Presentation on theme: "Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate Director for GRECC Clinical Programs Birmingham/Atlanta."— Presentation transcript:
Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate Director for GRECC Clinical Programs Birmingham/Atlanta Geriatric Research Education and Clinical Center – July 27, 2006 and Clinical Center – July 27, 2006 Assessment and Management of Urinary Incontinence in the Clinic
Hannestad et al., 2000 Prevalence of Incontinence Severity
UI - Treatment Seeking 1,104 Community Dwelling Older Adults with Urinary Incontinence on interview Burgio, et al: JAGS 42: 208, 1994 38% 62%
Reasons for Not Reporting Incontinence to Provider Not aware that can be treated Normal part of aging Personal problem (not medical) Embarrassed Fear of nursing home placement Afraid treatment requires surgery
Include Incontinence in the Review of Systems for all geriatric patients.
Patient Case u 75 year old man u Goes to the bathroom every 1-2 hours daytime and 3 times at night. u About once a week, on the way to the bathroom, he can’t make it and wets his clothes. Evaluation? Diagnosis? Appropriate treatment?
Overflow Urge Stress Functional Types of Incontinence
Work-up of Incontinence u History u Physical u Urinalysis u Post-void Residual Volume
Incontinence History Type Do you leak urine during physical activity such as coughing, sneezing, lifting, or exercising? u Do you get the urge to go and can’t make it without leaking? Onset Severity Frequency of leakage Need for absorbent products
Incontinence History Lower urinary tract symptoms Urgency, frequency, nocturia, dysuria, weak stream, straining to void, etc. Fluid intake – volume and type Previous treatments and effects on incontinence
Medical History Medical, neurological, history Surgical history Prostatectomy Review medications including OTC Habits (caffeine, tobacco, alcohol use)
Physical Exam u Brief Neurologic Exam u Gait u Lower extremity strength u Cogwheel rigidity u Sphincter tone and voluntary contraction u Rectal (and Pelvic for women)
Post-Void Residual Volume Measure amount of urine left in bladder after voiding. Ultrasound or catheter Normal: < 50 ml
Patient Case u 75 year old man u Frequent voiding and weekly urge incontinence u Work up u Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation. u Physical: hard stool in vault u UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) u PVR: 200 mL u Diagnosis? u Treatment Options?
Contributors to UI to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction
Contributors to UI to Treat First Drugs Sedatives including alcohol ACE inhibitors (cough) Antipsychotics (pseudoparkinsonism) Diuretics (bad timing) Alpha Blockers – worsen stress UI Anticholinergics – incomplete emptying
Contributors to UI to Treat First Drugs and Diet – Caffeine & Fluids Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction
Patient Case u 75 year old man u Frequent voiding and weekly urge incontinence u Work up u Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation. u Physical: hard stool in vault u UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) u PVR: 200 mL
Patient Case u 75 year old man u Frequent voiding and weekly urge incontinence u Work up u Hx: Otherwise negative u Physical: unremarkable u UA: normal u PVR: 45 mL u Diagnosis? u Treatment options?
First Line Treatments u Medications u Anticholinergics u Oxybutynin – generic, Ditropan XL, Oxytrol patch u Tolterodine - Detrol u Solifenacin - VESIcare u Trospium - Sanctura u Darifenacin - Enablex u Alpha blocker for BPH u Other treatments u Behavioral training – try BEFORE or with drug
PFM Training and Exercise PFM Training and Exercise Weight Loss Diet & Fluid Management Management Behavioral Approaches BehavioralStrategiesBehavioralStrategies Bladder Training BiofeedbackBiofeedback BladderDiariesBladderDiaries Least Invasive – Use First !!
Behavioral Treatment: Multi-component Program Pelvic floor muscle training Home practice of exercises Increase duration of contraction/relaxation over time Bladder Control Techniques Self-Monitoring w/ bladder diaries
When the Urge Strikes – Freeze and Squeeze u Stop and stay still u Squeeze pelvic floor muscles u Relax rest of body u Concentrate on suppressing urge u Wait until the urge subsides u Walk to bathroom at normal pace Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.
When to Void Worst Time Best Time Calm Period Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.
Other Behavioral Strategies u Stress Strategy u Squeeze before you sneeze (or cough or lift) u Post Void Dribbling Strategy u Squeeze after voiding
RCT Comparing Behavior and Drug Therapy 197 older women with urge incontinence Randomized to 8 weeks of: Behavioral training (biofeedback) Drug therapy (oxybutynin) Placebo control Burgio et al, JAMA, 1998
Patient Satisfaction with Treatment Burgio et al. JAMA. 1998; 280:1995-2000
Patient Case u 85 year old woman u Frequently leaks on the way to the bathroom u Work up u Hx: Aricept for dementia u Physical: Frail, walks slowly, uses a walker u UA: normal u PVR: 85 mL u Diagnosis? u Treatment Options?
The Patient with Functional Limitations u Avoid anticholinergic drugs in pts with dementia u Facilitate functional status u Mobility devices u Physical therapy u Bedside commode u Urinal for men u Prompted voiding – VERY effective
Post-Prostatectomy Incontinence u 65 yo had radical prostatectomy 1 year ago Leaks when he coughs, sneezes or lifts something heavy Wears a pad in the daytime, dry at night No problem making it to the bathroom u Diagnosis? u Treatment Options?
Behavioral Treatment of Post- Prostatectomy Incontinence 20 men; 55-87 years old Average 2 ½ years since surgery 8 weeks of biofeedback-assisted behavioral training 78.3% decrease in accidents (range of -12 – 100%) Burgio, et.al., J Urology, 1989
Behavioral Training for Post- Prostatectomy Incontinence u Case Series of 27 men with persistent post-prostatectomy UI u Taught pelvic floor muscle exercises without using biofeedback u 56.6% reduction in leakage Meaglia et al. J Urol. 1990;144:674
Post-Prostatectomy Incontinence u 65 yo considering radical prostatectomy u Continent u Read that 72% of patients reported incontinence persisting 1 year after surgery and 40% wearing pads u What can he do to help prevent incontinence? Stanford, et.al. JAMA, 2000
Pre-Prostatectomy Muscle Training (p =.032) N=125 Burgio, Goode, et al, J Urol, 175:196; 2006
Pre-Prostatectomy Muscle Training u Median Time to Continence: u Intervention Group - 3.5 months u Control Group - > 6 month u Number Needed to Treat to get 1 additional man out of pads at 6 months = 5 Burgio, Goode, et al, J Urol, 175:196; 2006
Summary - Work-up of Incontinence u History u Physical u Urinalysis u Post-void Residual Volume
Summary: Contributors to Incontinence to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction
Current Studies at Bham/ATL GRECC u MOTIVE - Combined medication and behavioral therapy for overactive bladder in men (VA Rehab R&D) u ProsTech – Behavioral therapy with and without biofeedback and electrical stimulation for persistent incontinence in men after radical prostatectomy (NIH ) u COMBO - Combined medication and behavioral therapy for urge incontinence in women (VA Rehab R&D) u ATLAS – Behavioral therapy or pessary or combined for stress incontinence in women (NIH ) u RUBI - Botox injections for refractory urge incontinence in women (NIH )
Contact Information u Patricia Goode, MD firstname.lastname@example.org 205-934-3249 u Kathryn Burgio, PhD email@example.com 205-558-7067 u Ken Shay, DDS, MS firstname.lastname@example.org 734-222-4325 u http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=2 2318