Urine For A Treat: Incontinence

*Please note that this post focuses on urinary incontinence (UI) in patients with a uterus who are not currently pregnant.

Urinary Incontinence

UI is the involuntary leakage of urine. It may be transient or chronic.

MANY risk factors for UI:

  • Age
  • Pregnancy
  • Pelvic floor trauma
  • Menopause
  • Hysterectomy
  • Obesity
  • Urinary tract infection
  • Functional/cognitive impairment
  • Chronic cough
  • Constipation
  • Medications/substance use
  • Stroke/Neurologic issues

Types of INCONTINENCE

  • Stress
    • Usually caused by sphincter muscle weakness/uretheral sphincter failure, resulting in an inability to retain urine with increases in intrabdominal pressure such as coughing, laughing, sneezing
  • Urge
    • Involuntary loss of urine associated with a sudden and compelling urge to void
    • Secondary to overactivity of the detrusor muscle
    • Usual complaints include frequency, urgency and nocturia
  • Mixed (stress + urge)
  • Overflow
    • Overdistension of the bladder leading to dribbling of urine, inability to empty bladder, urinary hesitancy
    • Usually secondary to detrusor muscle impairment, bladder outlet obstruction or both
  • Functional
    • Variable leakage of urine usually caused by environmental or physical barrier to toileting such as cognitive impairment or impaired mobility
    • Timed voiding is often helpful in these situations

Knowledge Check #1

An 80-year-old patient with dementia, hypothyroidism, and osteoarthritis is evaluated for increasing urinary incontinence, now needing to wear a diaper. Her daughter is concerned about mild skin irritation she has noticed on the patient’s buttocks. Medications are levothyroxine and as-needed acetaminophen.

On exam, vital signs are normal and BMI is 21. The patient is confused but cooperative. She appears frail and uses a walker for balance when standing and ambulating. Cardiopulmonary examination is normal. The abdomen shows no tenderness or suprapubic fullness. Erythema is present around the groin and buttocks, but no pressure ulcers are seen. Urinalysis is normal.

Which of the following is the most appropriate management?

A. Antimuscarinic agent
B. Pelvic floor muscle training
C. Prompted voiding
D. Transdermal estradiol

H&P

A 2006 study in the Annals of Internal Medicine found that a 3-item questionnaire is a simple, quick, and noninvasive test with acceptable accuracy for classifying urge and stress incontinence and may be appropriate for use in primary care settings.

Source: Brown et al. Ann Intern Med. 2006

A voiding diary is another approach to gauging incontinence. Patients record urinary frequency, amount, description of incontinence episodes and liquid/oral intake.

Evaluating for reversible causes (“DIAPERS”):

  • D = Delirium
  • I = Infection
  • A = Atrophic vaginitis
  • P = Pharmaceuticals
  • P = Psychologic component
  • E = Excessive urine output (i.e., excessive fluid intake, medications, DM/hyperglycemia)
  • R = Reduced mobility
  • S = Stool impaction

There are MANY medications and substances that can potentially induce urinary frequency/incontinence symptoms:

  • Alpha adrenergic agonists
  • ACE inhibitors
  • CCB
  • Diuretics
  • Selective Cox-2 NSAIDs
  • Opioids
  • Muscle relaxants
  • Antidepressants
  • Antipsychotics
  • Anti-parkinsonian agents
  • Sedative-hypnotics
  • Alcohol
  • Caffeine
  • Antihistamines
  • Anticholinergics
  • Thiazolidinediones

Work-up

Interestingly, laboratory testing is NOT routinely indicated for UI—evidence is lacking on the utility of urinalysis and bloodwork.

  • May consider urinalysis to rule out infection, hematuria, proteinuria, and glycosuria
  • May consider urine creatinine, which may be elevated in the case of urinary retention
  • Post-void residual (PVR) should be considered in patients who are suspected to have overflow incontinence or when a clear cause of UI is not obvious

Management of Stress Incontinence

ACP Recommendations

  1. ACP recommends first-line treatment with pelvic floor muscle training (PFMT) in women with stress UI. (Grade: strong recommendation, high-quality evidence)
  2. ACP recommends PFMT with bladder training in women with mixed UI. (Grade: strong recommendation, high-quality evidence)
  3. ACP recommends against treatment with systemic pharmacologic therapy for stress UI. (Grade: strong recommendation, low-quality evidence)
  4. ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence)

Non-pharmacologic

  • Pelvic floor muscle training (PFMT) = instruction on the voluntary contraction of pelvic floor muscles (aka Kegal exercises)
    • PFMT with biofeedback using vaginal EMG can give a patient visual feedback when they are properly contracting their pelvic floor muscles
  • Bladder training = behavioral therapy that includes extending the time between voiding
  • Continence service = treatment program involving multi-disciplinary approach with individuals trained in identifying, diagnosing and appropriately treating patients with UI

PFMT

Counseling points:

  • Identify pelvic floor muscles by stopping urine midstream
  • Tighten muscles by imagining sitting on a marble and lifting it upward
  • Focus on only on tightening pelvic floor muscles Be careful not to flex the muscles in your abdomen, thighs or buttocks. Avoid holding your breath. Instead, breathe freely during the exercises
  • Aim for at least 3 sets of 10 to 15 repetitions a day.
  • Don’t make a habit of using Kegel exercises to start and stop your urine stream

“Based on the data available, we can be confident that PFMT can cure or improve symptoms of stress UI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires… The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI.”

Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018

Knowledge Check #2

A 64-year-old patient is evaluated for difficulty controlling her urine. The patient works and maintains a very active lifestyle; the urinary leakage is restricting her activities. She needs to wear pads because of involuntary loss of urine with coughing, sneezing, and laughing, and occasionally with physical exertion. There is no dysuria or increased urinary frequency. She does not smoke and does not drink alcoholic beverages. Medical history is remarkable for hypertension, and her only medication is lisinopril.

On physical examination, temperature is normal, blood pressure is 130/78 mm Hg, pulse rate is 72/min, and respiration rate is 14/min; BMI is 29. General examination is unremarkable. Pelvic examination is normal except for mild anterior wall prolapse. Urinalysis is normal.

In addition to suggesting weight loss, which of the following is the most appropriate management?

A. Oxybutynin
B. Pelvic floor muscle training
C. Postvoid residual urine volume measurement
D. Prompted voiding
E. Urodynamic study

Pharmacologic

Pharmacologic therapy is largely limited to topical estrogen therapies (alone or in combination with PFMT) and duloxetine.

  • Most studies found either insufficient evidence or low quality evidence that either therapy reduced incontinence/achieved continence
  • ACP’s guideline notes that high quality evidence showed duloxetine did not statistically significantly improve UI compared with placebo

Management of Urge Incontinence

ACP Recommendations

  1. ACP recommends bladder training in women with urgency UI. (Grade: weak recommendation, low-quality evidence)
  2. ACP recommends PFMT with bladder training in women with mixed UI. (Grade: strong recommendation, high-quality evidence)
  3. ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication. (Grade: strong recommendation, high-quality evidence)
  4. ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence)

Non-pharmacologic

Bladder training starts with timed voiding.

  • Patients should keep a voiding diary to identify their shortest voiding interval, which is used when initiating bladder training
  • The patient is instructed to void by the clock at regular intervals while awake, using the shortest interval between voids identified on the voiding diary as the initial voiding interval
  • Urgency between voiding times is controlled with either distraction or mental relaxation techniques along with quick contractions of the pelvic floor muscles to suppress urgency and bladder contraction. When the patient can avoid leakage for one day using the initial urination interval, the time between scheduled voids is increased by 15 minutes. The intervals are gradually increased until the patient is voiding every 3-4 hours without urinary incontinence or frequent urgency

Pharmacologic

Antimuscarinics increase bladder capacity and decrease urgency through blockade of muscarinic receptor stimulation by acetylcholine during bladder storage 

  • Drugs include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium
  • ADE include
    • anticholinergic effects (e.g., dry mouth, constipation, tachycardia, palpitations, retention)
    • additive effects (e.g., anti-histamines, muscle relaxants, TCAs, antipsychotics, bronchodilators)
    • increased rates of dementia and Alzheimer disease 
    • somnolence and dizziness
    • drug-drug interactions with CYP3A4 agents
  • Contraindications include gastric retention, untreated narrow angle closure glaucoma, and supraventricular tachycardia
  • Dose adjustments needed in presence of renal impairment and hepatic impairment 
  • Monitoring:
    • 4-6 week initial follow-up to assess response
    • Check PVR in patients at higher risk for retention, including those who develop difficulty urinating or worsening incontinence on an antimuscarinic, those taking other medications with anticholinergic effects, and those with pelvic organ prolapse beyond the hymen
    • May take up to 12 weeks for medication to have full efficacy
    • Reasonable to try different types of antimuscarinics

Mirbegron, a beta-2 agonist, promotes selective beta receptor stimulation of the detrusor muscle to enhance smooth muscle relaxation.

  • Expensive but may be better tolerated than antimuscarinics, especially in patients with dementia
  • ADE include
    • HTN
    • Dry mouth and constipation (but less than antimuscarinics)
    • Retention
  • Contraindicated in presence of severe or uncontrolled HTN
  • Dose adjustments needed in presence of renal impairment and hepatic impairment 
  • Monitoring:
    • 4-6 week initial follow-up to assess response
    • Check PVR at follow-up OR if new symptoms arise suggesting incomplete bladder emptying (e.g., urinary hesitancy, incomplete emptying, worsening urinary incontinence, or frequency)

Urology?

Indications to consult urology include

  • Relapse /recurrent UTI
  • New onset neurologic symptoms/muscle weakness
  • Uterine/organ prolapse beyond/past vaginal introitus
  • Persistent hematuria
  • Persistent proteinuria
  • Elevated PVR (>200, 300)
  • Pelvic surgery/radiation
  • Uncertain diagnosis

Alternative referrals include urogynecology, geriatrics, and pelvic floor/pelvic dysfunction rehabilitation through physical therapy.

Knowledge Check: Answers

  1. C – prompted voiding
  2. B – pelvic floor muscle training

Blog post based on Med-Peds Forum talk by Melinda Delaney, MP Core Faculty

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