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Treating Incontinence
by Leslie Knowlton
Geriatric Times March/April 2001 Vol. II Issue 2
Treating incontinence in older adults was the topic of a recent workshop for primary care physicians given in New York City by Jonathan M. Vapnek, M.D., assistant professor of urology at Mount Sinai School of Medicine.Vapnek began with an overview of incontinence, saying it affects an estimated 10% to 30% of the community-dwelling elderly and 60% to 70% of nursing home dwellers. Twice as common in females, the disorder has direct annual health care costs in this country of at least $10 billion, plus indirect costs to patients including low morale, social isolation, embarrassment, reduced mobility, sexual problems, poor sleep and preventable institutionalization.
Vapnek cited a study (Borrie and Davidson, 1992) that found subjects spent an average of 52.5 minutes each day dealing with incontinence. He said the problem is underreported and undertreated because of a mistaken belief that incontinence is part of the normal aging process.
Vapnek reviewed the effects of aging on bladder function, noting that nocturia affects up to 60% of people over age 65. "There's decreased bladder capacity and urethral closure pressure as you get older, in addition to increased residual urine and larger urine volumes," Vapnek said. "There are also uninhibited detrusor contractions in up to 10% of women and 30% of men, and older people have slower reaction times and more limited mobility."
Vapnek said older women have a predisposition to develop urinary incontinence because of changes in bladder smooth muscle; degeneration and fibrosis of the bladder wall; diminished muscle tone in the bladder, internal and external sphincters, and pelvic floor musculature; childbearing and gynecological procedures; obesity; and postmenopausal changes.
"It's almost a conspiracy that by the time women reach a certain age, they will have a problem," he said.
Types of Incontinence
There are many ways to classify incontinence, Vapnek explained. "The traditional way is to divide between urge and stress, and see if it's more one than the other," he said. "The bladder is an unreliable witness, and very often there's overlap."
Urge incontinence (UI) is defined as leakage associated with an abrupt and uncontrollable desire to void caused by neurologic or non-neurologic causes. It is extremely common in multiple sclerosis, Parkinson's disease and central nervous system lesions such as stroke. UI from detrusor instability is also found after bladder surgery and radiation therapy. In postmenopausal females, estrogen withdrawal often results in UI.
"Urge incontinence is the urge to go, and you can't stop it," Vapnek told attendees. "It's a classic key-in-the-lock Pavlovian conditioning response and a hard habit to break."
Stress incontinence is defined as leakage secondary to an increase in abdominal pressure such as when coughing, sneezing, laughing or exercising; it is caused by pelvic floor muscle laxity, neuropathy and urologic surgery.
"The pathophysiology of genuine stress urinary incontinence is related to weakened pelvic ligaments and urethral hypermobility," reported Vapnek. "In women, there is loss of the backboard effect, with ineffective transmission of intra-abdominal forces to the urethra."
Another type is overflow incontinence. "Overflow incontinence is seen in bladders not working very well because of outlet obstruction, poor detrusor contractility and impaired sensation," Vapnek said, adding that there's also total incontinence, which is evidenced by continuous loss of urine, usually without bladder activity or any associated feeling of fullness or desire to void.
A related condition includes transient urinary incontinence, which refers to leakage associated with a variety of treatable problems. Vapnek said the mnemonic DIAPPERS is useful for describing these conditions, which should be identified and promptly treated (Figure).
Postprostatectomy incontinence most commonly occurs after treatment for prostate cancer, and functional incontinence most often is associated with states of confusion and poor mobility. Finally, mixed incontinence is the term used when patients "do not fall neatly into any one of the above categories," Vapnek explained.
Evaluating Incontinence
Vapnek said evaluations for incontinence are straightforward. "The history and the physical exam are still 90% of the evaluation," he said. "Other tests usually just confirm what you already know...So the take-home [message] is that most patients don't have to go to a urologist." Taking an incontinence history includes asking about the problem's onset, any particular event that may have preceded onset, symptoms of urge or stress, and progression of those symptoms.
"In many cases, symptoms will be mixed," Vapnek said. Especially in males, a history of obstructive symptoms such as straining to void, reduced stream force or sense of incomplete voiding should be taken. Information about amount of urine loss, types of protection used and effect on daily activities should also be obtained. Past medical history should include previous pelvic or spinal surgery, former radiation therapy or other trauma, obstetrical and menopausal history, and other pertinent medical problems such as diabetes mellitus and neurological diseases.
Finally, a list of all medications should be obtained, as significant urinary effects result from diuretics, antidepressants, antipsychotics, anticholinergics, sympathomimetics and many over-the-counter drugs.
When conducting the physical exam, Vapnek said the degree of urethral mobility should be assessed, as well as integrity of support of the urethra and bladder. The abdomen should be checked for tenderness, palpable bladder and old incisions. For men, a rectal examination should be done to assess size and consistency of the prostate, anal sphincter tone and perianal sensation, voluntary pelvic floor contraction, and bulbocavernosus reflex. For women, the genital examination should also include checking the vagina for assessment of pelvic floor descent and pelvic prolapse and a bimanual exam for atrophic vaginitis, mucosal friability, petechiae, telangiectasia and vaginal erosions.
For all patients, the clinician should try to reproduce urinary loss symptoms. To do this, the bladder should contain at least 200 cc of urine or water to avoid false-negative results. Also for all patients, a urinalysis by dipstick and microscopic examination should be done, followed, if necessary, by a culture or cytological study and assessment of serum blood urea nitrogen and creatine levels if renal compromise is suspected.
"If there's a UTI [urinary tract infection], nothing else need be done until after the UTI is treated," said Vapnek. "If after treatment the patient remains symptomatic, then do an evaluation. But if the symptoms go away, that's the end of it."
Other lab tests include renal sonography for men with postvoid residual urine volume (PVR) greater than 100 cc and the formal urodynamic evaluation, for which indicators include mixed incontinence symptoms, failure of empiric treatment, neurological illness, prior pelvic surgery and severe diabetes. The urodynamic study will yield data about bladder sensation, capacity, and presence or absence of unstable contractions. For the sphincter, it reveals data about length and closure pressure and behavior during filling and voiding.
"The urodynamic study takes only about 20 minutes and gives you a lot of valuable information. Its principal components are PVR, the filling phase and voiding phase. If you haven't done all that, you're not doing your job," said Vapnek, adding that drawbacks to the test are that it is not always available, often requires a special trip, can be uncomfortable, is expensive, is not well standardized and often is not needed.
Simplified tests reported in the Journal of the American Geriatric Society (Ouslander et al., 1989) include stress maneuvers, normal voiding, postvoid residual determination (catheterization), bladder filling (simple cystometry), repeat stress maneuvers and bladder emptying.
"Even these tests are unnecessary if symptoms are pure stress or urge incontinence, if the patient is examined with a full bladder to ensure an accurate stress test and the patient voids a normal volume with low PVR," reported Vapnek.
Treatment Options
Behavioral approaches, which Vapnek chooses as first-line treatment, include bladder training, decreasing fluid intake, changing medication schedules, assisted regular toileting, pelvic muscle floor exercises and biofeedback.
Medical therapy includes anticholinergics, hormones, a-agonists and other medications. Surgical procedures are bladder neck suspensions, sling procedures and artificial urinary sphincter implantation. Miscellaneous treatments include electrical stimulation and injectable materials such as collagen.
"Six months later you may have to do it again," said Vapnek of collagen injections. "But we're talking about a 10-minute office procedure with 65% [of patients] cured or improved."
New Medications
Vapnek said newly available medications include tolterodine (Detrol), which has equivalent efficacy to immediate-release oxybutynin (Ditropan, Ditropan-XL) but with fewer side effects.
"There are no head-to-head studies of these two drugs," he said. "It's a horse race, and I'm not going to tell you which is better."
Regarding hormone therapy for incontinent postmenopausal females, "studies on using estrogen delivered orally or vaginally to treat sensory urge incontinence showed subjective cure rates of 0% to 65%," Vapnek reported. "Studies of hormones to treat stress incontinence show variable response, with some showing increases in urethral closure pressure."
Vapnek said that indications for urological referral are high postvoid residual volume (>200 cc), severely limited bladder capacity (<100 cc), recent pelvic surgery or irradiation, frequent UTIs, hematuria, marked pelvic prolapse, men with stress incontinence, and women with stress incontinence who are surgical candidates.
"Incontinence is not a normal part of aging," Vapnek concluded. "There are many different kinds and multiple treatments, and no one should have to live with it, no matter how old or infirm."
References
Borrie MJ, Davidson HA (1992), Incontinence in institutions: costs and contributing factors. CMAJ 147(3):322-328.
Ouslander JG, Leach GE, Staskin DR (1989), Simplified tests of lower urinary tract function in the evaluation of geriatric urinary incontinence. J Am Geriatr Soc 37(8):706-714.
