INCONTINENCE

DR.SWATHI SINGH
MPT ORTHOPAEDICS,MIAP
Prevalence of Urinary Incontinence

• Age 15 to 64 1.5 - 5% men

10-30% women
• Noninstitutionalized 15-35%
>60 years old Twice as high in
women
• Homebound elderly 50%
• Nursing home residents 50% (two thirds if
catheterized
population included)
More is spent on incontinence
care than other chronic
diseases such as breast
cancer and osteoporosis.
 DEFINITION OF
URINARY INCONTINENCE

Complaint of any
involuntary leakage of urine
 Urinary Incontinence

• Transient Causes of Incontinence

• Urge Incontinence
• Stress Urinary Incontinence
• Mixed Incontinence
– Both Urgency & Stress Induced
• Overflow Incontinence
 URINARY
INCONTINENCE
Treatment Seeking (1)

• 3884 community-dwelling older adult

volunteers for a health promotion study

• Ages 65 – 79

• 1104 (28.4%) had self-reported

incontinence
 URINARY
INCONTINENCE
100 Treatment Seeking (2)
Volume
% reporting to M.D.

80

57
60
47
40 31

20

0
Drop or Two Cha nge Wet Outer
Underga rments Clothing
URINARY INCONTINENCE
Failure to Report UI to
Health Care Provider

• Personal problem (not medical)

• Embarrassed
• Normal after childbearing
• Normal aging change
• Fear of nursing home placement
• Afraid treatment requires surgery
 Diagnosis of UI

• History
• Physical Exam
1. Pelvic Organ Prolapse Assessment
2. In & Out Cath for Residual Urine Volume
3. U/A +/- Urine C & S
4. Qtip Test for Bladder Neck Hypermobility
 BLADDER DIARY
• Fluid intake
– Time, type, amount

• Urine output
– Time, amount

• Urine leakage
– Time, amount
– Precipitating events (cough, sneeze, exercise, etc.)
– Associated symptoms (urgency, pain, etc.)

• Pad usage
– Number, type
 Transient Causes of UI

• Drugs & Diet

• Infection
• Atrophic Urethritis
• Psychological - Depression, Delirium
• Endocrine - Diabetes, Hypercalcemia
• Restricted Mobility
• Stool Impaction
 Transient Causes of UI
• DRUGS
– ACE Inhibitors -- cough
– Alpha Blockers – relax internal sphincter
– Anticholinergics/Antimuscularinics – decrease
effective bladder emptying
– Diuretics -- timing
– Neuroleptics – pseudoparkinsonism
– Sedatives – especially in the demented
• DIET
– Caffeine – provokes detrusor instability
– Artificial Sweeteners-bladder irritants
Urgency Incontinence
(Overactive Bladder)

Therapeutic Options
 Behavioral Treatment:
Multi-component Programs
• Pelvic floor muscle training

• Home practice and exercise

• Self-Monitoring

• Voiding schedules—timed and prompted

voiding

• “Urge” strategies—FREEZE & SQUEEZE

 Biofeedback
• Teaching method

• Facilitates learned control of

physiological responses

• Patients learn by feedback of their

attempts to control bladder and
sphincter responses.
 Detrusor Contraction

10
mmHg
 Urge Wave

eaks
P

Su
ws

bsi
Gro

de s
ts
ar

S t
The Urge...
 When the Urge Strikes
“Freeze & Squeeze”
• Stop and stay still

• Squeeze pelvic floor muscles

• Relax rest of body

• Concentrate on suppressing
urge

• Wait until the urge subsides

• Walk to bathroom at normal

pace
When to Void

Worst Best Worst

Time Time Time

Calm
Period
Behavior and Drug Therapy
• 197 older, community-
dwelling women with Urge
Incontinence
• Randomized to:
–Behavioral training
(biofeedback)
–Drug therapy (oxybutynin)
–Placebo control
 Biofeedback-Assisted
Behavioral Treatment
• Visit #1: Anorectal BF to teach PFM control.
Home exercise instructions.

• Visit #2: “Urge strategies” and “stress

strategies”

• Visit #3: If not >50% improved,

bladder/sphincter biofeedback

• Visit #4: Individual adjustments and

reinforcement
 Reduction of Incontinence
in the Randomized Clinical Trial
100

80
% Reduction

81%
60
68%
40
39%
20

Behavioral Drug Control

Patient Satisfaction with Treatment
for Urge Urinary Incontinence
90% Behavior
78%
80% Drug
70%
Placebo
60%
49%
50%
40% 38%
40% 34%
28%
30% 22%
20% 11%
10% 0%
0%
Completely Somewhat Not satisfied
satisfied satisfied
 Reduction of Incontinence
in a Randomized Clinical Trial
100

80
% Reduction

60 69% 74%
64%
40

20

Biofeedback Manual Booklet

Training
Stress urinary incontinence is the
most common type of
incontinence in women
Stress incontinence = Urethral incompetence

Bladder Neck Hypermobility

Intrinsic Sphincter Deficiency
Pelvic Organ Prolapse
 Treatments for SUI
• Pelvic Floor Physical Therapy
• Topical Estrogen Therapy
• Urethral Plugs
• Incontinence Pessaries
• Surgical Therapy
Women’s lifetime risk of
surgery for SUI is 11%
 TVT – Transvaginal Tape

• Relatively new procedure

• Large cohort analysis shows cure
rate 80%, improvement 94%
 CONCLUSIONS regards
Surgical Care of SUI
• Numerous surgical techniques to
treat stress incontinence
• Important to know both objective
and subjective cure rates as well as
side effects of surgical procedures
• Thoughtful evaluation of patients
with individualization of therapy is
advisable
 Overflow Incontinence
• Common Causes
1. Obstuctive Uropathy such as BPH in men
and Pelvic Organ Prolapse in women.
2. Neurogenic Bladder
• Treatments
1. Relief of the Obstruction
2. Clean Intermittent Self Catheterization
3. Indwelling Catheters
4. Diversion Procedures
 SUMMARY
• Incontinence is very common, so
question ALL patients
• Reversible causes of UI
–D–I–A–P–E–R–S
• Behavioral Therapy
– Effective
– No side effects
 Transient Causes of UI

• Drugs & Diet

• Infection
• Atrophic Urethritis
• Psychological - Depression, Delirium
• Endocrine - Diabetes, Hypercalcemia
• Restricted Mobility
• Stool Impaction
 PATIENT CASE 1
History
• 48 year old woman
– Complains that she just can’t get to
the bathroom fast enough for the past
3 months
– 1-2 urge accidents per day (no stress)
– Nocturia x 2, often with an accident
– Wears a pad all the time
– Wants a bladder tack
 PATIENT CASE 1
History
• Last menstrual period 6 months
ago
– Having hot flashes
– Afraid to take hormone
replacement therapy

• Trying to lose weight; drinks 6-8

diet Cokes per day
 PATIENT CASE 1
• EXAM
– Vaginal mucosa mildly atrophic
– Otherwise exam normal

• URINALYSIS
– Normal

• PVR
– 40 cc
 PATIENT CASE 1
• Drugs & Diet
1. Caffiene
2. Taper off caffeine ½ per week
3. Begin Exercising
• Infection
• Atrophic Urethritis
1. Yes
2. Consider HRT
3. Vaginal estrogen cream – ½ gram 3
times/week to vaginal entrance
 PATIENT CASE 1
• Psychological - no
• Endocrine - no
• Restricted Mobility – no
• Stool Impaction – no
 PATIENT CASE 1
TREATMENT
• Taper off Caffeine
• Vaginal Estrogen

• Drugs?
– Hold off for now

• Behavioral Training
 PATIENT CASE 1
Behavioral Treatment
• Teach Kegel exercises during her exam
• Home Exercises
– 10 paired contractions and relaxations
– 3 seconds each – build up to 10
seconds
– TID (standing, sitting, lying)
• Urge Strategy
– Freeze/Squeeze to suppress urgency
• RTC 1 month
 PATIENT CASE 1
Return Visit
• Doing much better
• Down to 1-2 accidents per week
• Nocturia resolved
• Continue Behavioral Therapy
– Will continue to improve for 6 months
• RTC 3 months
 PATIENT CASE 2
History
• 26 year old woman, P 1001
• Leaks when she sneezes or coughs
• Has to wear a pad all the time
• Planning to have 2 more children
• Smokes 1 PPD
• Has diabetes – last Hgb A1C = 8.0
 PATIENT CASE 2
Exam
• Small cystocele
• Q tip test – 60o rotation with cough
• No leakage with cough
• Otherwise normal

Tests
• Normal Urinalysis
• PVR = 25
 PATIENT CASE 2
Treatment Options

• Surgery & Medication

– Still 2 more pregnancies planned

• Pessary
– She is not enthused

• Behavioral Training
 PATIENT CASE 2
Behavioral Treatment
• Teach Kegel exercises during her exam
• Get/Read “7 Steps to Normal Bladder Control”
• Home Exercises
– 10 paired contractions and relaxations
– 3 seconds each – build up to 10 seconds
– TID in 3 positions (standing, sitting, lying)
• Stress Strategy
– Squeeze before you sneeze or cough
• RTC 1-3 months
 PATIENT CASE 2
Other Diagnoses
• Diabetes – suboptimal control
• Tobacco use

Other Treatments
• Quit Smoking
• Diabetes Education
 PATIENT CASE 2
Return Visit
• She is much improved, both in
volume and frequency of
accidents
• Only wearing a minipad when
she goes out
• Completely satisfied with her
treatment
 PATIENT CASE 3
History
• 65 year old woman
• Can’t reach the bathroom in time
• 5-6 accidents / day
• Urinary frequency and urgency
interfering with her golf game
• Wants something done yesterday!
 PATIENT CASE 3
History
• Meds
– HCTZ 50 mg/day
– Aspirin
• NKDA
• S/P TAH
 PATIENT CASE 3
Exam
• Atrophic mucosa
• Small Cystocele
• No leakage with cough

Testing
• Urinalysis - normal
• PVR = 30 cc
 PATIENT CASE 3
Treatment
• Dx – Urge UI, Atrophic Vaginitis
• D/C HCTZ, start beta blocker or
ACE inhibitor for BP control
• Estrogen Cream ½ gram 3x / wk
(apply into introitus with finger
amount like kidney bean size)
• Ditropan XL 5 mg daily
• RTC 1 month
 PATIENT CASE 3
Visit 2
• Doing better
• Only 1-2 accidents per day versus 5-6,
but often large volume, still afraid to play
golf.
• Taking Ditropan XL 5 mg, but mouth is
quite dry
• Teach pelvic muscle exercises and urge
strategies
• RTC 1 month
 PATIENT CASE 3
Visit 3
• Doing much better
• Able to play golf
• 1 accident in last 2 weeks
• Continue Behavioral Therapy,
Meds, Estrogen cream
• RTC 3 months
 PATIENT CASE 3
Visit 3
• Continues to do well
• Golf game improving
• Rare accident in last 2 months
• D/C Ditropan XL?
 PATIENT CASE 4
History
• 80 year old woman, referred by
her golf partner
• Can’t reach the bathroom in
time
• 5-6 urge accidents / day
• Gave up golf
 PATIENT CASE 4
• Exam
– Mildly atrophic vaginal mucosa

• Urinalysis
– Normal

• PVR = 80
 PATIENT CASE 4
Treatment
• Declines Estrogen Vaginal cream

• You prescribe Detrol LA 4 mg daily

• She calls and tells you her

frequency and urgency are worse

• What is going on?

 PATIENT CASE 4
Return Visit
• Urinalysis normal
• PVR = 200 cc
• What do you do?
• D/C Detrol
• Teach her pelvic muscle
exercise and the urge strategy
• RTC 1 month
 PATIENT CASE 4
Return Visit
• Urgency is much better
• Urge strategy really works
• Only 1-2 very small accidents per week;
also she’s gained control of her flatus
• She thinks she will try golf again
• PVR = 50 cc
• Continue Pelvic Muscle Exercises and
Urge Strategy
• RTC 3 months
 PATIENT CASE 5
History
• 90 yo woman brought in by her daughter
(also your patient) for urinary
incontinence
• Stands up to go to the bathroom and
voids on her clothes and the floor on the
way
• About 4 accidents per day
• Moderately advanced Alzheimer’s
dementia
• Refuses to wear pads (takes them off
and hides them)
• Drinks 2-3 Diet Pepsi’s per day
 PATIENT CASE 5
Exam
• Repeats herself frequently during the
exam
• Slow, shuffling gait
• Mild atrophic vaginal mucosa
• Soft fecal impaction

Testing
• Urinalysis – normal
• PVR – 45 cc
 PATIENT CASE 5
Treatment
• Functional Incontinence
– Prompted Voiding –
• Before and after each meal, Q am, & Q HS
• Q 2 hours even hours while awake
– Stop Caffeine
– Consider Physical Therapy
– If needed, pull-up diapers and hide regular
underwear
– Manage Constipation
– Consider Geriatric Assessment
 PATIENT CASE 5
Return Visit
• Daughter reports she is continent.
• Didn’t realize she was constipated,
now daily BM with prunes each
morning.
• Didn’t need the pull-up diapers
since the prompted voiding
schedule worked so well.