URINARY INCONTINENCE

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URINARY INCONTINENCE

• Carly Conly FMR1
• FM Grand Rounds
• Jan. 25/07

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CASE

• 68 y.o. female presents to your office wanting to
  discuss something personal. After some
  hesitancy, she tells you that she has been
  wetting herself.
• What further history would you like to know?

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OUTLINE

• DEFINITION
• CLASSIFICATION
• OVERVIEW
• ANATOMY AND CONTRIBUTION TO CONTINENCE
• BLADDER PHYSIOLOGY
• RISK FACTORS
• DESCRIPTION OF EACH TYPE
• WORK-UP
• MANAGEMENT
• REFERRAL

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DEFINITION

• THE INVOLUNTARY LOSS OF URINE AT UNDESIRED OR
  INAPPROPRIATE TIMES THAT MAY RESULT IN SOCIAL,
  PSYCHOLOGICAL, AND HYGIENIC CONSEQUENCES, AND
  DIMINISHED QUALITY OF LIFE

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CLASSIFICATION

• STRESS INCONTINENCE (SUI)
• URGE INCONTINENCE (UI)
• MIXED INCONTINENCE
• OVERFLOW INCONTINENCE
• TRANSIENT INCONTINENCE
• FUNCTIONAL INCONTINENCE

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OVERVIEW

• Overall prevalence of 45-53 in women aged 20-80
  years
• Prevalence among ambulatory, community-dwelling
  females gt65 years 17-55 (50) (12 of those
  with daily incontinence) males gt65 years 11-34
  (17) (4 of those with daily incontinence)
• Rates in men are 1/3 those in women, until age
  80, when rates converge
• Affects nearly 50 of institutionalized
  individuals
• Rate of spontaneous remissions 11-33 (primarily
  in elderly -1/3 of cases are due to transient
  causes)
• lt1/2 of incontinent individuals seek medical care

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Female anatomy
Muscarinic innerv
Adrenergic innerv
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ANATOMY

• Female urethra is 4 cm in length and 6mm in
  diameter
• Urethral mucosal lining contains a rich vascular
  plexus inside a matrix of collagen elastic
  fibers
• Outer layer of striated muscle surrounds proximal
  2/3 of urethra

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FACTORS CONTRIBUTING TO CONTINENCE

• Integrity of lower urinary tract
• Intact neurological control
• Cognition
• Mobility
• Motivation
• Environmental factors

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ANATOMICAL CONTRIBUTION TO CONTINENCE

• Extrinsic urethral support anterior vaginal wall
  and overlying endopelvic fascia provide stable
  base on which urethra rests
• Increases in abdominal P force urethra down on
  this base, thus compressing and closing lumen to
  maintain urethral P
• Weak support structures hypermobility

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NEUROLOGICAL CONTRIBUTION TO CONTINENCE

• Depends on intact sympathetic reflex that
  inhibits detrusor contraction during bladder
  filling and activates ? -adrenergic receptors in
  urethra to contract, thus increasing P

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BLADDER PHYSIOLOGY

• 2 fxns
• 1) filling and storage
• 2) expulsion of urine
• Sm m of bladder wall/ureter innervated by
  cholinergic sacral parasympathetic nerves (S2-S4)
• Bladder outlet - dual sphincter mechanism
  internal - level of bladder neck, continuous with
  musculature of detrusor m external - striated
  fibers innervated by pudendal nerve
• Distal sphincter mechanism is surrounded by
  pubococcygeus m of levator ani musculature

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BLADDER PHYSIOLOGY

• Cortical control - parietal lobes and thalamus
  receive detrusor afferent stimuli frontal lobes
  and BG modulate inhibitory signals coordination
  center located in the pons
• Peripheral coordination - S2-S4
• Sympathetic efferents from T11-L2 via hypogastric
  nerve mediate ?1-adrenergic contraction of
  sphincter and relaxation of detrusor
• Pudendal nerve (S2-S4) stimulation leads to
  contraction of striated muscle portion of
  sphincter mechanism

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MICTURITION REFLEX

• Detrusor afferent stimuli send message to cortex
  ? pons indicating need to void parasympathetic
  activation via S2-S4 causes muscarinic (M3)
  contraction of detrusor m and simultaneous
  inhibition of sympathetics and pudendal nerve
  leading to relaxation of sphincter controlled,
  coordinated voiding

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RISK FACTORS

• Childbearing
• Obesity
• Functional/cognitive impairment
• Increasing age
• Diabetes
• Constipation
• Estrogen deficiency

• Medication
• Depression
• COPD
• Smoking
• Chronic cough
• CHF
• Genitourinary sx
• Neurological disorders

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ASSOCIATED MORBIDITY

• Candida infection
• Cellulitis
• P ulcers
• UTI /- sepsis
• Falls /- fractures
• Sleep disturbance

• Low self-esteem
• Social withdrawal
• Depression
• Sexual dysfunction
• Caregiver burden

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STRESS INCONTINENCE

• Most common cause in women lt55 years
• Involuntary loss of urine during an increase of
  intra-abdominal pressure produced from activities
• Causes
• 1) urethral hypermobility caused by loss of the
  normal anatomic supports of the urethrovesical
  junction
• 2) intrinsic sphincter deficiency - anatomic and
  neural dysfunction
• 3) hypoestrogenic state

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INTRINSIC SPHINCTER DEFICIENCY

• Concept rather than diagnosis
• Neuromuscular failure of sphincter mechanism at
  rest or during minimal exertion resulting in
  incontinence
• No specific diagnostic criteria

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STRESS INCONTINENCE

• Immediate leakage sphincter failure
• Delayed leakage maneuver-induced uninhibited
  detrusor contraction

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URGE INCONTINENCE

• Most common cause in women gt65 years (70)
• Involuntary loss of urine preceded by a sudden
  strong urge to void
• Overactive bladder syndrome including urgency,
  frequency, nocturia, /- urge incontinence

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URGE INCONTINENCE

• Presumed etiology detrusor over-activity
• Causes
• age-related changes
• interruption of CNS inhibitory pathways
• bladder irritation
• idiopathic

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MIXED INCONTINENCE

• Very common
• Overlap of detrusor hyperactivity and impaired
  urethral sphincter function

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OVERFLOW INCONTINENCE

• Urine loss associated with over-distension of the
  bladder
• Causes
• Hypoactive detrusor (rare - 5 usually
  secondary to neurological cause or chronic
  disease)
• Outlet obstruction 2nd leading cause in men
  uncommon in women

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TRANSIENT INCONTINENCE

• Urine loss associated with a reversible condition
• Suspect when incontinence is of sudden, recent
  onset

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DIAPPERS

• D - DELIRIUM
• I - INFECTION
• A - ATROPHIC URETHROVAGINITIS
• P - POLYPHARMACY
• P - PSYCHOGENIC
• E - ENDOCRINE
• R - RETENTION
• S - STOOL IMPACTION

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FUNCTIONAL INCONTINENCE

• Inability or unwillingness to toilet because of
  physical, cognitive, psychological, or
  environmental factors
• Major cause in 1/2 of institutionalized patients
• Diagnosis of exclusion

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OTHER CAUSES

• Fistulas, ectopic ureters, diverticulae

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HISTORY

• All women who have undergone childbirth, prior hx
  of pelvic surgery, gt65 years
• Screening questions
• Do you ever leak urine when you dont want to?
• Do you ever leak urine when you cough, laugh,
  exercise?
• Do you ever leak urine on the way to the
  washroom?
• Do you ever wear pads or cloth in your underwear
  to catch urine?

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HISTORY

• Severity index
• How often do you experience urine leakage?
• 0 never
• 1 lt1/month
• 2 gt1/month
• 3 gt1/week
• 4 daily
• How much urine do you leak?
• 1 drops 2 more
• Severity score of 1 x score of 2
• 0 no incontinence 1-2 slight
• 3-4 moderate 6-8 severe

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HISTORY

• Onset
• Course
• Associated lower urinary tract symptoms
• Frequency - leakage and urinary
• Volume
• Timing
• Urgency
• Hesitancy

• Nocturia
• Straining
• Sensation of incomplete emptying
• Precipitants
• Bowel fxn
• Medical conditions
• OBGYN hx
• Medications
• Surgical hx

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HISTORY

• Critical to explore impact on patients life
  work, ADLs, sleep, sexual activities,
  recreational activities, social interactions,
  relationships, self-concept, emotions

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VOIDING DIARY

• 48-72h documentation of continent and incontinent
  voids
• Obtain patients baseline voiding pattern,
  bladder capacity, severity of incontinence
• Provides NB diagnostic and therapeutic clues
• Time, volume, wet vs dry, associated activities,
  fluid intake

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DISTINGUISHING INCONTINENCE ETIOLOGY BY HISTORY
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PHYSICAL EXAM

• Alertness/functional status
• VS
• Cervical spine assessment
• Careful back exam
• CVS - volume status

• Abdominal exam
• Joint mobility
• Pelvic exam
• Rectal
• Neurological exam

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PHYSICAL EXAM

• Pelvic assessment muscle tone, estrogen status
  (thin, pale, shiny vaginal epithelium),
  inflammation, infection, discharge, prolapse,
  cystocele, rectocele, mass, bladder neck mobility

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PHYSICAL EXAM

• Neurological exam lower thoracic, lumbar, and
  sacral nerves perineal sensation, anal sphincter
  tone, strength of LE, DTR, anal reflex,
  bulbocavernosus reflex

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CLINICAL TESTING

• 1) Stress test sensitive for impaired sphincter
  function full bladder single, vigorous cough in
  lithotomy position and standing determine if
  leakage is immediate or delayed
• 2) PVR via catheterization or U/S lt50-100ml is
  normal (lt10 of voided urine) gt200ml is abnormal

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CLINICAL TESTING

• 3) Mobility Q-tip test assess urethrovesical
  junction mobility does not confirm dx, but
  helpful in surgical planning angle gt30? is
  abnormal
• 4) Labs RFT, glucose, calcium, Vit B12
  (elderly), U/A (midstream), urine culture, urine
  cytology, and cystoscopy if hematuria or pelvic
  pain are present

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CLINICAL TESTING

• 5) Urodynamic studies
• assesses lower urinary tract fxn - bladder
  proprioception, capacity, detrusor stability,
  contractility, flow rate
• routine testing not recommended
• gives precise diagnosis when surgery is being
  considered
• Recommendation from SOGC In women presenting
  with pure SUI that can be objectively
  demonstrated during examination, pre-operative
  urodynamic testing is not necessary. For women
  with other lower urinary tract symptoms and/or
  mixed incontinence, the clinicians judgement
  must guide the use of urodynamic testing.

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CLINICAL TESTING

• 5) Urodynamic studies cont
• urine flow rate normal gt12-15ml/s
• cystometry P-volume test test of bladder
  filling in normal state, intravesicular P never
  gt20cm H2O above baseline P normal bladder
  capacity 400cc
• 6) Cystoscopy rule out intrinsic bladder
  pathology
• 7) Pyridium test to differentiate b/w vaginal
  discharge and urine single dose of
  phenazopyridine turns urine orange

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GENERAL MANAGEMENT

• Cure
• Improved QOL
• ? total number of incontinent episodes
• Alter timing
• ? volume
• Nocturia
• Leakage with exercise
• etc

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GENERAL MANAGEMENT

• Rule out causes of transient incontinence
• Weight reduction
• Avoid excess fluid intake lt2L/d
• Reduce consumption of caffeine-containing
  beverages/EtOH lt8oz/d
• Avoid diuretics
• Smoking cessation
• Void regularly/ensure access to toilet
• Education

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TREATMENT OPTIONS

• 1) Behavioral
• 2) Pharmacologic
• 3) Surgical

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SUI TREATMENT

• Kegel exercises
• to improve tone of voluntary external urethral
  musculature (pubococcygeous) careful
  instruction close monitoring high patient
  motivation/commitment
• Regimen 3-4 sets of 10 slow velocity
  contractions sustained for 10 sec each/day x
  12-16 wk, then indefinitely
• 50-95 improvement (A)

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SUI TREATMENT

• Adjuncts to Kegels
• Vaginal cones
• Progressively weighted, retained inside vagina x
  15 min during ambulation
• 68-80 improvement (B)
• Biofeedback
• Uses P readings to provide visual feedback
  regarding status of pelvic floor musculature
• Weekly or twice weekly office sessions
• Time-consuming
• 50-87 improvement (A)
• Electrical stimulation
• Transvaginal or transrectal probe, 15-30 min BID
• 50-94 improvement (B)

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SUI TREATMENT

• Vaginal devices
• Pessaries
• Helpful in presence of pelvic floor laxity
• Compress urethra against pubic symphysis and
  stabilizes bladder neck in appropriate anatomic
  position
• 3 available (all ring shaped)
• Office check 2-7 days post-placement
• Question about comfort, continence, BM, bleeding
  speculum exam for mucosal tears
• Clean 1-2x/wk
• Successful in 50-75

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SUI TREATMENT

• Vaginal devices cont
• Diaphragms
• Bladder support prosthesis
• Urethral plugs

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SUI TREATMENT

• Pharmacotherapy
• Effectiveness remains questionable
• ? agonists
• not FDA approved
• Pseudoephedrine 15-30 mg TID ? resting tone
  50 improvement, 10 cure
• Duloxetine not approved in Canada, SNRI,
  stimulates pudendal nerve, dose 40 mg BID S/E
  nausea

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SUI TREATMENT

• Estrogen
• Urgegtstress
• Postmenopausal women
• Combination therapy/oral form - worsens
  incontinence
• Vagina, urethra, and bladder neck are all
  hormonally responsive
• ? mucosal secretions and thickness, ?
  periurethral vascularity, and ? and
  responsiveness of ? receptors to adrenergic
  stimulation

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SUI TREATMENT

• Estrogen
• Estring - insert q3/12
• Vagifem - 1 tab _at_ hs EOD
• Topical cream - Premarin 0.625mg/g 1g pv OD x
  1-2/12, then twice weekly

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SUI TREATMENT

• Surgery offers highest cure rate success rate
  declines with repeated attempts
• Divided into procedures that restore anatomic
  support of the proximal urethra and bladder neck
  and those that compensate for a poorly
  functioning sphincter
• Reserved for
• Women who have completed childbearing
• Refuse or failed conservative therapy
• Those with associated prolapse/cystocele, etc
• Proven obstruction

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SUI TREATMENT

• Procedure dictated by whether symptoms are due
  to
• Hypermobility
• Retropubic urethropexy (Burch) - cure rates for
  primary incontinence approach 90 50-60 for
  recurrent incontinence
• Suburethral sling - TVT
• Transvaginal needle suspensions
• Burch procedure gold standard until late 90s
• Today, TVT is favored because less invasive,
  greater long-term (5 yr) success rate, more cost
  effective

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SUI TREATMENT

• ISD
• Periurethral injections - bulking agent
  (Contigen) injected under proximal urethra to
  produce firm, local expansion of periurethral
  tissues, excellent short term improvement
  (70-80), but poor long term success (gt1/3
  required re-injection)
• Sub-urethral slings - ie TVT
• Urethral plugs

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SUI TREATMENT

• Surgical complications
• Urinary retention - resolves within 1/52
• Detrusor over-activity - obstruction due to
  excessive elevation by suspension sutures
• Bladder or ureter injury
• Infection
• Hemorrhage
• Irritative voiding symptoms

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URGE INCONTINENCE TREATMENT

• Behavioral therapies
• 1st line
• 2 underlying principles
• 1) keep bladder volume low by frequent voiding
• 2) inhibit detrusor contractions by retraining
  cerebral and pelvic continence mechanisms

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URGE INCONTINENCE TREATMENT

• Behavioral therapies
• Bladder retraining
• Education regarding continence mechanism, normal
  and abnormal voiding patterns, and importance of
  a strict voiding schedule
• Attempting to re-establish cortical inhibition of
  reflex bladder emptying
• Using voiding diary as a guide, determine voiding
  interval that is more frequent than the
  incontinence episodes, patient instructed to void
  regularly during waking hours according to
  present interval, told to ignore other urges to
  void using distraction or relaxation methods.
  Follow this interval x 7-10 days. If there are
  fewer incontinence episodes, the voiding interval
  can be increased by 15-30 min. Continue this
  process until voiding interval is q3-4 hours.
  50 cure rate.
• Kegel exercises

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URGE INCONTINENCE TREATMENT

• Medications - 2nd line
• Antimuscarinics
• Compared with placebo, these meds have 40 gt rate
  of improvement
• Oxybutynin IR (Ditropan), Oxybutynin ER (Ditropan
  XL), Oxytrol (transdermal patch)
• Tolterodine (Detrol and Detrol LA)

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URGE INCONTINENCE TREATMENT

• Oxybutynin non-selective anti-cholinergic agent
  all forms have similar efficacy, but long-acting
  form is preferred because of favorable S/E
  profile
• Oxybutynin IR 2.5-10mg TID
• Oxybutynin XR 5-10mg OD (maximum 30 mg/d)
• Oxytrol one patch (3.8 mg) twice weekly /-
  skin irritation

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URGE INCONTINENCE TREATMENT

• Tolterodine selective anticholinergic agent with
  more action in bladder than other organs, so
  fewer S/E than oxybutynin
• Tolterodine (short-acting) 1-2 mg BID
• Tolterodine XR 2 or 4 mg OD
• Maximum effect seen after 5-8/52

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URGE INCONTINENCE TREATMENT

• Study comparing short-acting oxybutynin and
  tolterodine oxybutynin slightly more effective
  in controlling incontinence, but tolterodine
  associated with fewer S/E and better tolerated
• Similar results found when the long-acting forms
  were compared (using 10 mg of oxybutynin and 4 mg
  of tolterodine)
• RCT comparing Kegel exercises with oxybutynin -
  81 ? in incontinent episodes vs 69 ? in
  oxybutynin group

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MIXED INCONTINENCE TREATMENT

• Treat most bothersome symptom
• Imipramine
• TCA
• Dual ? agonist and anticholinergic activity
• Dose starting dose 10-25 mg _at_ hs and ? by 25 mg
  q3days up to a maximum of 150 mg/d

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OVERFLOW INCONTINENCE TREATMENT

• Treatment depends on etiology
• Control DM, replace Vit B12, surgical correction
  of adhesions from prior sx, surgery for prolapse,
  pessary, meds for BPH (Prazosin)
• Intermittent self-catheterization
• Double voiding
• Credes maneuver
• Bethanachol muscarinic agonist, causes detrusor
  contraction use only in non-obstructive cases
  dose 25-50 mg TID-QID effectiveness is
  questionable

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TRANSIENT INCONTINENCE TREATMENT

• Treat underlying cause

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FUNCTIONAL INCONTINENCE TREATMENT

• Scheduled voiding time - preset intervals that
  are designed to match patients normal voiding
  frequency
• Prompted voiding - for cognitively impaired
  individuals regular monitoring, encourage
  patients to report continence status, prompting
  patients to use toilet, positive reinforcement
  for their attempt
• Modify environment to maximize toilet access
• Catheter

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EVALUATION AND TX OF URINARY INCONTINENCE
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SPECIALIST REFERRAL

• Interest in surgical tx
• Recurrent SUI after incontinence sx
• Men with severe incontinence or high PVR
• Pelvic pain
• Hematuria in absence of UTI
• Pts with complex neuro conditions
• Prolapse/prostate nodule
• Persistent symptoms following therapeutic trial
• Uncertain diagnosis

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REFERENCES

• www.guideline.gov
• www.myhq.com/public/s/a/saskfm/
• www.uptodate.com
• Culligan PJ, Heit M. Urinary Incontinence in
  Women Evaluation and Management. American Family
  Physician, Dec 2000.
• Lange Family Medicine Ambulatory Care
  Prevention. McGraw Hill, 4th ed.2005
• Weiss BD. Selecting Medications for the Treatment
  of Urinary Incontinence. American Family
  Physician, Jan 2005.