Balanced information for better care. Evaluating and managing urinary incontinence

Transcription

1 Balanced information for better care Evaluating and managing urinary incontinence

2 Evaluating and managing urinary incontinence Principal Author: Dae Kim, M.D., Sc.D. Series Editors: Jerry Avorn, M.D., Niteesh K. Choudhry, M.D., Ph.D., Michael Fischer, M.D., M.S., Eimir Hurley, BSc (Pharm), MBiostat, Ellen Dancel, PharmD, MPH Reviewers: Jason Block, M.D., MPH, Alayne D. Markland, D.O., M.Sc. Medical Writer: Stephen Braun Consultants: Vatche Minassian, M.D., MPH, Janet Li, M.D. The Independent Drug Information Service (IDIS) is supported by the PACE Program of the Department of Aging of the Commonwealth of Pennsylvania and the Massachusetts Department of Public Health. This material is provided by the Alosa Foundation, a nonprofit organization which is not affiliated with any pharmaceutical company. None of the authors accepts any personal compensation from 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. For more information, visit alosafoundation.org

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4 Alosa Foundation Evaluation and management of urinary incontinence Accreditation: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Harvard Medical School and the Alosa Foundation. The Harvard Medical School is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: The Harvard Medical School designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity overview: The primary goal of this educational program is to inform primary care physicians about the need to assess and effectively treat urinary incontinence (UI). UI is more common, more serious, and more treatable than is often recognized by health care professionals across many practice settings. UI is not a normal part of aging, even though many patients are reluctant to discuss the topic with their health care professional. Doing so, however, and formulating adequate treatment plans, can be transformative. In addition to providing this evidence report about UI epidemiology, burdens, and management options, the education program uses an innovative approach, academic detailing, one-on-one educational sessions with specially trained outreach educators (pharmacists or nurses) who present the educational material interactively. Reference cards for clinicians and education materials for family members are also provided. Target Audience: The educational program is designed for primary care physicians practicing internal medicine, primary care, family practice, and geriatrics, and other health care professionals who deliver primary care. Learning Objectives: Upon completion of this activity, participants will be able to: Implement a simple screening question to reveal cases of incontinence that would otherwise go undetected and untreated. Identify and manage reversible causes of incontinence. Distinguish among urgency, stress, mixed, and other types of incontinence to guide treatment. Employ caffeine and fluid reduction, pelvic floor muscle training, bladder training, and weight loss as first-line treatments. Use medications judiciously to treat urgency incontinence and be aware of their modest benefits and variable side effects. Evaluating and managing urinary incontinence iii

5 Disclosure Policy: Harvard Medical School (HMS) adheres to all ACCME Essential Areas, Standards, and Policies. It is HMS's policy that those who have influenced the content of a CME activity (e.g. planners, faculty, authors, reviewers and others) disclose all relevant financial relationships with commercial entities so that HMS may identify and resolve any conflicts of interest prior to the activity. These disclosures are provided in the activity materials along with disclosure of any commercial support received for the activity. Additionally, faculty members have been instructed to disclose any limitations of data and unlabeled or investigational uses of products discussed. Disclosures: This material is provided by the Alosa Foundation, a nonprofit organization which is not affiliated with any pharmaceutical company. No commercial support has been received for this activity. None of the planners/authors have any financial relationships to disclose. The Independent Drug Information Service (IDIS) is supported by the PACE Program of the Department of Aging of the Commonwealth of Pennsylvania. Faculty and Planners: Jerry Avorn, M.D., is a Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital. An internist, he has worked as a primary care physician and geriatrician and has been studying drug use and its outcomes for over 30 years. Dr. Avorn has no relevant financial relationships to disclose. Niteesh K. Choudhry, M.D., Ph.D. is an Associate Professor of Medicine at Harvard Medical School and a hospitalist at Brigham and Women's Hospital. His research focuses on the use of medications to treat common chronic conditions. Dr. Choudhry has no relevant financial relationships to disclose. Michael Fischer, M.D., M.S., is an Associate Professor of Medicine at Harvard Medical School and a primary care internist who studies clinically appropriate and cost effective drug use in outpatient practice. Dr. Fischer has no relevant financial relationships to disclose. Dae Kim, M.D., Sc.D., is an Instructor in Medicine, Harvard Medical School and a geriatrician and epidemiologist. Dr. Kim has no relevant financial relationships to disclose. Vatche Minassian, M.D., MPH, in an Associate Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School. He has no financial relationships to disclose. Janet Li, M.D., FACOG, Instructor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical. She has no financial relationships to disclose. Eimir Hurley, BSc (Pharm), MBiostat, is the Program Director at the Alosa Foundation. Her interest lies in the design, implementation and evaluation of programs to improve prescribing. Ms. Hurley has no relevant financial relationships to disclose. Ellen Dancel, PharmD, M.P.H., is the Director of Clinical Materials Development at the Alosa Foundation. Ms. Dancel has no relevant financial relationships to disclose. Stephen R. Braun, B.A., is a medical writer based in Amherst, MA. Mr. Braun has no relevant financial relationships to disclose. iv Evaluating and managing urinary incontinence

6 Susan O Brien is a CME Consultant and CME reviewer for Harvard Medical School Department of Continuing Education. Her role is to review CME proposals for compliance with regulatory requirements. Ms. O'Brien has no relevant financial relationships to disclose. Reviewers Jason Block, M.D., M.P.H., is an Assistant Professor at Harvard Medical School and the Harvard Pilgrim Health Care Institute. He is a primary care internist at Brigham and Women s Hospital and also works in the Brigham and Women s Program for Weight Management. His research focuses on governmental and institutional approaches to improving dietary choices and environmental determinants of body weight. Dr. Block has no relevant financial relationships to disclose. Alayne D. Marlkand, D.O., M.Sc., is an Associate Professor of Medicine at the University of Alabama - Birmingham and is a geriatrician who specializes in the evaluation treatment of urinary and fecal incontinence. She has no financial relationships to disclose. Media used: Printed educational material. Instructions for Participation and Credit: There are no fees to participate in this activity. To receive credit, participants must (1) read the statements on target audience, learning objectives, and disclosures, (2) study the educational activity, and (3) complete the post test and activity evaluation. To receive AMA PRA Category 1 Credit, participants must receive a minimum score of 60% on the post test. Tests and evaluations should be submitted to the Alosa Foundation via , mail, or fax. cme@alosafoundation.org Mailing address: Alosa Foundation 419 Boylston Street, 6 th Floor Boston, MA Fax: The activity will take approximately 1.25 hours to complete. Activity publication date: April 1, 2015 Termination date: April 1, 2018 Please any questions to cme@alosafoundation.org or call (617) Evaluating and managing urinary incontinence v

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8 Table of contents Introduction... 1 Relevant anatomy and physiology... 2 Major types of urinary incontinence... 4 Stress incontinence... 4 Urgency incontinence... 5 Mixed incontinence... 5 Other types of urinary incontinence... 5 Epidemiology and burden of urinary incontinence... 6 Burden... 9 Reversible causes of urinary incontinence Excessive caffeine intake Excessive fluid intake/fluid retention Urinary tract infection Stool impaction Atrophic urethritis/vaginitis Reduced mobility or access Delirium Medication side effects Overview of incontinence evaluation and initial treatment Clinical assessment Screening: Ask about it! Bladder diaries Other assessment tools Assess use of medications and/or herbal products Physical examination Urinalysis Additional tests When to refer Overview of urinary incontinence management options Managing stress urinary incontinence in women Behavioral approaches Pharmacotherapy Surgery for stress incontinence in women Managing stress urinary incontinence in men Behavioral treatments Evaluating and managing urinary incontinence vii

9 Pharmacotherapy Surgery Managing urgency incontinence in women Behavioral approaches Pharmacotherapy More invasive treatments for urgency incontinence in women Managing urgency incontinence in men Behavioral approaches Pharmacotherapy Managing mixed incontinence in men and women Managing functional incontinence Putting it all together Appendix 1: Sample bladder diary Appendix 2: International Consultation on Incontinence Questionnaire Short Form Appendix 3: Costs of urinary incontinence medications References viii Evaluating and managing urinary incontinence

10 Introduction Urinary incontinence the involuntary loss of urine is more common, more serious, and more treatable than is often recognized by health care professionals across many practice settings. It affects almost one in three older people, especially women. 1 But this does not mean it should be accepted as a normal part of aging, or dismissed as merely a mildly bothersome occurrence with no real impact. On the contrary, urinary incontinence can pose significant physical and emotional challenges for patients, families, and other caregivers. 2 It can also be both a cause and a result of important urogenital conditions. It is associated with an increased risk of falling, depression, and social isolation, and it doubles the risk of 3, 4, 5,6 nursing home admission for women, while tripling it for men. Figure 1: Urinary incontinence prevalence among men and women in community and nursing home settings. 7 Because it is not life-threatening, not widely appreciated as a serious condition, and not an easy subject to discuss, urinary incontinence can fly under the radar of health care providers, resulting in needless preventable suffering and increased costs of care. The annual direct cost of urinary incontinence in community and institutional settings is roughly $19 billion (Figure 2). 8 Direct costs include routine care (e.g., absorbent products and laundry), diagnosis, treatment, and cost of treating resulting symptoms (e.g., urinary tract infections). Indirect costs, such as the cost of lost productivity, are also important but are not shown in Figure 2. Evaluating and managing urinary incontinence 1

11 Figure 2: Direct costs associated with urinary incontinence 8 Fortunately, urinary incontinence is often highly treatable with a range of behavioral, pharmacological, and surgical approaches. This condition presents healthcare providers with an opportunity to make real, positive change in their patients lives. By using some simple screening questions, performing brief evaluations and medication reviews, and initiating a tailored initial set of non-invasive interventions, physicians can make a big difference in the physical and psychological well-being of patients and caregivers. In some cases, intervening may allow a patient who would otherwise require institutional care to continue living independently. This document summarizes the current medical literature about urinary incontinence and offers practical strategies for its diagnosis and management. Primary care physicians can do much of the evaluation and management without a need for specialized referral or testing. Relevant anatomy and physiology Complex neural and neurochemical systems maintain continence and normal urination. At the most basic level, urination is controlled by a balance between stimulatory signals arising from the sacral micturition center in the spinal cord and inhibitory signals generated in the cerebral cortex. The urge to urinate, arising from the bladder and lower spinal cord, can be consciously controlled for some time period, depending on several factors. Eventually, the urge to urinate overrides this inhibitory response, leading to urination. The parasympathetic nervous system controls bladder contraction via the detrusor muscle, which is activated by cholinergic receptors. Relaxation of the detrusor is mediated by sympathetic beta-3 2 Evaluating and managing urinary incontinence

12 receptors. Activation of the alpha-1 and nicotinic receptors leads to contraction of the urethral smooth muscles of the bladder neck and urethral striated muscles in the internal and external sphincters. Urine storage requires relaxation of the detrusor (β-adrenergic) and contraction of the internal (αadrenergic) and external (voluntary) sphincters. Normal bladder emptying and voiding requires bladder contraction (parasympathetic innervation) in coordination with sphincter relaxation. Figure 3: Innervation and neurotransmitter control of bladder function NA = noradrenaline; Ach = acetylcholine; M3 receptor = muscarinic receptor; β3 receptor = adrenergic receptor; α1 receptor = adrenergic receptor. Reproduced with permission from: Clare J. Fowler, Derek Griffiths & William C. de Groat. The neural control of micturition. Nature Reviews Neuroscience 2008;9(6): Urine loss occurs when bladder pressure exceeds outlet resistance (Figure 4), which can be influenced by a wide range of factors including: Medication effects Conditions affecting the structural integrity of the lower urinary tract Increased urine production Impaired mobility Impaired cognition Lack of motivation Evaluating and managing urinary incontinence 3

13 Figure 4: Factors affecting lower urinary tract function bladder muscle (detrusor) INCREASED BLADDER PRESSURE > DECREASED OUTLET RESISTANCE sphincter muscles urethra Detrusor overactivity Increased intra-abdominal pressure (e.g., constipation) Conditions affecting the lower urinary tract Increased urine production Contributing factors Urethral sphincter weakness Pelvic floor muscle weakness (e.g., childbirth, surgery) Impaired mobility or cognition Lack of motivation External factors BOTTOM LINE: parasympathetic nerves contract the detrusor muscle, inducing voiding, whereas sympathetic nerves relax the detrusor and constrict the urethral sphincter, allowing urine storage. Maintaining continence generally requires: effective lower urinary tract function and neural control; mobility; intact cognitive function; motivation; absence of drugs and restraints; an available toilet. Major types of urinary incontinence The major types of urinary incontinence are: stress, urgency, and mixed. Subtypes include incontinence with high post-void residual (formerly called overflow incontinence ), functional incontinence, and postprostatectomy incontinence. 9 These subtypes can overlap, or present as, one of the three main types. For example, functional incontinence can present as urgency urinary incontinence, and post-prostatectomy incontinence can present as stress urinary incontinence. Stress incontinence Stress urinary incontinence is involuntary leakage on effort or exertion (e.g., when sneezing, coughing, or laughing). A fundamental cause is decreased outlet resistance due to such factors as pelvic floor muscle weakness, bladder outlet or urethral sphincter weakness, or damage to the urethral sphincter from childbirth, pelvic surgery, or prostatectomy. 10 Stress urinary incontinence also can be caused by a lack of urethral support by the endopelvic fascia, leading to ureteral hypermobility. The two etiologies may coexist or be sole causes of the incontinence. Stress incontinence is generally more common in women, and is associated with pregnancy and childbirth. During pregnancy the release of relaxin softens the pelvic floor muscles. One study found that women with C-section or vaginal delivery had higher rates of stress incontinence compared to nulliparous women (odds ratios 1.4 and 3.0, respectively) Evaluating and managing urinary incontinence

14 In younger women, relaxin is also released each month prior to ovulation, and if fertilization does not occur, production stops until the next cycle. These effects of relaxin may account, in part, for stress urinary incontinence experienced by some women immediately prior to menstruation. 12 In addition to the effects of relaxin, vaginal delivery may increase the risk of stress incontinence due to the pressure, stretch, and shearing effects on pelvic muscles, ligaments, and nerves. Episiotomy, forceps, and vacuum assisted delivery can compound the risk of damage to the pelvic floor supports. Hysterectomy, pelvic floor surgery, chronic constipation, obesity, prolapse, and urinary tract infections are additional risk factors. 12 In men, prostate surgery is the most common cause of stress urinary incontinence. Incontinence after radical prostatectomy is caused by sphincter deficiency in most patients, although detrusor over-activity may also exist. 13 Urgency incontinence Urgency incontinence is involuntary leakage accompanied, or immediately preceded by, a strong urge to urinate. Other symptoms may include increased urinary frequency and nocturia. Urgency incontinence is caused by an involuntary increase in bladder pressure due to bladder smooth muscle (detrusor) overactivity, which, in turn, can be caused by a range of factors such as drug effects, outflow obstruction, infection, central nervous system conditions, or local conditions such as a bladder stone or tumor. 10 Overactive bladder syndrome (OAB) is a condition that can lead to urinary incontinence, but which is clinically distinct. OAB is classified as either wet (when urgency results in urine leakage) or dry (when the condition manifests simply as increased urinary frequency, urgency, or nocturia without leakage). Wet OAB is clinically identical to urgency urinary incontinence. Mixed incontinence Mixed Incontinence is a combination of urgency and stress incontinence and is the most common type of urinary incontinence in older women. 10 The symptoms may vary depending on which type of incontinence predominates. Other types of urinary incontinence Incontinence with high post-void residual This type of incontinence results from urinary retention due to detrusor muscle weakness, bladder outlet obstruction, or both. Common causes of detrusor weakness include the use of medications with anticholinergic effects (e.g., antihistamines and tricyclic antidepressants), diabetic neuropathy, and other neurologic diseases. Bladder outlet obstruction can result from prostatic hypertrophy, prostate cancer, urethral stricture, or kidney stones. About two-thirds of men who present with this type of incontinence have bladder outlet obstruction, generally caused by prostate disease. 14,15 They may have symptoms of dribbling, weak urinary stream, intermittency, hesitancy, frequency, and nocturia. There may be a substantial overlap in symptoms with other types of urinary incontinence. 1 In women, severe pelvic floor prolapse can cause outlet obstruction by creating a kink at the bladder neck. Constipation or fecal impaction can also cause incontinence with high post-void residual, as well as other types of incontinence, by compressing the urethra, bladder, or bladder neck. Evaluating and managing urinary incontinence 5

15 Functional incontinence Functional incontinence is urine loss in an otherwise continent person due to difficulty reaching a toilet when needed. It can result from impaired mobility caused by a wide range of physical or mental conditions, or oversedation. Functional barriers may exacerbate this or any type of urinary incontinence. Post-prostatectomy incontinence Radical prostatectomy to treat prostate cancer can damage the urethral sphincter or cause nerve damage that can lead to urinary incontinence, primarily of the stress urinary incontinence type. 16 Transurethral procedures to treat low-grade prostate cancer or reduce prostate bulk in patients with benign prostatic hyperplasia (BPH) may also impair the functioning of the urethra, internal sphincter, and bladder neck, but the development of urinary incontinence following such procedures is less common than with radical prostatectomy. 16 BOTTOM LINE: Stress urinary incontinence is primarily caused by decreased bladder outlet resistance (weak sphincter or pelvic floor muscle). Urgency urinary incontinence is primarily caused by increased detrusor muscle activity and is clinically identical to overactive bladder with urine loss. Mixed urinary incontinence is caused by decreased bladder outlet resistance and increased detrusor muscle activity. Subtypes of incontinence include high post-void residual, functional, and post-prostatectomy incontinence, any of which may present as one of the three main types of incontinence. Epidemiology and burden of urinary incontinence Based on Medicare data, roughly 14 million people have urinary incontinence in the US. The actual prevalence, however, is likely to be considerably higher because Medicare data do not capture those who are unable, or unwilling, to report these symptoms. This prevalence is greater than that of either heart disease (12.1 million people) or diabetes (8.3 million people). 7 More than twice the number of women (10 million) have urinary incontinence as men (about 4 million) 7 but the prevalence rates for women and men begin to converge at age One survey of frail older community-dwelling people found prevalence rates of 52% of women and 49% of men. 18 These rates have been rising steadily in the past several decades and particularly recently, possibly due to factors such as rising rates of obesity, rising numbers of older adults, and rising rates of diagnosis due to a greater awareness of the condition. 6 Evaluating and managing urinary incontinence

16 Figure 5: Prevalence of Urinary Incontinence Number of Medicare Beneficiaries with UI (Million) Female Male Stress incontinence is the most common type of urinary incontinence in younger women, but as women age the prevalence of urgency and mixed incontinence increases. 19 Figure 6: Prevalence of urinary incontinence in Women, by Type 19 60% Women 50% 40% 30% 20% unknown mixed urgency stress 10% 0% Age (years) Several factors raise the risk of experiencing urinary incontinence in women (Table 1). Evaluating and managing urinary incontinence 7

17 Table 1: Risk factors for urinary incontinence among women 19 Risk factors Adjusted OR (95% CI) History of Cesarean vs. vaginal delivery 0.59 ( ) Nonwhite 0.68 ( ) Age, per decade of life 1.14 ( ) Number of deliveries 1.17 ( ) History of hysterectomy 1.33 ( ) High comorbidity burden 1.34 ( ) Excessive Body Mass Index (overweight) 1.22 ( ) 30 (obese) 2.39 ( ) Current major depression 2.48 ( ) Urinary incontinence prevalence in men rises with age, with urgency incontinence being the most common at any age. Incontinence in men is often associated with BPH or other prostate disease and its treatment. Symptoms generally includes hesitancy, poor stream, and dribbling. 16 Figure 7: Prevalence of urinary incontinence in men by type 16 30% Men 25% 20% 15% 10% mixed urgency stress 5% 0% Age (years) The risk factors for urinary incontinence among men are significantly different than for women (Table 2). 8 Evaluating and managing urinary incontinence

18 Table 2: Risk factors for urinary incontinence among men 16 Risk factors Adjusted OR (95% CI) Poor general health * Stroke 1.5 ( ) Diabetes 1.4 ( ) Urinary tract infection 3.6 ( ) Prostate disease history 6.2 ( ) Prostate cancer history 2.0 ( ) Radial prostatectomy 4.3 ( ) Radiation therapy 2.3 ( ) Physical limitations 3.3 ( ) Cognitive impairment 2.7 ( ) Burden Urinary incontinence can lead to a wide range of physical, emotional, and functional burdens. The three major types of urinary incontinence, for example, have been shown to significantly impair health-related quality of life, with mixed urinary incontinence having the largest impact. 5 Despite these potential burdens, only an estimated 25% of those with urinary incontinence seek medical care. 20 Figure 8: Despite the high prevalence of incontinence, most patients do not seek or receive care 20 No urinary incontinence (60%) Incontinent, but did not seek care (30%) Sought care (10%) Evaluating and managing urinary incontinence 9

19 Incontinence also leads to an increased risk for falls (Table 3). 3 This may be due to rushing to the toilet coupled with distress or anxiety related to urine loss. Fall risk might also be raised by the multi-tasking cognitive demands of walking, controlling one s bladder, and negotiating obstacles in the home. The association between falls and urinary incontinence suggests that if an elderly person seeks help for either falls or management of urinary incontinence, they should also be evaluated for their risk of the other problem. Table 3: Urinary incontinence and risk of falling 3 Type of urinary incontinence (Reference: no urinary incontinence) Pooled odds ratio Urgency urinary incontinence Stress urinary incontinence Mixed urinary incontinence % confidence interval Coping with urinary incontinence can be stressful. Daily activities may have to be carefully planned to avoid accidents, and the fear of urinary leakage or associated odor can lead to social isolation. Strong associations between urinary incontinence and depressed mood were found in a study of 3536 women in a large HMO in Washington State. 19 The causality of these associations is undoubtedly bi-directional. People who are depressed may be at higher risk, either physiologically or behaviorally, for incontinence. It s also likely that incontinence can precipitate or exacerbate a depressed mood, particularly when it results in social isolation. 4 Figure 9: Urinary incontinence and depression 19 Severity of UI Type of UI Major Depression (%) Major Depression (%) No Mild Moderate Severe 0 No Stress Urgency 10 Evaluating and managing urinary incontinence

20 Importantly, urinary incontinence has been shown to double (for women) or triple (for men) the risk of being admitted to a nursing home. 6 It is estimated that if urinary incontinence were adequately treated, nursing home admissions for women would drop by 6% and admissions for men would drop by 10%. 21 BOTTOM LINE: roughly 14 million people in the U.S. have urinary incontinence. Its prevalence in women is more than twice that of men, although prevalence rates between the genders begin to converge at age 80. Urinary incontinence can be a significant physical and emotional burden, increasing the risk of falls and depression, as well as the risk of nursing home admission. Only an estimated 25% of people with urinary incontinence seek medical care for it. Reversible causes of urinary incontinence One of the reasons urinary incontinence is so highly treatable is that so many of its causes are potentially reversible. Identifying these possible causes may help clinicians avoid more complicated evaluations and treatments, and often results in amelioration or elimination of symptoms. 22 Reversible urinary incontinence is often characterized by sudden onset, usually related to an acute illness, medication, or other iatrogenic cause; it subsides with the resolution of the acute cause. Persistent urinary incontinence is unrelated to an acute illness, although potentially reversible conditions may still contribute. Excessive caffeine intake Caffeine is uniquely irritating to bladder tissue and stimulates urine production. Moderate-to-heavy intake of caffeine (i.e., 450 mg/d, equivalent to about 3 cups of coffee daily) is associated with increased risk of urinary incontinence in women: a 19% increase in the frequency of urinary incontinence episodes and a 34% increase in urgency incontinence. 23 In men, consumption of 2 cups of coffee daily (~250 mg/d) is associated with moderate to severe urinary incontinence. 24 Although no intervention studies have been conducted of caffeine and fluid modification on urinary incontinence in men, avoidance or limitation of caffeine intake is likely to be a useful component of treatment. Excessive fluid intake/fluid retention Polyuria is urine output greater than 2500 ml in 24 hours and may contribute to urinary incontinence. Some common medical conditions such as hyperglycemia, hypercalcemia, and congestive heart failure can cause polyuria. A bladder diary (see Appendix 1) can help identify excessive fluid intake or indicate whether medicines or comorbid conditions may be contributing. Nocturnal polyuria occurs when 24 hour urine volume is normal but the total volume of all-night voids and the first void on rising in the morning represents over a third of 24 hour urine volume. Conditions associated with nocturnal polyuria include heart failure, atrial fibrillation, sleep apnea, renal insufficiency, daytime fluid retention, and medications such as diuretics. 25 Nocturia is very common in the older population, with 78% of women over 75 years reporting symptoms. 25 It can also affect sleep quality and pose a falls risk. Evaluating and managing urinary incontinence 11

21 Urinary tract infection Urinary tract infections are the most common infections in older people, and are 50 times more frequent in women than men. They are a common cause of acute (but not chronic) incontinence even if dysuria and frequency are not prominent presenting complaints. Conversely, incontinence is also a risk factor for urinary tract infection. Stool impaction Constipation is common in the elderly, with rates as high as 30% reported in residents in nursing homes. 26 Constipation can contribute to the burden of incontinence, and identifying and treating it can make an important difference to urinary incontinence treatment. Many common medications can cause or exacerbate constipation (e.g., opioids and anticholinergics) and less constipating alternatives are often available. Other common causes of constipation include immobility, depression, reduced fluid/fiber intake, bowel obstruction, hypothyroidism, and hypercalcemia. Atrophic urethritis/vaginitis A decline in estrogen levels from the premenopausal period onward causes changes in vaginal tissues and vaginal ph, which may contribute to urinary incontinence. Recurrent UTI and vaginal infections also may occur in women with atrophic vaginitis. Reduced mobility or access Impaired mobility in the elderly can be caused by numerous medical conditions, as well as by the loss of confidence following a fall. Mobility is also influenced by problems with vision, cognitive function, medications, arthritis, and aids such as canes or walkers. These factors can all increase the time needed to reach the toilet and manage clothing appropriately to avoid urine leakage. Mobility is also impaired by restraints if they are used in institutional settings. A lack of easily-accessible toilets, or toilets that do not have necessary aids, such as height-extenders or grab rails, can also contribute to functional incontinence. Delirium Delirium is an acute loss of orientation and cognitive function, characterized by a reduced ability to focus, sustain, or shift attention. Delirium can lead to urinary incontinence by making older adults become less attentive to their physiologic need to void. Delirious patients may have more difficulty in finding a bathroom on time. Medication side effects Many drug classes can cause, or contribute to, urinary incontinence (Error! Reference source not found.4). A review of all prescription and non-prescription medicines should be conducted as part of any clinical assessment of urinary incontinence. 12 Evaluating and managing urinary incontinence

22 Table 4: Drugs that can cause, or exacerbate, urinary incontinence 27 Effect on continence Urinary retention Sedation, delirium, immobility Increased urine production Urethral muscle relaxation Stool impaction Cough Bladder irritation Drug class α-agonists, anticholinergics, antidepressants, antipsychotics, calcium channel blockers, inhaled anticholinergics, opioids alcohol, anticholinergics, antidepressants, antipsychotics, opioids, sedative-hypnotics alcohol, caffeine, diuretics α-blockers, sedative-hypnotics anticholinergics, Opioids ACE inhibitors caffeine BOTTOM LINE: urinary incontinence can improve with treatment of a wide range of reversible/modifiable conditions that affect lower urinary tract function, urine production, mobility, cognition, or function. Evaluating and managing urinary incontinence 13

23 Overview of incontinence evaluation and initial treatment Figure 10 summarizes the basic steps of evaluation an initial treatment for any patient with urinary incontinence. Figure 10: Evaluation and treatment of urinary incontinence Ask Does uncontrolled urine loss bother you, and would you like to know more about how it could be treated? If yes: Assess history and physical, drugs and labs bladder diary Treat external and reversible causes If incontinence persists: Diagnose and treat incontinence by type Stress incontinence Involuntary leakage with effort or exertion (e.g., coughing) Urgency incontinence Involuntary leakage with a strong urge to urinate Mixed incontinence Combination of stress and urgency symptoms If incontinence persists or an anatomical abnormality is suspected, refer to a urologist or urogynecologist. 14 Evaluating and managing urinary incontinence

24 Clinical assessment Screening: Ask about it! Patients are often embarrassed to mention symptoms of urinary incontinence, and older patients may assume urinary incontinence is an expected part of normal aging. 1 Simple screening questions can facilitate an open exchange, although such screening does not occur often enough. In one study, only 38% of women with known urinary incontinence were screened for the condition. 28 Such questions can be integrated with other types of screenings for such things as fall risk or pain. Phrasing the question as being about a common and sometimes difficult-to-raise issue may be helpful. 1 Asking even a single question about incontinence can be powerful. A quality improvement intervention found a 15% increase in the appropriate care of urinary incontinence in older adults among providers who asked the following question: 29 Do you have a problem with losing your urine that bothers you enough that you would like to know more about how it could be treated? If the patient answers yes to this or another screening question, take a more detailed history, probing for details about when, where, and under what circumstances urine leakage occurs In addition, ask about caffeine and alcohol intake, the presence of diabetes or constipation, previous injuries or surgeries affecting the urinary tract, and the use of prescription and non-prescription drugs. Inquire about the severity of incontinence and its impact on the patient s quality of life. (Note that these are not necessarily the same things: even mild urinary incontinence can have a significant impact on a patient s quality of life.) An important potential aspect of quality of life is sexual functioning, which can be affected by urinary incontinence. Although patients may be embarrassed to mention stress incontinence that occurs during intercourse, they may talk about it if asked. Exclude other pathology Patients who have typical stress or urgency incontinence should not have any of the following features: Dysuria Obstructive symptoms such as straining to void, or a sensation of incomplete bladder emptying Recurrent urinary tract infections Neurological symptoms such as new-onset numbness or tingling, weakness, back pain, or visual disturbances Constipation or fecal incontinence Patients who have atypical features, major pelvic organ prolapse, and/or severe symptoms should be considered for specialist referral and are likely to warrant full assessment with cystoscopy and urodynamic study. Evaluating and managing urinary incontinence 15

25 Bladder diaries Bladder diaries (also called voiding diaries or frequency volume charts) are a practical method of quantifying urinary frequency and incontinence episodes. 14,32,33 Bladder diaries are highly reproducible, correlate well with urodynamic diagnoses, 14 and should be used as part of the initial assessment of urinary incontinence. 22,33 (See Appendix 1 for an example of a bladder diary.) A bladder diary allows for a 24-hour recording of voiding times and volumes; fluid intake; pad usage; leakage episodes and degree of incontinence; urgency and sensation; and activities during or immediately preceding the loss of urine. 10 It may also provide information about the excessive intake of dietary irritants such as caffeine and alcohol. The patient should complete the diary for a minimum of 3 days in a month. These days do not need to be consecutive but should cover both working and leisure days. A 3-day period allows that capture of variation in day-to-day activities while limiting the burden and time required to record the information. 10 A bladder diary provides an objective measure of the patient s symptoms, engages the patient in treatment, and can allow comparison of symptoms over time and with treatment. It also encourages patient awareness of voiding habits and can therefore serve as an important tool in patient education or bladder retraining regimens. Table 5: What bladder diary patterns can reveal 32 Pattern Frequent small volume voids Frequent large volume voids Nocturnal polyuria Possible Causes Overactive bladder or deliberate patient restriction of fluid intake Excessive fluid intake, diabetes mellitus or insipidus, or hypercalcemia Obstructive sleep apnea, cardiac failure, poorly timed diuretic use, or excess evening fluid intake Other assessment tools There are several incontinence-specific quality of life and symptom severity scales. 22,33 The International Consultation on Incontinence (ICI) has produced a validated questionnaire (the ICIQ) which assesses both the severity and impact on quality of life of urinary symptoms. 34 Its short form (ICIQ-SF) is a four-item screen which can simplify and standardize assessment and is compatible with busy primary care practice settings (see Appendix 2). A higher score on the ICIQ-SF indicates a higher severity of incontinence symptoms. Assess use of medications and/or herbal products Review all prescription and over-the-counter medicines (including complementary and alternative medicines), alcohol, and caffeine. Oral hormone replacement therapy increases urinary incontinence. 35 The mechanism is not completely understood, but some evidence suggests that it may do so by causing degradation of paraurethral connective tissue Evaluating and managing urinary incontinence

26 Many drugs have anticholinergic adverse effects, which are usually dose-related, may be additive, and tend to be greater in the elderly. Even if the contribution of each individual agent is small, a patient s total anticholinergic load may be sufficient to cause or worsen urinary incontinence. St John s Wort, an herbal medicine often used without a prescription to attempt to treat depression, has been associated with voiding difficulty; other complementary medicines containing guarana or large amounts of caffeine can increase diuresis, aggravate detrusor instability, and worsen urgency incontinence. Table 6: Relative risk values for selected drugs that can cause, or exacerbate, urinary incontinence Medications Evidence from randomized controlled trials Oral estrogen and progesterone Oral progesterone Evidence from observational studies Alpha blockers Alpha blockers + loop diuretics Other antihypertensive classes SSRI antidepressants Anxiolytics, hypnotic-sedatives Cholinesterase inhibitors Evidence from case reports Levodopa, antipsychotics, SNRI Only included in drug label Opioids, anticonvulsants RR (95% CI) or Range 1.4 ( ) 1.5 ( ) 4.5 ( ) 8.8 ( ) Non-significant (RR: ) 1.6 ( ) 1.4 ( ) 1.6 ( ) NA NA Physical examination The physical exam in women presenting with symptoms of incontinence should include pelvic, abdominal, rectal, neurological, and cardiac examinations. 14,31,32 Evaluating and managing urinary incontinence 17

27 Table 7: Physical examination finding and implications in women Organ System Exam Findings Implications Pelvic Pelvic organ prolapse Incontinence with a high-post void residual (from bladder outlet obstruction) or voiding dysfunction Vulvar/vaginal atrophy Weak pelvic floor muscle assessment Anterior vaginal wall palpation for urethral tenderness or discharge Bimanual exam for pelvic masses Incontinence with a high-post void residual or voiding dysfunction Stress incontinence Irritative symptoms (frequency, urgency, burning) from urethral infection or inflammation Voiding dysfunction from pelvic masses Abdominal Fullness, bloating, masses, ascites Voiding dysfunction from abdominal pressure Palpable bladder Incontinence with a high-post void residual Rectal Reduced or absent anal sphincter tone Stress incontinence or Incontinence with a high-post void residual Fissures may indicate chronic constipation or fecal impaction Overflow incontinence (from bladder outlet obstruction) or voiding dysfunction Neurologic Mental status Functional or mixed incontinence due to decreased awareness of need to void Abnormal perineum and lower extremity exam (motor/sensory) Incontinence with a high-post void residual Cardiac Volume overload Nocturia or nocturnal incontinence Assess pelvic floor muscle strength in women Digital assessment of pelvic floor strength is easy to perform, correlates well with invasive assessment, and should be performed before the use of pelvic floor muscle training. Pelvic floor muscle strength can be determined by asking the patient to contract her pelvic floor muscles while the examiner performs a digital vaginal examination. Women who cannot consciously contract their pelvic floor muscles can be instructed to contract the muscles they would use to keep from passing gas or to stop themselves from voiding. During digital vaginal palpation, the examiner places the index finger at 4 o clock and then 8 o clock. The tone and strength of the pelvic muscles at rest and with contraction of the pelvic floor muscles can be rated with a subjective 5 point scale: 0 (no tone or strength) to 5 (strong tone and strength). 31 If pelvic floor muscles are weak, refer the patient for pelvic floor muscle training (see below) Evaluating and managing urinary incontinence

28 Urine stress test The stress test involves observation for urine loss with coughing or a Valsalva maneuver. In either the standing or lithotomy position, urine loss from a comfortably full bladder with stress (Valsalva or cough) indicates the presence of stress incontinence. 31 A meta-analysis of five cohort studies found that a positive urine stress test increases the likelihood of stress incontinence by threefold, and a negative test decreases its likelihood by about two-thirds. 31 No additional diagnostic accuracy is obtained with more complicated stress tests (such as sequential emptying/filling or supine/standing positioning). One caveat is that the patient should not have incomplete bladder emptying. Before or after the stress test, women should have post-void residual volume objectively determined with portable ultrasound machines or less commonly urinary catheterization. (For many in primary care, this may be a reason to refer the patient to a specialist.) Women with incomplete bladder emptying and overflow incontinence could have a positive supine stress test, yet the diagnosis and treatment are completely different from those for stress urinary incontinence. Urinalysis A urine dipstick test may be important in women with new onset symptoms (or mixed urinary incontinence symptoms) and urinary incontinence that is associated with dysuria, hematuria, or pyuria. 22,33,37 Additional tests In select patient groups additional tests may be useful for ruling out other conditions contributing to incontinence. These tests include: Post-void residual determination Urine culture Cytology Blood glucose and calcium Kidney function Renal ultrasound BOTTOM LINE: routinely ask older patients about incontinence, and ask those with incontinence to keep a bladder diary. Review medication lists for drugs that contribute to incontinence. History, physical exam (abdominal, pelvic, and rectal), and urinalysis can guide evaluation and management. When to refer Refer to a specialist for the following reasons: High post-void residual volume suggestive of urinary retention Abnormal urine cytology Abnormal renal ultrasound Cystourethroscopy Urodynamic testing Evaluating and managing urinary incontinence 19

29 Although urodynamic studies are sometimes considered the gold standard test for urinary incontinence, they are expensive, uncomfortable, and lack evidence that they affect outcomes. One trial found women who underwent urodynamic studies were twice as likely to receive medical or surgical treatment as those who did not undergo urodynamic studies. However, there were no differences between the groups in outcomes of cure rates, incontinence episodes, or health status measures. 38 A Cochrane review concluded that there is insufficient data to determine the benefits of urodynamic studies in relation to clinical outcomes. 39 Primary care physicians should consider referring a patient if he or she manifests any of the features summarized in Table 8. Table 8: Examples of urinary incontinence cases appropriate for referral to a specialist 27 Examples History of surgery or irradiation involving pelvic area or lower urinary tract within 6 months Rationale Suspect a structural abnormality related to recent procedure 3 or more symptomatic UTIs in the past year Suspect a structural abnormality predisposing to infection Marked pelvic organ prolapse or prostate enlargement Postvoid residual 200mL Difficulty passing a 14-French straight catheter Hematuria ( 3 RBCs/HPF) on urinalysis (pathology in the urinary tract) Failure to respond adequate therapeutic trials Suspect an anatomical abnormality or rule out BPH or prostate cancer Suspect an anatomic obstruction or neurologic abnormality Suspect an anatomic obstruction Suspect a pathologic condition in the lower urinary tract Consider urodynamic test to guide therapy BOTTOM LINE: urodynamic studies should not routinely be performed in patients with urinary incontinence. Indications include an uncertain diagnosis despite adequate history and exam, discordance between history and exam, voiding dysfunction, or failure to improve with conservative or surgical therapy. Overview of urinary incontinence management options Whatever the type of urinary incontinence, clinicians can draw from an array of well-established treatment options than can be deployed in a step-wise manner, starting with behavioral interventions and progressing, if needed, to pharmacological or surgical options. In the primary care setting, behavioral management options are a readily available, safe, and potentially helpful means of helping patients deal with their symptoms. Much can be accomplished by encouraging 20 Evaluating and managing urinary incontinence

30 them to talk about their condition, framing urinary incontinence as a common condition, and educating patients about a range of basic concepts such as how the bladder works, the role of liquids and caffeine, the potential negative consequences of excessive reliance on pads or absorbent under-garments, the value of making environmental changes such as having a safe, well-lit path to the bathroom, and the use of toilet substitutes such as urinals or bedside commodes. 1 Education, behavioral, and physical interventions are well-studied, are generally non-invasive, can be effective for many common types of incontinence, are suitable for the outpatient setting, and are recommended by most guidelines as an initial approach to therapy. 1,40 In one study of women with incontinence, behavioral and physical therapy that included group and individual instruction, keeping a bladder diary, pelvic muscle exercises, and bladder training resulted in a 50% reduction in the mean number of incontinence episodes compared with a 15% reduction in controls, a difference that was maintained for 6 months. 40 There were no differences in treatment efficacy by type of incontinence (stress, urgency, mixed). 40 Some general principles to keep in mind: Some behavioral interventions require functional, motivated patients who are capable of learning and practice Most evidence for treatment efficacy is based on studies of women. Urinary incontinence in men is less well-studied, except as it relates to prostate-related dysfunctions Drug therapies, when appropriate, are primarily used to help symptoms of urgency urinary incontinence and/or overactive bladder No drugs are FDA-approved to treat stress or mixed urinary incontinence Containment products Containment products include absorbent under-garments, pads, and sanitary napkins. These may be useful in managing incontinence but should not replace active workup and treatment. 22 Patients prescribed behavioral, physical, or drug therapies may need them for the short- or long-term depending on the frequency and severity of episodes and response to treatment. 22 Although readily available, containment products are relatively expensive and are not covered by Medicare or most other insurance plans. Patients also may choose to use them to avoid the embarrassment of seeing a clinician. Because of their lower cost and reduced stigma, some women prefer sanitary napkins or mini-pads for incontinence. These, however, are less effective than incontinence pads. 41 Managing stress urinary incontinence in women Behavioral approaches Caffeine reduction and fluid management Intervention studies of caffeine reduction 42,43 and fluid intake reduction 44,45,46 in women have shown inconsistent results on their effectiveness in reducing UI episodes. Caffeine is contraindicated for patients with any type of urinary incontinence because it is both a bladder irritant and a diuretic. 23 Despite the Evaluating and managing urinary incontinence 21