Urinary Incontinence in the Elderly

Urinary Incontinence in the Elderly: Practical Approaches for the Primary Care Internist Bree Johnston, MD MPH San Francisco VAMC UCSF Overview Prevalence and clinical importance  Transient ( or potentially reversible) causes of incontinence  Chronic incontinence  Clinical evaluation  Treatments  Some recent studies  Clinical Importance Common, especially in women (ratio 4:1 in age <60, 2:1 in age > 60)  Women age 60+: 30-50% have “any” UI, 614% have daily UI  Common cause of institutionalization, social isolation, and decline in function  Increased risk of fractures  Often not mentioned to physicians  Physicians often ill prepared to deal with it  Normal physiology   Neural control  Frontal lobe inhibits  Micturition center in pons  Detrusor under cholinergic control  Urethra under alpha adrenergic control  External sphincter under voluntary control Normal urination requires intact neural control, intact anatomic structures, mobility, and awareness of need to urinate Case #1  80 year old man is scheduled for a TURP for nocturia and urge incontinence. He has not seen an internist for 3 years, and comes to you for “surgical clearance”. He is healthy and is on no medications. He states that he has “slowed down” over the past 2 years, and has put on 20 pounds over the past five years. ROS is otherwise unremarkable except for mild erectile difficulty over the past few years.  What do you do? Step #1: Rule out Transient Causes D elirium  I nfection  A trophy  P harmeceuticals  P sychologic  E ndocrine or excess urine output  R estricted mobility  S tool impaction  Common Drug Causes of Incontinence Anticholinergics  Alpha agonists  Alpha antagonists  Diuretics (including caffeine)  Calcium channel blockers  Sedative hypnotics and any CNS depressants, including ETOH  Case #1    80 year old man is scheduled for a TURP for nocturia and urge incontinence. You do a physical exam, which is normal except for mild obesity, a slightly enlarged prostate, and mild peripheral neuropathy. Labs show normal renal panel, CBC, calcium, PSA 4, and glucose of 358. UA is normal except for glucose and protein in the urine. Evaluation of UI Step #1: Rule out transient causes  Step #2: Get a bladder diary  Step #3: Directed history and physical  Step #4: Make a diagnosis based on history, physical, PVR, and your knowledge of UI  A Bladder Diary T im e U sed to ile t In c o n tin e nce e p is o d e (s m a ll o r la rg e ? R eason O th e r fa c to rs (m e d ic in es) L iq u id s and c a ffe in e 7 -1 0 1 0 -1 1 -4 4 -7 7 -1 0 N ig h t O b s e rv a tio n s Step #3: History & Physical   History: night-time (better or worse?), volume, stress, urgency, bladder diary Physical:  Neuro exam, mental status, mobility  Men: Prostate, AUA  Women: Pad Test, Bimanuel with “Kegel test”  Both men and women: PVR, UA  Consider: glucose, calcium, electrolytes Step #4: Make a Diagnosis Overactive Detrusor Underactive Detrusor Open Sphincter Closed sphincter Case #2  A 60 year old woman comes in complaining of worsening incontinence with sneezing and coughing. Her pad test is +, she has some vaginal atrophy, and her PVR is 5cc  What do you do? Pattern #1: “Open sphincter” Presentation: Stress incontinence  Common cause in women  Causes: Childbirth, pelvic floor laxity, radical prostatectomy, alpha antagonists  PE: Often normal  + “Pad Test  Low PVR  Treatments for Stress Incontinence Reduce or alter fluid intake, caffeine, etc.  Timed voiding  Kegel’s, biofeedback & “vaginal cones”  Alpha agonists  Pessaries  Surgery  Collagen injections  Estrogen and Stress Incontinence      Meta-analysis of 6 small RCTs: oral estrogen may subjectively improve UI, Fantl 1994 Recent RCT found no improvement Fantl 1996 More efficacy with topical estrogens Epidemiologic studies find increased risk of UI in women on ERT Brown JAGS 1998 Bottom Line: Worth a trial of topical estrogen in presence of atrophy and irritative sx, otherwise questionable Alpha agonists Most studies done with phenylpropanolamine – now not available  Pseudoephedrine 15-30mg TID or prn  Contraindications: HTN, CAD, obstruction  Side effects: hypertension, dysrythmias, anxiety, insomnia, CVA, agitation, respiratory difficulty, sweating  Pelvic Floor exercises in Stress Incontinence Single blind RCT of 107 women with urodynamically proven stress incontinence with 6 months of intervention with: •Pelvic floor exercises (N =25) 8-12 contractions TID •Electrical Stimulation (N= 25) 30 minutes daily •Vaginal Cone (N=27) use 20 minutes daily •Control group (N=30) Bo et al. BMJ 1999 Results at 6 months 60 50 40 30 20 10 0 % Reporting "Incontinence No Longer a Problem" Pad Leakage Control Stimulation Kegel Cones Bo, BMJ 1999 Case #2  A 60 year old woman comes in complaining of worsening incontinence with sneezing and coughing. Her pad test is +, she has some vaginal atrophy, and her PVR is 5cc  Patient begins topical estrogen and, Kegel exercises, and sudafed, and has marked improvement. After two years, however, her symptoms are worse, and she has developed HTN, forcing her to stop the sudafed. She undergoes bladder suspension surgery with resolution of symptoms. Pattern #2: “Overactive Detrusor” Presentation: Urgency  Causes: Neurologic illness, idiopathic  PE: Often normal  PVR low  Case #3  A 70 year old woman comes in with frequent urination and incontinence. She often can’t make it to the bathroom in time, and is staying home more. Her exam is normal. Her pad test is negative, and her PVR is 3 cc. Behavioral Approaches Reduce caffeine, liquids  Timed voiding - go often enough to avoid accidents  Bladder training - lengthen time between voids gradually  Prompted voiding - caregiver positively reinforces dryness, neutral response to wetness  Treatments    Timed voiding, bladder training, prompted voiding Biofeedback & electrical stimulation Anticholinergics Oxybutinin XL (Ditropan XL) 5-30 mg QD  Oxybutinin 2.5mg QD - 5mg TID  Tolterodine 1-2mg PO BID  Imipramine 25-50mg QD or other TCAs  Dicyclomine, propantheline  Behavioral vs. Drug Treatment for Urge Incontinence RCT of 197 women (55-97) with urge or mixed incontinence with urge as predominant pattern  8 weeks of biofeedback assisted behavioral treatment, drug treatment (oxybutinin 2.5 mg QD - 5 mg TID) or placebo for 8 weeks  Burgio JAMA 1998 Results 100 90 80 70 60 50 40 30 20 10 0 100% 75% 50% Percent Reduction in Incontinence Behavioral Drug Control Mean # of Accidents per Week 18 16 14 12 10 8 6 4 2 0 Baseline 2 weeks 4 weeks 6 weeks 8 weeks Behavioral Drug Control Mixed incontinence  Stress and urge incontinence commonly coexist. One symptom may predominate. Treatment can be directed at both or either component. Case #3  A 70 year old woman comes in the frequent urination and incontinence. She often can’t make it to the bathroom in time, and is staying home more. Coughing and sneezing often bring on her sx. Her exam is normal. Her pad test is negative, and her PVR is 3 cc.  Patient begins ditropan XL and begins biofeedback, and her symptoms improve markedly. After two months, she is able to discontinue the ditropan with only occasional accidents. Pattern #3: “Closed sphincter” Presentation: Irritative sx, retention, high AUA score  Causes: BPH, complex cystocele, urethral stricture, alpha agonists, cancer, impaction  PE: May be normal, may find large prostate, may have urinary retention  PVR may or may not be high  Low urinary flow rate  Case #4  An 80 year old man comes in with increasing difficulty with urinating over the past two years. He gets up 6 times at night to urinate, and has to go multiple times during the day. His AUA score is 25, and he has a large prostate on exam. His PVR is 150 cc. AUA Score Distribution A U A S co re M ild (0 -7 ) M o d e ra te (8 -1 9 ) S e v e re (2 0 -3 5 ) T o ta l B P H P a tie n ts 20% 57% 23% 100% C o n tro l s u b je c ts 83% 15% 2% 100% Barry, Fowler, O’Leary 1992 Treatment Guidelines    Patients with mild BPH sx (AUA score < 8) can be followed with watchful waiting Patients with AUA score of >8 should be given information on watchful waiting, drugs, or surgery or other related options Surgery indicated for: Refractory retention  Recurrent UTI’s, hematuria, bladder stones, or renal impairment due to BPH  AHCPR 1994 Drug Treatments for BPH   Alpha antagonists - prazocin, terazocin, tamsulosin, doxazocin - choose based on BP and price Finasteride may take 6-12 months for maximum effect  Mixed results in RCTs (Lepor NEJM 1996), McConnell NEJM 1998)   Saw palmetto - evidence suggests better than placebo and similar to finasteride in efficacy Wilt JAMA 1998 TURP, Prostatectomy, and UI Stress incontinence in 1-2% of men postTURP AHCPR BPH Clinical Practice Guidelines, 1994  Urge incontinence in about 1% of men post-TURP AHCPR BPH Clinical Practice Guidelines, 1994  Post radical prostatectomy, about 20-25% of men have incontinence, but only 8% rate as “big problem” at 2 years  Sanford JAMA 2000 Incontinence Post Prostatectomy Baseline Incontinence 2.7% “moderate to big problem” Age < 60 1.7% > 2 times/day Age >75 4.1% >2 times/day 6-12 month 24 months 25% 8% 13% 35% 10% 41% Sanford J: JAMA 2000; 283: 354-60. The Good News     102 patients with incontinence post radical prostatectomy randomized to pelvic floor exercises up to one year or control group Intervention: Pelvic floor muscle contractions 90 times a day (training with biofeedback) Follow up: One year Outcome: Incontinence Van Kempen Lancet January 8, 2000 Outcomes Percentage of Patients Still Incontinent Treatment Control Months of FU 1 12 50% 5% 81% 19% Van Kampen The Lancet January 8, 2000 Case #4  An 80 year old man comes in with increasing difficulty with urinating over the past two years. He gets up 6 times at night to urinate, and has to go multiple times during the day. His AUA score is 25, and he has a large prostate on exam. His PVR is 150 cc.  Patient wants to try medications first. Despite treatment with maximum doses of alpha blockers and finasteride, patient does not improve over 2 months. TURP is performed and the patient has excellent results. Pattern #4: “Flaccid Detrusor” Presentation: Retention, overflow  Causes: Neurologic illness, longstanding obstruction, anti-cholinergics  Exam: Large bladder Underactive  High PVR Detrusor  May have abnormal neuro exam  Case #5  A 60 year old comes in complaining of lower extremity weakness and abdominal pain. He has had back pain for months, which has been evaluated multiple times and thought to be “mechanical”. Exam shows abdominal distension and loss of lower extremity strength. PVR is 500 cc. Treatments No good medication options  Crede manuever  Catheterization or suprapubic catheter  Surgery  Case #5  A 60 year old comes in complaining of lower extremity weakness and abdominal pain. He has had back pain for months, which has been evaluated multiple times and thought to be “mechanical”. Exam shows abdominal distension and loss of lower extremity strength. PVR is 500 cc.  Urinary catheter is placed. MRI reveals cord compression and workup reveals metastatic prostate cancer. Patient transiently improves after XRT and hormonal treatment, although he continues to require intermittent catheterization. Case #6    A 75-year-old man comes in three months after his TURP. He is furious because his incontinence was not improved by the surgery. The urologist saw him last month and said that everything seemed “fine” and offered no specific advice. What would you do next? How would you manage his problem? Case #7    An 80-year-old man comes in for a new patient appointment with a complaint of abdominal pain. He has had increasing difficulty with urinating over the past two years, and for the past week has had difficulty passing his urine at all. He has a palpable bladder on exam, a large prostate and his PVR is 1.5 L cc. His AUA score is 30. What would you do next? How would you manage his problem? Is a transient cause present? Yes Treat transient cause See if condition improves No Bladder diary Physical exam UA & PVR Pad Test AUA score for men High PVR? Urology referral &/or catheter placement Treat for BP H if present Low PVR ? Treat for urge or stress incontinence Summary  Urinary incontinence is common, often not     mentioned to MDs, and can lead to serious quality of life impairment Rule out transient causes first (UA, labs, meds) Bladder diary, simple H&P, PVR will establish pattern in most chronic cases Primary Care MDs can manage many cases of “low PVR” incontinence Many cases of “high PVR” incontinence will require referral or more involved evaluation