30 mg/d
- Oxybutynin (Ditropan): 2.5-5 mg q.i.d.
- Tolterodine (Detrol IR): 1-2 mg b.i.d.
- Tolterodine (Detrol LA): 2-4 mg/d
- Trospium chloride (Sanctura): 20 mg b.i.d
- Topical estrogen
- Flavoxate (Urispas): 100-200 mg t.i.d.
- Imipramine (Tofranil): 25-50 mg t.i.d.
• SUI
- Pseudoephedrine (Sudafed): 30-60 mg t.i.d.): Weak evidence to suggest alpha-adrenergic agent is better than PBO
- Imipramine (Tofranil): 25-50 mg t.i.d.
- Topical estrogen
• Overflow incontinence secondary to BPH
- Doxazosin (Cardura): 1-8 mg/d
- Terazosin (Hytrin): 1-10 mg/d
- Tamsulosin (Flomax): 0.4-0.8 mg/d
- 5-alpha reductase inhibitors
- Finasteride (Proscar): 5 mg/d
- Dutasteride (Avodart): 0.5 mg/d
• Contraindications
- Review each medication before initiation.
- Anticholinergic agents are contraindicated in patients with glaucoma, decreased gastrointestinal motility, or bladder outlet obstruction (e.g., prostatic hypertrophy).
• Precautions
- Use the smallest dose possible in elderly
- Common side effects include dry mouth, blurred vision, constipation, postural hypotension (alpha-blockers), and cognitive dysfunction.
• Significant possible interactions: These vary for each of the drugs listed.
Second Line
Desmopressin (DDAVP) nasal spray (nocturnal enuresis)
SURGERY
• Male patients with overflow incontinence secondary to prostatic hypertrophy benefit from prostatic reduction (e.g., TURP). Men with post-radical prostatectomy incontinence and post-TURP incontinence may benefit from bulking agents (4-20% report being dry), artificial sphincter (success rates range from 59-85%), or male sling (cure rate ranging from 76-86%).
• Female patients with stress incontinence may benefit from open colposuspension (cure rate 85%, A), autologous sling, transvaginal tape procedure (cure rate 81%, level of evidence 2)
• Female patients with poor urethral tone may benefit from periurethral bulking agents (low morbidity but low long-term success rate), or sling procedures.
• Neuromodulation for women with refractory UUI.
• Rarely with refractory UUI augmentation cystoplasty
FOLLOW-UP
DISPOSITION
Discharge Criteria
Most surgical procedures are outpatient procedures or overnite stay. Most patients are taught clean intermittent catheterization prior to surgical intervention.
Issues for Referral
• Recurrent UTIs
• Microscopic hematuria
PROGNOSIS
• Generally good; most patients can achieve an increase in bladder control with appropriate medical/behavioral management
• Some experts feel sphincter incompetence is best treated surgically.
COMPLICATIONS
• Urinary tract infections
• Hydronephrosis (with atonic bladder or outlet obstruction)
• Renal failure (with obstructive hydronephrosis)
• Bladder calculi
• Skin irritation or infection
• Increased incidence of falls and fractures in elderly with overactive bladder
• Adverse drug events
PATIENT MONITORING
• With medical, behavioral, and PFMT regular follow-up is indicated to ensure proper technique and compliance and to assess response.
• Ask about side effects of medication.
• Check for orthostatic hypotension (in patients using alpha-blockers).
REFERENCES
1. Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. 3rd ed. Plymouth, UK: Health Publication Ltd; 2005.
2. Alhasso A, Glazener CMA, Pickard R. N'Dow Adrenergic drugs for urinary incontinence in adults. Cochrane Database of Systematic Reviews. 2005;(4).
3. Hay-Smith J, Herbison P, Ellis G, Moore K. Anticholinergic drugs versus placebo for OAB syndrome in adults. Cochrane Database of Systematic Reviews. 2002;(3):CD003781.
4. Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane Database of Systematic Reviews. 2002;(1):CD002114.
5. Borello-France D, Burgio KL. Nonsurgical treatment of urinary incontinence. Clin Obstet Gynecol. 2004;47:70-82.
6. Fine P, Antonini TG, Appell R. Clinical evaluation of women with lower urinary tract dysfunction. Clin Obstet Gynecol. 2004;47:44-52.
MISCELLANEOUS
See also: Prostatic hyperplasia, benign (BPH); Urethritis; Urinary tract infection in females; Urinary tract infection in males;