Hospital Medicine

Incontinence

I. Problem/Condition.

The focus of this discussion will be primarily Urinary Incontinence which is more commonly encountered. Though it is seldom by itself a reason for admission, in the inpatient setting it is noted either in the review of systems or as a secondary problem which needs to be addressed.

Urinary Incontinence (UI) is defined as " any involuntary leakage of urine". In patients older than 65yrs, 1/3 in the community experience UI and in long term care facilities its prevalence is almost 2/3rds. Nevertheless it is not a normal process of aging.

Normal urinary continence requires the following:

a) Accommodation of increasing urine volumes by the bladder at low intravesical pressures

b) A bladder outlet that is closed at rest and remains closed even during increased abdominal pressures (e.g., coughing)

c) Absence of involuntary bladder contractions

d) Adequate cognitive ability and motivation to toilet oneself appropriately

e) And finally adequate mobility and manual dexterity to gain timely access to the toilet.

Abnormalities in any of the above steps, either singularly or in combination can lead to UI. This is also the basis of the following categorization to guide management. Fortunately most patients can be helped with diligent history taking without leading questions, a focussed physical exam and simple lab tests. Specialist referral and complex Urodynamic tests are required only in a small group of patients.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

The following are the different categories of UI encountered:

Stress urinary incontinence (SUI): Involuntary leakage of small amounts of urine on effort, exertion or sneezing, coughing lifting etc. It is due to weakness or laxity of pelvic floor muscles resulting in hypermobility of bladder base and proximal urethra.

Urge urinary incontinence (UUI): It is involuntary urine leakage accompanied by a sense of urgency or the sudden compelling desire to pas urine which cannot be deferred. It is also characterized by daytime frequency and nocturia. The amount of urine loss is variable. It is due to either Bladder hyperactivity (Overactive Bladder), or Bladder irritabilty (e.g, stone, uti) or low bladder capacity/compliance. In older men this the most common type noted.

Mixed urinary incontinence (MUI): Patients give history consistent with a combination of both stress and urge UI. In older women this is the most common type encountered.

Incomplete urinary emptying:Previously called overflow incontinence but is best characterized as high postvoidal residual. Patients in this category have frequency and urgency but in addition also characteristically have a sensation of incomplete emptying after voiding. They may also have urinary retention. A classic example is symptoms due to benign prostatic hypertrophy (BPH).

Functional incontinence or transient incontinence (FUI): This category is meant to highlight certain causes which are self limiting, transient and potentialy reversible if recognized (e.g., stool impaction). A well known pnemonic to remember causes is DIAPPERS -Delirium/Dementia, Infection,Atrophic Vaginitis,Psychological,Pharmacological,Endocrine (uncontrolled diabetes),Restricted mobility andStool impaction.

Please note that the above categories are more to group symptoms for broader understanding and to guide initial management. They are unreliable in predicting the underlying pathophysiology as one cause can present with symptoms of both stress and urge incontinence, for example.

Differential diagnosis of stress UI: prior prostatectomy, prior bladder pelvic surgery, obesity, neurogenic etc

Differential diagnosis of urge UI: idiopathic, UTI, cystitis, calculi, malignancy, stroke, dementia, Parkinsons disease, spinal cord Injury.

Differential diagnosis of incomplete urinary emptying: BPH, cystocele, spinal cord Injury, urethral stricture.

Differential diagnosis of functional UI: DIAPPERS - See above for expansion of pnemonic.

B. Describe a diagnostic approach/method to the patient with this problem.

The main objectives of evaluation are:

1) To identify causes of Functional Incontinence i.e. those causes which are reversible e.g., stool impaction.

2) To identify causes which need further testing or urology/gynecology evaluation.

3) To develop a management plan which might include, behavior therapy, medication trial or even further outpatient referral.

1. Historical information important in the diagnosis of this problem.

Start with history of onset of incontinence, duration, amount of leakage, frequency, timing, precipitating factors, associated symptoms of pain, blood, bowel and sexual function, impact of incontinence on social life, Activities of daily living (ADL's), number of pads used if any etc. Focus on symptoms of voiding difficulty, hesitancy etc.

Voiding diaries are diagnostic and therapeutic. Download a sample diary athttp://www.augs.org/portals/0/voiding_dairy.pdf

The following specific questionnaires are widely accepted:

3IQ questionnaire:

a) In the past 3 months have you leaked urine?

b) What precipitants led to leakage?

c) What precipitants leaked most often?

SeeTable I

Table I.

Questionnaire for Urinary Incontinence Diagnosis - QUID:
Score 0 1 2 3 4 5
Do you leak urine or wet yourself
1) When you coughor sneeze?
2) When you bend downor lift up something?
3)When you walk quicklyor jog?
4) While you areundressing to usethe toilet?
5) Do you get such astrong and uncomfortableneed to urinate that youleak urine or wet yourselfbefore reaching the toilet?6) Do you have to rushto the bathroom becauseyou get a sudden strongneed to uriante
Stress UI - Score items - 1,2,3; Stress score>=4
Urge UI - Sore items 4,5,6; Urge score>=6
Mixed UI - Combined stress score>=4 and urge score>=6

Past history:

  • Ask for diabetes, CHF, stroke, pulmonary diseases, pelvic radiation, Parkinsons disease, spinal cord Injury, multiple sclerosis etc

  • Obstetric/gynec history - parity, vaginal delivery, episiotomy, instrumental delivery, large infant birth weight, pelvic organ prolapse etc

  • Surgical history - pelvic surgery, incontinence surgery

Medications:

Review med. list extensively specifically for Diuretics,ACE-I, Anticholinergics, Opiates, Thiozolidinidiones, Antiparkinsonians, Antipsychotics

Social history:

Ask about smoking, caffeine intake and alcohol intake.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

  • Focus specifically on CVS, abdomen, joints/mobility

  • Neurological exam with emphasis on cognition, functional status, pyramidal tract and extra pyramidal signs is important

  • Note the integrity of sacral roots S2, S3,S4, resting and volitional anal tone, anal wink reflex. Look for peripheral neuropathy in diabetics.

  • Digital rectal exam for prostate size, consistency

  • Pelvic exam in women for prolapse signs - look if urethra remains firmly fixed or swings quickly forward on coughing and if anterior vaginal wall bulges (cyctocele).

Two specific tests are considered a part of a comprehensive intial evaluation to help decision making:

  • Stress test: This is done in cases of suspected stress UI or mixed UI symptoms. It is done by asking the patient, with a full bladder, to stand, relax and cough vigorously. A pad is held underneath the perineum and the clinician observes directly for urethral leakage. Instantaneous leakage suggest stress UI.

  • Postvoid residual volume (PVR):The bladder is catheterized in a sterile manner 5-10 minutes after the patient has voided and the amount of urine remaining is measured. Generally speaking, PVR of less than 50ml is considered adequate emptying and more than 200ml is considered inadequate emptying signifying either bladder outlet obstruction or detrusor weakness. Values in between are equivocal and the test may have to be repeated at a later point.

Testing for PVR is specifically recommended in the following cases:

1) Women with recurrent or new type on incontinence after prior incontinence repair

2) Those with significant pelvic organ prolapse

3) Patients with spinal cord Injury

4) Patients with Parkinsons disease

5) Those with recurrent UTI's - i.e. those with more than 2 episodes/year

6) Those with prior history of urinary retention

7) Failed medication therapy

8) Those with DM and peripheral neuropathy

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

  • Check CBC, renal function, calcium.

  • UA with microscopy. Cytology and Urine culture as appropriate.

  • If Renal function is abnormal patient will need a Renal Ultrasound.

  • In appropriately suspected cases computed tomography (CT) Brain for Normal Pressure Hydrocephalus.

Routine Urodynamic testing is not indicated in the intial evaluation of Incontinence. Though it is considered the physiological " Gold Standard " it is not usually necessary to make the diagnosis, is expensive, invasive and requires special equipment.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

See above.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

  • Routine CT abdomen and pelvis is not indicated

  • Routine PSA levels are not indicated

III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Incontinence.

Step-by-step approach

Step 1 - In keeping with the above mentioned objectives, identify causes of functional incontinence and treat aggressively.

In patients with recent post prostatectomy incontinence reassure them that it usually subsides spontaneously within the first few weeks to months after surgery. If it persists after one year despite medical therapy and conservative therapy, surgery may be needed.

Step 2 - Identify patients who need immediate Specialist evalution. They are the following:

1) UI with persistent abdominal or pelvic pain

2) Persistent hematuria after treatment of UTI

3) Neurological conditions (e.g., spinal cord Injury, Parkinsons disease, suspected normal pressure hydrocephalus, stroke etc)

4) Pelvic mass or severe pelvic organ prolapse

5) Pelvic floor radiation within past 6 months

6) Abnormal prostate exam on digital rectal exam

Step 3 - Depending on the type of UI, patients will benefit from conservative/behavioral modification steps, medications and/or surgical interventions.

General measures like caffeine reduction, weight loss will help. Encourage fluid intake to avoid getting dehydrated but limit it to 6- 8 ounces/day .

  • Ensure all reversible causes of incontinence are recognized early.

  • Elderly patients with cognitive impairment in long term care facilities are at high risk for medication side effects and incontinence can complicate patient care with frequent falls.

  • Use of defined skin care regimen that includes a cleanser and a moisture barrier is associated with low incidence of incontinence associated dermatitis.

For stress UI:

Pelvic floor exercises (Kegel exercises) are the main stay. After a verbal explanation reinforce with written materials.

Download printed instructions from these pages/sites:

  • http://kidney.niddk.nih.gov/kudiseases/pubs/exercise_ez/#how

  • www.nafc.org

  • http://www.simonfoundation.org/about_incontinence_treatment_options_pelvic_floor_exercises.html

A recommended regimen:

  • Tell patient to tighten up muscles that they use to hold in gas (flatus)

  • Contract muscles for 2 sec- 15 attempts- 3 times/day

  • Every week increase by 1 second

  • Keep training until you can squeeze and hold for 10sec - 10 times/day

  • Caution patient that it may take up to few weeks to note results

  • Squeeze before you sneeze: "If it happens too suddenly squeeze anyway, it may be too late that time but it will help establish a habit."

These behavioral techniques can also be implemented by Advanced Nurse Practitioners or Physical therapists:

  • http://www.wocncenter.com/public/member_directory.cfm

  • http://www.apta.org

Selected patients with mild stress UI may benefit from perineal pads or panty liners. Given that half of the women who attempt pessary use initially continue to use it after 2 years suggests that they do have a role.

There is no FDA approved drug therapy for stress UI.

If patient fails above conservative steps she will need a specialist opinion for possible surgical intervention.

For urge UI:

Behavior modification and medications are the main stay of management.

Bladder training: This will help increase bladder capacity and reduce incontinence episodes.

  • Instruct patient to void every hour during the day.

  • When 1hr voiding interval is achieved, increase intervals by 15 - 30 minutes/week, depending on tolerance.

  • Aim for a 2 - 3hr voiding interval but may need to be personalized.

  • When the urge hits, instead of rushing to the bathroom, stay still and repeatedly tighten the pelvic muscles without relaxing them until urge is gone. i.e. freeze and squeeze. Then walk to the bathroom at a normal pace. If urgency recurs freeze and squeeze again.

  • If specific factor triggers the urge - i.e. opening the door or running water - anticipate and squeeze the pelvic muscles before the trigger.

Bladder drills or timed voids: Patients are placed on a voiding schedule in which they are prompted by a timer or caregiver to void rather than responding to the urge to void. The interval between voids is gradually lengthened.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

Ensure all reversible causes of incontinence are recognized early.

Elderly patients with cognitive impairment in long tem care facilites are at high risk for medication side effects and incontinence can complicate patient care with frequent falls.

Use of defined skin care regimen that includes a cleanser and a moisture barrier is associated with low incidence of incontinence associated dermatitis.

Medications

Antimuscarinic (anti cholinergic) medications are the main stay of therapy despite lower efficacy than behavioral therapy (Table II). They block cholinergic receptors on the bladder and decrease contractility. Choice of medication depends on cost, potential side effects, comorbid conditions etc. They can be used in both men and women. If one medication doses not provide relief it can substituted for by another.

Table I.

Medications and their adverse effects
Medication Brand name Dose Comment
Fesoterodine Toviaz 4-8mg/d Not recommended in severe renal failure
Oxybutinin IR Ditropan 5mg bid - quid Caution in elderly with cognitive impairment
Oxybutinin ER Ditropan XL 5- 30mg/d Lower incidence of dry mouth than IR form
Oxybutinin(Transdermal patch) Oxytrol 1 patch/3-4days Much lower incidence of dry mouth
Oxybutinin 10% (Transdermal gel) Gelnique 1gm/d Applied to thigh, abdomen or upper arm etc
Solifenacin
Vesicare 5-10mg/d Caution in severe renal failure
Darifenacin Enablex 7.5 - 15mg/d Not recommended in severe liver failure
Tolterodine IR Detrol 1- md bid Caution in severe renal failure
Tolterodine ER Detrol LA 2 - 4mg/d
Trospium IR Sanctura 20mg bid Must be taken on empty stomach, caution in severe renal failure
Trospium ER Sanctura XR 60mg/d Contraindicated if Creat. clearance<30ml/min.

All anti-muscarinics are contraindicated in narrow angle glaucoma, gastric retention and if PVR>150ml. Most common side effects are dry mouth, constipation. Rarely, blurred vision and tachycardia.

For men with BPH, seeTable III

Table I.

For men with BPH the following medications are used
Medication Dose Comment
Alpha Blockers
Alfuzosin 10mg/d Watch for postural hypotension
Doxazosin 1-8mg/qhs
Prazosin 1-5mg bid Also used in Post traumatic stress disorder in men
Tamsulosin 0.4- 0.8mg/d
Terazosin 1- 10mg/qhs
5 Alpha reductase Inhibitors
Dutasteride 05./d
Finasteride 5mg/d

IV. What's the evidence?

Ingrid, Nygaard. "Idiopathic Urgency Urinary Incontinence". NEJM. vol. 363. 2010. pp. 1156-1162.

Edward, J McGuire.. "Urodynamics of the Neurogenic Bladder". Urol Clin N Am. vol. 37. 2010. pp. 507-516.

Donna, Deng. "Urinary Incontinence in Women". Med Clin N Am. vol. 95. 2011. pp. 101-109.

Tomas, L Greibling. "Urinary Incontinence in the Elderly". Clin Geriatric Med.. vol. 25. 2009. pp. 445-457.

Alayne, D.Markland, Camille, P Vaughan. "Incontinence". Med Clinc N Am. vol. 95. 2011. pp. 539-554.

Emily, K Saks, Lily, A Arya. "Pharmacologic Management of Urinary Incontinence, Voiding Dysfunction and Overactive Bladder". Obste Gynecol N Am. vol. 36. 2009. pp. 493-507.

Felix, W.Leung, John, F Schnelle. "Urinary and Fecal Incontinence in Nursing Home Residents". Gastroen Clin N Am. vol. 37. 2008. pp. 697-707.

David, R Rahn, Shayzreen, Roshanravan. "Pathophysiology of Urinary Incontinence Voiding Dysfunction and Overactive Bladder". Obste Gynecol N Am. vol. 36. 2009. pp. 463-474.

Michael, L Guralnick. " Assessment and Management of Irritative Voiding Symptoms". Med Clin N Am. vol. 95. 2011. pp. 121-127.

Robert, Wilkins, Setti, L Rengachary. "Neurosurgery Text Book. Neurourology". vol. Volume 1.

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