Urinary incontinence: your patients don't have to just go with the flow

It's common in the elderly, causing reduced quality of life, social isolation, embarrassment, and often-preventable nursing home admissions. But it's not "a normal part of getting old." Several simple interventions can make a big difference.

Ask a few simple questions.

Many people with urinary incontinence go undiagnosed and untreated. Patients often don't volunteer that they have a problem, and clinicians often don't ask about it.¹Incontinence can be the 'last straw' that determines whether a person can continue to live at home or requires institutional care.

Asking some simple screening questions about "a common and sometimes difficult to raise issue" can be helpful:¹

• Do you have trouble with your bladder?
• Do you ever lose urine when you don't want to?
• Do you wear pads or adult diapers for protection?

If the patient answers 'yes' to any of these questions, a more detailed assessment is warranted.^2-4

History, physical examination, and basic tests

The history, physical examination and a few simple tests will usually be adequate to determine what kind of incontinence a patient has. This in turn will help guide treatment. Referral for invasive testing is needed only in a minority of cases.

The 5 basic types of urinary incontinence are described below.^1,5 Some patients may have more than one cause, or may transition from one type to another over time.

Define the causes, precipitants, and severity of incontinence^2-4

• How often do you pass urine during the day?
• How often do you get up at night to pass urine?
• When do you leak urine?
• What is your alcohol and caffeine intake?
• What prescription and non-prescription drugs do you take (see below)?
• Do you have diabetes? Constipation?
• Have you had any previous urinary tract or gynecological surgery such as incontinence or prolapse procedures, or hysterectomy?

Also determine risk factors for stress incontinence including parity, history of large babies, forceps and breech deliveries, chronic cough, and obesity.

Have the patient records a 3-day bladder diary and complete a severity/quality of life questionnaire6 (provided by iDiS). Bladder diaries are a practical and reliable way to quantify urinary frequency and incontinence episodes, and can help in monitoring response to therapy.

Exclude other pathology^2-4

Patients with typical stress or urge incontinence should not have any of the following features:

• hematuria
• dysuria
• acute onset of symptoms
• obstructive symptoms such as straining to void, or a sensation of incomplete bladder emptying
• recurrent urinary tract infections
• neurological symptoms such as new numbness of tingling, weakness, back pain, visual disturbances, or altered bowel habit with acute-onset constipation or fecal incontinence

Patients with these atypical features, major pelvic prolapse, a mass in the urinary tract, and/or severe symptoms should be considered for specialist referral.

Physical examination

The physical exam should include pelvic, abdominal, rectal, neurological, and cardiac examinations.^3,4,7

Tests^2-4,7

A few simple tests can help with assessment:

• Stress test: Observe for urine loss with coughing or Valsalva maneuver.
• Urinalysis: If urine dipstick is positive for nitrites or leukocytes or the patient has symptoms of urinary tract infection, send midstream urine sample for culture and antibiotic sensitivity.
• Blood tests: Measure serum glucose if either polyuria or glycosuria are present; check serum calcium if the patient has polyuria.
• Post-void residual: Use catheter or ultrasound to measure the urine left in the bladder after normal voiding. More than 200ml is abnormal.

Use "DIAPPERS" to identify reversible causes

The "extra P" is intentional, and fits the problem:⁸

Delirium: Common precipitants include hypoxia, fever, renal failure, dehydration, pneumonia, urinary tract infections, drugs (includes withdrawal of some medicines), stroke, and myocardial infarction. Treatment varies with cause.

Infection (urinary tract): UTIs are the most common infections in older people and are 50 times more frequent in women than men. It is a common cause of acute (but not chronic) incontinence.

Atrophic urethritis/vaginitis: A decline in estrogen levels with menopause causes changes in vaginal tissues and vaginal pH; symptoms related to vaginal atrophy include dysparuenia, stress incontinence, urgency, frequency, and dysuria. Recurrent UTI and vaginal infections may be more frequent in women with atrophic vaginitis.

Pharmaceuticals: Many drugs can cause or worsen urinary incontinence (see below).

Psychological: Rare and generally cause incontinence only if severe. Especially severe depression (rare).

Excess urine production: Hyperglycemia, hypercalcemia, heart failure, sleep apnea, renal insufficiency, daytime fluid retention, and drugs such as diuretics can produce polyuria.

Reduced mobility: Can result from numerous medical conditions as well as loss of confidence following a fall. Mobility is also influences by problems with vision, cognitive function, medications, severe arthritis, muscle weakness, sedation, and aids such as canes or crutches. (See iDiS module on falls and mobility disorders.)

Stool impaction: Constipation is common in the elderly and can contribute to overflow incontinence through bladder outlet obstruction. Many common medications can cause it, and less constipating alternatives are sometimes available. Other common causes of constipation include immobility, depression, reduced fluid/fiber intake, bowel obstruction, hypothyroidism, and hypercalcemia.

Medications can be part of the problem

Some drugs can cause or worsen incontinence. Review all drugs, including over the counter and alternative/complementary therapies, alcohol, and caffeine to determine whether any are contributing to the problem. Medication review can also help identify drugs that lead to functional incontinence by causing impaired mobility, sedation, blurred vision, dizziness, delirium, and confusion. Pay particular attention to total anticholinergic load and psychotropics.

Many commonly used drugs have anticholinergic properties, which can be additive. Because bladder contraction is innervated through the parasympathetic nervous system, anticholinergic effects can weaken bladder contractility, leading to overflow incontinence. Even if the contribution of each individual drug is small, a patient's total anticholinergic load may be sufficient to cause or worsen symptoms. For some indications, a less anticholinergic drug may be available. Beginning with half the usual starting dose may effectively manage urinary symptoms whilst reducing the risk of adverse effects in the frail elderly.¹²

Behavioral and physical therapies can make a big difference

These interventions are safe, non-invasive, work well in outpatient primary care, and can be strikingly effective for many common types of incontinence.^1,13

Pelvic floor muscle training: This can be a very useful treatment for women with stress and mixed incontinence,^7,14 and may also be effective in combination with bladder training in treating urge incontinence.¹⁴ The goal is to increase the strength, endurance, and coordination of pelvic floor muscles.

In the office, tell the patient to maximally contract the pelvic muscles as if trying to hold in urine. At home, she then does 8–12 contractions, each sustained for 6–8 seconds. This is repeated three times daily.^{15, 16} Continue training for 3–4 months before assessing outcomes.^15-17

Bladder training: Bladder training aims to increase the time interval between voiding, and works best in patients who are physically and cognitively unimpaired. The approach is most commonly used to manage urge incontinence, but may also improve symptoms of stress and mixed incontinence.⁷

• Determine the initial voiding interval based on how frequently the patient is currently voiding while awake.
• Have the patient try and increase the duration between voids by 15–30 minutes per week, up to an interval of  2–3 hours between voidings.¹⁶
• A bladder diary can record the number and amount of urine leaks each day, and for the week.
• Increase the interval between voids when the patient is leak-free for more than 75% of the time between voids.

A trial of bladder training should be conducted for at least 6 weeks.¹⁵ For most elderly patients, reducing bathroom visits to every 2 to 3 hours is a good result.

Other behavioral interventions include losing weight (can help with stress and urge incontinence); increasing physical activity (can help in functional incontinence); prompted voiding (caregivers regularly ask about the need to go to the toilet; can reduce incontinence episodes by about 1 episode per day); reducing alcohol and caffeine intake (can help with urge incontinence); smoking cessation; relieving constipation (can help with stress and overflow incontinence).

Drug treatment

Drugs can help some patients with incontinence. They are best used after ruling out reversible causes, and a trial of behavioral interventions. In considering drug treatment:

• establish a clear baseline with a careful history and bladder diary;
• plan a time-limited trial for 6-12 weeks to assess benefits and side effects; review after 6 months to determine continuing need;
• have the patient or caregiver continue the bladder diary to determine the effectiveness of treatment;
• discontinue treatment if it isn’t working.

Most medications in a given class work as well as others, though costs can vary substantially.

Sometimes, a drug prescribed to treat one type of incontinence may contribute to another type. For example, an anticholinergic agent such as oxybutynin used for urge incontinence may cause urinary retention and contribute to overflow and functional incontinence.^7,9-11 Alpha-antagonists used to treat overflow incontinence caused by prostatic hypertrophy may cause excessive sphincter relaxation, and contribute to stress incontinence; these drugs may also precipitate or worsen incontinence in women.^7,9-11

1. Gibbs CF, Johnson TM, 2nd, Ouslander JG. Office management of geriatric urinary incontinence. The American Journal of Medicine. Mar 2007;120(3):211-220. 2. The American College of Obstetricians and Gynecologists (ACOG).  Urinary incontinence: ACOG patient education 2005.  Available at: http://www.acog.org/publications/patient_education/bp081.cfm. 3. Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA. Mar 26 2008;299(12):1446-1456. 4.McKertich K. Urinary incontinence-assessment in women: stress, urge or both? Australian Family Physician. Mar 2008;37(3):112-117. 5. Abrams P, Cardozo L, Fall M, et al. The standardization of Terminology of Lower Urinary Tract Function: Report from the standardization Sub-committee of the International Continence Society. Neurology and Urodynamics. 2002;21:167-178. 6. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourology and Urodynamics. 2004;23(4):322-330. 7. American College of Obstetricians and Gynecologists. Urinary Incontinence in women. ACOG Practice Bulletin 63: Clinical Management Guidelines. Obstetrics and Gynecology. 2005;105(6):1533-1545. 8.Resnick NM. An 89-year-old woman with urinary incontinence. JAMA. Dec 11 1996;276(22):1832-1840. 9. Royal Australian College of General Practitioners.  Managing Incontinence in General Practice: Clinical Practice Guidelines 2002.  Available at: http://www.racgp.org.au/guidelines. 10. DuBeau CE, Kuchel GA, Johnson T, 2nd, Palmer MH, Wagg A. Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence. Neurourology and Urodynamics. 2010;29(1):165-178. 11. Rowett D. Medicines and Urinary incontinence Australian Pharmaceutical Formulary and Handbook (APF-20) and Australian Medicines Handbook Aged Care Companion 1st and 2nd Editions. 12. Hay-Smith J, Herbison P, Ellis G, Morris A. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database of Systematic Reviews (Online). 2005(3):CD005429. 13. Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet Gynecol. Jul 2002;100(1):72-78. 14.Scottish Intercollegiate Guidelines Network 2005. Management of urinary incontinence in primary care: a national guideline.  Available at:http://www.sign.ac.uk/pdf/sign79.pdf. 15. National Collaborating Centre for Women’s and Children’s Health; Urinary incontinence: The management of urinary incontinence in women.  Commissioned by the National Institute for Health and Clinical Excellence.  Available at: http://www.nice.org.uk/nicemedia/pdf/CG40fullguideline.pdf. 2006. 16. Santiagu SK, Arianayagam M, Wang A, Rashid P. Urinary incontinence-pathophysiology and management outline. Australian Family Physician. Mar 2008;37(3):106-110. 17. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD005654. DOI:10.1002/14651858.CD005654.pub2. 

Additional references documenting these recommendations are provided in the evidence document accompanying this material.

This material was produced by Leslie Jackowski, B.Sc.(Hon).,MBBS, Senior Clinical Consultant, Harvard University; Niteesh K. Choudhry, M.D., Ph.D., Assistant Professor of Medicine, Harvard Medical School; Michael A. Fischer, M.D., M.S., Assistant Professor of Medicine, Harvard Medical School, Debra Rowett, B.Pharm., Service Director, Drug and Therapeutics Information Service, Repatriation General Hospital, South Australia, Danielle Scheurer, M.D., M.Sc., F.H.M., Assistant Professor of Medicine, Harvard Medical School, and William H. Shrank, M.D., M.S.H.S., Assistant Professor of Medicine, Harvard Medical School. Series editor: Jerry Avorn, M.D., Professor of Medicine, Harvard Medical School. Drs Avorn, Choudhry, Fischer, Scheurer, and Shrank are all physicians at the Brigham and Women’s Hospital in Boston. None of the authors receives any personal compensation from any drug company.

The Independent Drug Information Service (iDiS) is supported by the PACE Program of the Department of Aging of the Commonwealth of Pennsylvania, the Massachusetts Department of Public Health, and the Washington, D.C. Department of Health .

This material is provided by The Alosa Foundation, a nonprofit organization that is not affiliated in any way with any pharmaceutical company.

These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient’s clinical condition.