Urinary Incontinence

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Urinary Incontinence

• Stephen J. Titus MD

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Objectives

• Define the main causes of urinary incontinence.
• Formulate an approach to their diagnosis.
• Identify the treatment strategies for each.
• Remind each of us to not eat Yellow Snow

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Impact

• Direct cost of treatment in 1995 was 26.3
  billion
• More common in women then men
• gt1/3 women gt65 have some degree of incontinence
• Fewer than 50 will raise complaint to physician
• Routine examinations should address screening for
  urinary incontinence

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Types of Urinary Incontinence

• Urge Incontinence
• Overactive Bladder, Detrusor overactivity
• A strong sense to void followed by involuntary
  loss of urine
• Usually idiopathic, but can be due to infection,
  bladder stones, bladder cancer

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Types of Urinary Incontinence

• Stress Incontinence
• Involuntary loss of urine due to increased
  intra-abdominal pressure
• Coughing
• Sneezing
• Laughing
• Most common type in young women
• Due to pelvic floor muscle weakening resulting in
  urethral hypermobility

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Types of Urinary Incontinence

• Mixed Incontinence
• Most common in women overall
• Exact mechanism not well understood
• Characteristics of both Urge and Stress
  Incontinence

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Types of Urinary Incontinence

• Overflow Incontinence
• Due to overdistension of the bladder
• Frequent or constant dribbling
• Either due to an outlet obstruction (prostate) or
  detrusor underactivity (medications, spinal chord
  injury, diabetic neuropathy, MS)
• Post void residual is often elevated

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Types of Urinary Incontinence

• Functional Incontinence
• Especially in the elderly
• Cognitive or Physical limitations
• Diagnosis of exclusion as other types might be
  present in functionally limited individuals

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Types of Urinary Incontinence

• Incontinence due to secondary causes
• Medications
• Urinary Tract Infections
• Stool Impaction
• Hyperglycemia
• Heart Failure
• Interstitial Cystitis
• Bladder Malignancies

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Medications

• Diuretics
• Caffeine
• Alcohol
• Anticholinergics
• Alpha agonists
• Beta agonists
• Sedatives/Antidepressants/Antipsychotics

• Urge
• Urge
• Urge
• Overflow
• Overflow
• Overflow
• Overflow

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Medications

• Narcotics
• Alpha blockers
• ACE inhibitors(cough)

• Mixed
• Stress
• Stress

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Notre Dame
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Evaluation

• History
• Screen patients
• Have you leaked urine in the last 3 months?
• What preciptants led to leakage?
• Which precipitant caused leakage most often
• Comorbid conditions
• DM2, Stroke, Dementia, Spinal Stenosis
• Constipation

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Evaluation

• History
• GYN history
• Surgical history
• Medication list
• Bladder Diary

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Evaluation

• Physical
• above the waist
• CV exam signs of volume overload
• Abd exam masses, tenderness
• Neuro exam
• Genital Exam
• Atrophy, cystocele, rectocele, pelvic masses
• Rectal Exam
• Prostate enlargement, rectal mass, stool
  impaction

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Evaluation

• Post Void Residual
• Controversial in primary care setting at first
  presentation
• Catheter or Ultrasound
• lt50mls complete voiding
• gt200mls suggests obstruction/detrusor
  underactivity

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Evaluation

• Laboratory
• Urinalysis (with culture if infection suspected)
• Renal function
• Fasting Glucose

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Evaluation

• Urodynamic Testing
• Routine testing is not recommended
• Gold Standard
• Expensive, Invasive, specialized equipment

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Venus de Milo
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Treatment

• Urge Incontinence
• Behavior therapies are recommended first-line and
  more effective than medications alone
• However, a combination of the 2 is most
  successful
• Behavior therapy depends on patient adherence and
  motivation

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Treatment

• Urge Incontinence
• Bladder training (holding urine longer between
  voids)
• Kegel Excercises to strengthen pelvic floor
• 81 reduction in episodes vs 69 reduction in
  oxybutynin treated patients
• 3 sets of 8-12 contractions x 6sec, 3x/week, x
  15wks

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Treatment

• Urge Incontinence
• Medications
• Anticholinergics
• Oxybutynin (short acting, long acting,
  transdermal)
• Tolteradine (short acting, long acting)
• Oxybutynin slightly more effective, but higher
  side effects (Dry Mouth)

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Treatment

• Stress Incontinence
• Kegel Excercises
• No difference shown between Kegels alone vs.
  Kegels Biofeedback/Weighted Vaginal Cones
• Devices
• Pessaries (short or long term uses)
• Urethral occlusion plugs (short term)

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Treatment

• Stress Incontinence
• Medications
• Likely not on test as none currently FDA approved
• Alpha adrenergic agonists (Duloxetine)
• DO NOT use Estrogen replacement
• Only consider for atrophic vaginitis
• Invasive Treatments
• Surgery
• Bulking agent injections

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Treatment

• Mixed Incontinence
• Target therapy at most prominent component
• Overflow Incontinence
• Identify and relieve obstruction
• Men usually due to the prostate (BPH medication,
  Surgery, catheterizaton)
• Women usually with history of previous surgery
  and referral is warranted

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Treatment

• Functional Incontinence
• What are the physical/mental function
  limitations?
• Improve mobility
• Improve access
• Decrease evening fluid intake
• Schedule voidings

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Napoleans Tomb
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Practice

• A 70 y.o. white female complains of two episodes
  of urinary incontinence. On both occasions she
  was unable to reach a bathroom in time to prevent
  loss of urine. The first episode occurred when
  she was in her car and the second while she was
  in a shopping mall. She is reluctant to go out
  because of this problem.
• The most likley cause of her problem is

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Practice

• Overflow incontinence
• Stress incontinence
• Urge incontinence
• Functional incontinence

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Practice

• Overflow incontinence
• Stress incontinence
• Urge incontinence
• Functional incontinence

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Practice

• A 56 yo male presents to your clinic with a
  chief complaint of Leaking Urine.
• The most appropriate next step in the evaluation
  of this patient is to
• A) Obtain a post void residual
• B) Conduct urodynamic testing
• C) History and Physical Exam
• D) Obtain a urinalysis

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Practice

• A 56 yo male presents to your clinic with a
  chief complaint of Leaking Urine.
• The most appropriate next step in the evaluation
  of this patient is to
• A) Obtain a post void residual
• B) Conduct urodynamic testing
• C) History and Physical Exam
• D) Obtain a urinalysis

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Practice

• A 42 yo otherwise healthyAfrican American
  female states she has had several episodes of
  leaking urine. She has noticed it mostly with
  coughing or sneezing and has had to begin wearing
  absorbent undergarments. She has 2 children, both
  of which were vaginal deliveries. The best
  first-line treatment option for this patient is

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Practice

• Tolterodine ER 4mg daily
• Pessary Placement
• Oxybutynin 5mg tid
• Kegel Excercises

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Practice

• Tolterodine ER 4mg daily
• Pessary Placement
• Oxybutynin 5mg tid
• Kegel Excercises

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Practice

• A 62 yo otherwise healthy female states she
  has had several episodes of leaking urine. She
  has noticed it mostly at night when she awakens
  with an intense desire to void. The best
  first-line treatment option for this patient is
• Tolterodine ER 4mg daily
• Pessary Placement
• Oxybutynin 5mg tid
• Kegel Excercises

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Practice

• A 62 yo otherwise healthy female states she
  has had several episodes of leaking urine. She
  has noticed it mostly at night when she awakens
  with an intense desire to void. The best
  first-line treatment option for this patient is
• Tolterodine ER 4mg daily
• Pessary Placement
• Oxybutynin 5mg tid
• Kegel Excercises

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Summary

• Most cases of urinary incontinence can be
  diagnosed and initially treated with an HP and
  routine labwork
• First line treatment for Urge, Stress and Mixed
  incontinence is behavioral and centered around
  Kegels
• Overflow Think prostate in men, scar tissue
  /previous surgery in women.

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Questions?
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Resources

• Culligan PJ, Heit M. Urinary Incontinence in
  Women Evalauation and Management. Am Fam Phys
  2000622433-44.
• Brown JS, Choi SC, et al. The sensitivity and
  specificity of a simple test to distinguish
  between urge and stress urinary incontinence. Ann
  Intern Med 2006 144715.
• Association of Womens Health, Obstetric and
  Neonatal Nurses (AWHONN). Continence for
  women-evidence based practice guideline.
  Washington (DC). AWHONN 2000.
• Fantl JA, Newman DK, et al. Urinary Incontinence
  in Adults Acute and Chronic Management.
  Clinical Practice Guideline, No. 2, 1996 Update,
  AHCPR Publication No. 96-0682, Public Health
  Service, Agency for Health Care Policy and
  Research, Rockville, MD.
• Griffiths D, Kondo, et al. Dynamic testing. In
  Incontinence, 3rd ed. Abrams P, Cardozo L, Khoury
  S, Wein A (Eds), Health Publications, Plymouth,
  2005.
• Wagner TH, Hu TW. Economic costs of urinary
  incontinence in 1995. Urology 199851355-61.
• Resnick NM. Improving treatment of urinary
  incontinence. JAMA 19982802034-5.
• Weiss B. Selecting Medications for the Treatment
  of Urinary Incontinence. Am Fam Physician
  200571315-22.
• Burgio KL, Locher JL, Goode PS, Hardin JM,
  McDowell BJ, Dombrowski M, et al. Behavioral vs
  drug treatment for urge urinary incontinence in
  older women a randomized controlled trial. JAMA
  19982801995-2000.