SOAP. – Urinary Incontinence – SỔ TAY LÂM SÀNG

Cheryl A. Glass

Definition

A.Urinary incontinence (UI) is the involuntary loss of urine severe enough to have unpleasant social or hygienic consequences. UI is diagnosed primarily on history; inquire about UI at every interview. UI is a symptom of an underlying disease process in most cases; some cases are reversible with appropriate treatment. The International Consultation on Incontinence Questionnaire (ICIQ) or the ICIQ Short Form Questionnaire for UI survey can be requested from www.iciq.net/background.htm.

B.Incontinence is not considered a part of normal aging. Morbidity related to incontinence includes urinary tract infections (UTIs), indwelling catheters, falls/fractures, sleep interruption, social withdrawal, and depression.

C.Successful toileting depends on ready access to facilities, motivation to remain dry, mobility and manual dexterity, and the cognitive ability to recognize/react to the urge to void.

D.UI can be divided into the following categories: Functional, urge, overflow, stress, and mixed. Each category has a unique etiology, pathophysiology, symptoms, and management.

Incidence

A.The exact incidence of UI is unknown. The prevalence of incontinence increases with age.

B.The incidence of women identified with the definition of any leakage at least once in the past year ranges from 25% to 51%. The incidence is reported to be 10% when identified with weekly urinary leakage. The 2014 American College of Physicians guideline notes the following incidence of UI in women:

1.In young women (aged 14–21 years), incidence is approximately 25%.

2.Incidence of middle-age and postmenopausal women (aged 40–60 years) is approximately 44% to 57%.

3.Elderly (≥ 75 years of age) have approximately a 75% incidence of UI.

C.The prevalence of UI in men is approximately half that of women. The incidence of UI is affected by treatment of prostate disease. Men with incontinence have a higher risk of institutionalization compared to men without UI.

D.The elderly are more frequently affected with UI; 6% to 10% of admissions to long-term care facilities are related to incontinence.

Pathogenesis

UI can be caused by pathologic, anatomic, or physiologic factors and differs by type of incontinence:

A.Functional incontinence: Loss of urine because of the inability to get to the bathroom, either because of problems of mobility or cognition.

B.Urge incontinence/overactive bladder (OAB): Inability to delay voiding after the sensation of fullness is perceived. Common causes are detrusor hyperactivity or hyperreflexia associated with disorders of the lower urinary tract, tumors, stones, uterine prolapse, cystitis, urethritis, or impaired bladder contractility. Central nervous system (CNS) disorders such as stroke, dementia, parkinsonism, or spinal cord injury also can be causative factors.

C.Overflow incontinence: Loss of urine associated with an overdistension of the bladder. Common causes are anatomic obstruction by an enlarged prostate, a prolapsed cystocele, a contractile bladder caused by diabetes, spinal cord injury, multiple sclerosis (MS), or suprasacral cord lesions.

D.Stress incontinence: Involuntary loss of urine during coughing, sneezing, laughing, bending over, or other physical activity that increases intraabdominal pressure. Prostate surgery is the most common cause of stress incontinence in men.

E.Mixed incontinence: Combination of stress and urge incontinence in which the bladder outlet is weak and the detrusor is overactive.

Predisposing Factors

A.Age for both males and females.

B.Female: 85% of cases are in women.

C.Increased parity.

D.Previous genitourinary (GU) surgeries (e.g., prostate surgery and hysterectomy).

E.Restricted mobility.

F.Menopause.

G.Infections.

H.Chronic illnesses (e.g., diabetes).

I.Fecal impactions.

J.Excessive urinary output.

K.Delirium.

L.Dementia.

M.Neurologic disorders (e.g., stroke, spinal cord injury).

N.Variety of medications (e.g., antihypertensive medicines, diuretics, sedatives).

O.Pelvic trauma (e.g., episiotomy, forceps delivery).

P.Obesity.

Q.Sleep apnea.

R.Depression.

S.High-impact exercise.

Common Complaints

A.Urgency: Sudden and compelling desire to pass urine.

B.Urge incontinence: Involuntary leakage accompanied by urgency with the following precipitating factors:

1.Hearing running water.

2.Placing hands in water.

3.Trying to unlock the door when returning home.

4.Exposure to a cold environment.

C.Stress incontinence: Involuntary leakage with the following precipitating factors:

1.Exertion.

2.Sneezing/coughing.

3.May experience leakage with little or no activity.

D.OAB: Symptoms may occur with or without urge incontinence.

1.Urgency.

2.Frequency.

3.Nocturia.

Other Signs and Symptoms

A.Mixed incontinence: Urge and stress leakage.

B.Experiencing leakage with little or no activity.

C.Continuous leakage (i.e., dribbling).

D.Daytime frequency.

E.Nocturia: Up one or more times a night to void.

F.Slow urine stream, intermittent stream, or hesitancy.

G.Need to strain to start, maintain, or improve voiding.

H.Incomplete emptying sensation.

Subjective Data

A.Question the patient regarding onset, duration, and severity of the incontinence:

1.Do you ever leak urine when you do not want to?

2.Do you ever leak urine when you cough, laugh, or exercise?

3.Do you ever leak urine on the way to the bathroom (urgency)?

4.Do you ever use pads, tissue, or cloth in your underwear to catch urine?

B.Elicit situations when UI is worse, when it is improved, and what stimuli are associated with increasing UI (high fluid intake, high caffeine intake, agitation).

C.Review whether the female patient is pre- or post-menopausal.

D.Review other lower urinary tract symptoms (LUTS) such as nocturia.

E.Review the patient’s history of bowel function (i.e., fecal incontinence). If constipation is a problem, abdominal pressure from a large retained stool can cause symptoms, including retention.

F.Review medications, including over-the-counter (OTC) drugs and herbals:

1.Review if the presence of medications, such as angiotensin-converting-enzyme (ACE) inhibitors, can trigger a chronic cough.

2.Review medications prescribed for UI:

a.Evaluate their effectiveness.

b.Evaluate if the medications were discontinued because of side effects:

i.Dry mouth (oxybutynin).

ii.Constipation.

iii.Dizziness (tropium).

iv.Blurred vision.

v.Insomnia (oxybutynin).

vi.Hallucinations (tolterodine).

G.Review previous continence therapy and its effectiveness:

1.Pelvic floor muscle training (PFMT), first-line therapy with stress incontinence.

2.Bladder training, including timed voiding for urge incontinence.

3.PFMT + bladder training for mixed UI.

4.Weight loss and exercise in obese women.

5.Lifestyle changes, including timed urination, dietary changes, and fluid limitation.

6.Abobotulinumtoxin A therapy (BXT).

7.Percutaneous nerve, magnetic, or electrical stimulation.

8.Previous surgical treatments.

H.Review the impact of incontinence on quality of life, including work impairment, sexual dysfunction, activities of daily living, sleep, recreational activity, social interaction, and depression.

I.Assess whether the elderly patient has incontinence despite toileting.

J.Review sexual function.

K.Review history and previous treatment for prostate disease.

L.Review other comorbid medical diagnoses such as neurologic disabilities, narrow-angle glaucoma, and diabetes:

1.Do not prescribe a muscarinic medication in a patient with narrow-angle glaucoma unless approved by the treating ophthalmologist.

2.Use caution when prescribing antimuscarinic for OAB with a frail patient because anticholinergic side effects can result is increased risks that outweigh the benefits.

M.Review the diabetic patient’s blood glucose averages (polyuria is increased with uncontrolled diabetes).

Physical Examination

Both sexes:

A.Check temperature (if an infection is suspected), pulse, blood pressure (BP), and respirations.

B.Inspect:

1.Inspect for evidence of cardiac overload: Pedal edema.

C.Auscultate:

1.Auscultate the lungs for evidence of fluid overload: Rales.

D.Palpate:

1.Palpate the abdomen for masses, fullness over bladder, and tenderness.

E.Neurologic examination:

1.Assess to determine the presence of sensation of the perineal area:

a.Ask the patient if he or she feels pressure in the bladder or rectal area when he or she needs to urinate or defecate.

b.Ask the patient if he or she can feel when wiping.

c.During the physical exam, assess for perineal sensation.

2.Assess cognitive and functional status, including mobility, transfers, manual dexterity, and ability to toilet in the elderly.

3.Screen for depression.

Females.

A.Inspect:

1.Assess perineal skin for irritation, thinning, vaginal atrophy, and vaginal discharge.

B.Palpate:

1.Perform a bimanual pelvic exam for prolapse, masses, or tenderness.

2.Perform a rectal exam for sphincter tone, masses, and fecal impaction.

3.Perform a pelvic examination:

a.Remove the top blade of the speculum and evaluate the vaginal wall support.

b.Ask the woman to cough to reevaluate the vaginal wall support.

c.Ask the patient to perform a Kegel to evaluate the pelvic floor muscles.

Males.

A.Inspect:

1.Inspect the glans penis for abnormalities in urethral meatus. (Hypospadias may cause postvoid dribbling.)

2.Uncircumcised men should be evaluated for phimosis and balanitis.

B.Palpate:

1.Perform a rectal exam for sphincter tone, masses, fecal impaction, prostate size, and contour.

2.Palpate the scrotum to evaluate masses.

3.Evaluate the presence of an inguinal hernia since straining with a partial urinary obstruction can worsen an inguinal hernia.

Diagnostic Tests

The history, physical examination, and urinalysis are sufficient to guide initial therapy. Other tests include the following:

A.Urine culture and sensitivity if infection is suspected.

B.Urine cytology if hematuria or pelvic pain is present.

C.Cystometry. See Section II: Procedure Cystometry.

D.Postvoid residual (PVR) by catheterization or ultrasound. A PVR of less than 50 mL is considered adequate emptying, and greater than 200 mL is considered inadequate, suggesting either detrusor weakness or obstruction. Indications for PVR:

1.Men with mild to moderate lower urinary symptoms.

2.Men with OAB (urgency).

3.Persons with spinal cord injury or Parkinson’s disease.

4.Persons with prior episodes of urinary retention.

5.Persons with severe constipation.

E.A serum prostate-specific antigen (PSA) should be considered.

F.Routine urodynamic testing is not recommended.

G.Cystoscopy is not required for incontinence; however, it is indicated for hematuria.

Differential Diagnoses

A.Eight reversible causes of transient incontinence can be remembered by using the mnemonic

Delirium

Infection (urinary)

Atrophic urethritis and vaginitis

Pharmaceuticals

Psychologic disorders, especially depression

Excessive urine output

Restricted mobility

Stool impaction

Plan

A.Functional UI: Therapy is directed at the cause of the condition, such as overdiuresis, inability to go to the toilet, or poor access to toilet facilities.

B.Behavioral interventions should be reviewed:

1.A bladder diary (see Table 15.7) may provide information on usual timing and circumstances of UI.

2.Timed scheduled voiding and/or prompted caregiver-scheduled toileting.

3. See Section III: Patient Teaching Guide, Genitourinary Disorders for a copy of Table 15.7 to hand out to patients.

C.Bladder training by systematic ability to delay voiding through the use of urge of inhibition.

D.Stress incontinence: Kegel perineal exercises may improve UI by 30% to 90%. Exercises using graduated vaginal cones or weights induce pelvic muscle tone and strength, reducing UI.

E.Overflow UI: Crede’s method is used for expressing the bladder, by applying pressure with the hands placed in the suprapubic area after voiding to assist in emptying.

F.Intermittent catheterization is an option frequently utilized after other measures have failed or overflow UI occurs.

G.Weight loss.

H.Dietary changes including elimination of bladder irritants: caffeine, citrus/acidic foods, alcohol, and carbonated drinks.

I.Avoid constipation. (Refer to the section Constipation in Chapter 14.)

J.Reduce excessive fluid intake, with no fluid intake 3 to 4 hours before bedtime if nocturia is a problem.

K. See Section III: Patient Teaching Guide Urinary Incontinence: Women.

L.Other alternatives:

1.Surgical treatment is based on the cause of incontinence.

2.Continence pessaries may benefit women with stress UI.

3.Electrical stimulation may be prescribed to inhibit bladder instability and improve striated and levator contractility and efficiency.

4.Treatment of concomitant constipation is an important step in the treatment of incontinence.

5.Treatment of vulvo vaginal atrophy is another important step in the treatment of incontinence. (Refer to Genitourinary Syndrome of Menopause in Chapter 17.)

6.Injection of BTX (Botox) is an option for treatment of urge incontinence in selected patients.

7.Transurethral bulking agents injected into the submucosal tissues of the urethra or bladder neck is an option for women and men with UI caused by BPH.

8.Indwelling catheters are not recommended as a management strategy for OAB.

M.Pharmaceutical therapy:

1.Do not prescribe a muscarinic medication with patients when they are currently on other medications with anticholinergic properties.

2.Use anticholinergic and antispasmodic drugs to decrease reflex bladder contractions and increase bladder capacity (contraindicated in uncontrolled narrow-angle glaucoma, urinary retention, gastric retention, and frail patients).

3.The choice of pharmacologic therapy should be based on the patient’s age, comorbidities, concurrent medications, adverse effect profile, tolerability, ease of use, and cost of the medication.

4.The Food and Drug Administration (FDA) has not approved any medications for stress incontinence.

5.The American College of Physicians (ACP) recommends against systemic pharmacologic therapy for stress UI:

a.Oxybutynin chloride (Ditropan): Tablets and syrup formulation:

i.Adults: 5 mg orally two to three times per day (maximum of 20 mg/d).

ii.A lower starting dose of 2.5 mg two or three times a day is recommended for the frail elderly.

b.Oxybutynin chloride (Ditropan XL): ER tablets:

i.Adults: Initially 5 to 10 mg once a day. May increase the dosage weekly in 5 mg increments (maximum of 20 mg/d).

c.Oxybutynin chloride (Gelnique):

i.Ten percent topical gel is available in a 1-g gel sachet or a metered-dose pump that dispenses 1 g unit dose (30 metered dose/metered-dose pump).

ii.Apply 1-g gel sachet or one actuation of the metered-dose pump once a day to intact skin abdomen, upper arms/shoulders, or thighs. Application sites should be rotated.

d.Oxybutynin (Anturol) 3% gel:

i.84 mg/d (three pumps) applied daily to intact skin of the abdomen, upper arms/shoulders, or thigh. Application sites should be rotated.

e.Oxybutynin transdermal (Oxytrol), the first available over-the-counter (OTC) medication:

i.3.9 mg/d patch applied twice weekly (every 3–4 days). Application sites should be rotated with each new system to avoid reapplication to the same site within 7 days.

f.Tolterodine tartrate (Detrol):

i.Initial recommended dose is 2 mg twice a day. The dose may be lowered to 1 mg twice a day based on individual response and tolerability.

ii.The ER dose of Detrol LA is 2 to 4 mg orally per day.

g.Fesoterodine (Toviaz): ER capsule:

i.The recommended starting dose is 4 mg once a day (maximum of 8 mg/d). The daily dose should not exceed 4 mg in the following populations:

•Patients with severe renal impairment (creatinine clearance [CLCR] <30 mL/min).

•Patients taking potent CYP3A4 inhibitors, such as ketoconazole, itraconazole, and clarithromycin.

ii.Fesoterodine is not recommended for use in patients with severe hepatic impairment (Child-Pugh C).

h.Darifenacin (Enablex):

i.7.5 mg oral once a day.

ii.May increase to 15 mg once a day.

i.Solifenacin (VESIcare):

i.Initially 5 mg orally once a day.

ii.May increase to 10 mg daily.

6.Alpha-adrenergic antagonists stimulate urethral smooth muscle contraction.

7.Beta-3 adrenergic agonist: Mirabegron (Myrbetriq):

a.Initially 25 mg once a day is effective within 8 weeks.

b.May increase to 50 mg once a day.

c.Daily dose should not exceed 25 mg/d in the following populations:

i.Patients with severe renal impairment (CLCR <30 mL/min).

ii.Patients with moderate hepatic impairment (Child-Pugh Class B).

d.Mirabegron is not recommended for use in the following populations:

i.Patients with end-stage renal disease (ESRD).

ii.Patients with severe hepatic impairment (Child-Pugh Class C).

8.For postmenopausal women, vaginal estrogen may restore urethral mucosa; use the same type, dosage, and patient selection criteria as with estrogen therapy (ET). Systemic estrogen such as the estrogen patch should not be prescribed for UI.

Follow-Up

A.Follow-up is based on the type and cause of UI.

Consultation/Referral

A.When to consult a physician for UI depends on the type and cause of UI. UI is a problem that can be successfully treated.

B.Refer to a specialist for incontinence with abdominal and/or pelvic pain or hematuria in the absence of a UTI, or when surgical treatment is desired.

C.Refer for urodynamic testing, which is considered the gold standard. Testing requires special equipment and training.

D.Refer to a gynecologist or urology clinic experienced in fitting a continence pessary.

E.Refer to a urologist for hematuria and/or risk factors of bladder cancer.

Individual Considerations

A.Pregnancy: Stress incontinence is frequently associated with pregnancy and is treated with pelvic exercises.

B.Geriatric syndrome assessments:

1.Falls: Incontinence in the elderly is a risk factor for falls. Many falls occur en route to the bathroom, especially at night.

a.Avoid consumption of diuretics in the hours prior to bedtime (caffeine, alcohol, diuretic medications). Avoid fluids 1 to 2 hours before bedtime.

b.Safety measures to reduce falls in the home include removing small area carpets, keeping night lights along the path to the bathroom, and installing a toilet seat with grab bars or nearby grab bars.

c.Durable medical equipment such as a bedside commode or a urinal should be considered.

2.Depression: Incontinence increases social isolation and depression.

3.Constipation: Fecal impaction is a risk factor for UI. Constipation is a common side effect of anticholinergic and antispasmodic drugs.

4.Functional incontinence is common in older adults with arthritis or Parkinson’s or Alzheimer’s diseases. Patients are unable to hold their urine until they reach the bathroom and undress. A toileting program usually assists in this situation. UI is exacerbated with medications such as diuretics. Timing diuretics at least 4 hours prior to bedtime or prior to situations in which a bathroom would not be easily accessible can help, as can a toileting program.

5.Patients who use pads or adult diapers should be informed of risks associated with infrequent changing. Because of the high cost of absorbent pads and undergarments, infrequent changing is common and contact dermatitis and candidal rashes may develop. If these occur, patients should be encouraged to change pads/garments more frequently, and avoid wearing absorbent garments overnight and instead should use mattress/bedding pads.

6.Pharmacologic caution in geriatrics:

a.Antimuscarinic medications may increase confusion and should be avoided in frail older adults or adults with dementia and are contraindicated in people with narrow angle-closure glaucoma. Ask about the effectiveness of the medications versus the appearance of side effects such as constipation, dry eye/mouth, blurred near-vision, tachycardia, drowsiness, or reduced cognitive function. Carefully consider benefits versus risks in older adults.

b.First-generation alpha-1 blockers are linked with falls in older adults because of orthostatic hypotension. Educate older men prescribed alpha-1 blockers for benign prostatic hypertrophy (BPH) to use caution, getting up slowly from seated or lying positions. Avoid first-generation alpha-1 blockers (Hytrin, Cardura) in older men with a history of syncope.

7.Beers list caution: Avoid use of desmopressin for nocturia or nocturnal polyuria: High risk for hyponatremia in older adults. Desmopressin is a potentially inappropriate medication to use in the elderly; safer alternative treatments are available.