1. Urinary Incontinence Allison Batchelor, M.D. Geriatric Medicine Muntean Health Care

2. Urinary Incontinence: Definition The passing of urine in an undesirable place and at an undesirable time Urinary Incontinence is not a normal aging process Urinary Incontinence is often treatable

4. Urinary incontinence : Affects > 25 million Americans and over 20 million adults worldwide Costs > $76 billion in the U.S. annually (est) Women wait average of 6.5 years before seeking help with incontinence Affects 30-50% of elderly >60 living at home Affects more than 50% of U.S. nursing home residents Is a major cause of institutionalization (nursing home placement)

5. Incontinence Implications: Decreased quality of life Depression Embarrassment Restricted social activity Increased risk of skin breakdown Delayed healing of pressure sores Cost (linen changes, padding products, medications)

7. Urinary Incontinence is under-diagnosed and under-reported Only 32% of primary care physicians routinely ask patients about incontinence 50-75% of all incontinent community-dwelling patients never describe their symptoms to their physicians “You won’t know if you don’t ask” Less than half of all incontinence problems are known to the physician

8. Bladder Physiology Detrusor “dome muscle” (balloon muscle) Cholinergic (parasympathetic) control from S2 – S4 sacral plexus Contraction of detrusor causes bladder emptying Bladder Outlet Internal urethral sphincter (smooth muscle) Alpha-adrenergic (sympathetic) control from hypogastric plexus T11-L2 Contraction causes storage of urine External urethral sphincter (striated muscle) Somatic voluntary control from pudendal nerve which also innervates pelvic floor muscles Contraction of external sphincter (voluntary / somatic control) causes storage of urine

11. Normal bladder function Bladder filling and storage phase Detrusor is relaxed and sphincters are contracted First urge to void at 150-300 cc Bladder capacity 300-600 cc Bladder emptying / voiding phase Detrusor muscle contracts and sphincters relax Detrusor pressure exceeds urethral resistance

14. Urinary changes with normal aging Decrease in: Bladder capacity Force of detrusor muscle contractions Ability to postpone voiding Urethral compliance Strength of pelvic support muscles Increase in: Post-void residual volume Involuntary bladder (detrusor muscle)contraction=urgency Nocturia (1-2 times a night) Prostate size in most men

15. Urinary Incontinence work-up History : Ask the question: “In the past year have you ever lost urine or gotten wet?” Duration, severity, symptoms, previous treatment, medication, GU surgery The 3 P’s Position of leakage (supine, sitting, standing) Protection requirement (pads per day, wetness of pads) Problem (quality of life issues)

16. Physical Examination : Assess mental status Assess mobility Look for peripheral edema / congestive heart failure signs Abdominal examination : Look for bladder distension Neurological examination : Evaluation of LS nerves Focal findings Peripheral neuropathy

17. Pelvic examination : Atrophic vaginitis Cystocele Rectocele Uterine prolapse Mass Vaginal muscle tone Rectal examination : Anal sphincter tone to assess integrity of sacral plexus Fecal impaction (presses forward on bladder/urethra) Mass

20. Drug Sedatives / hypnotics Alcohol Anticholinergics antipsychotics antidepressants antihistamines Narcotic analgesics Effect on Continence Sedation, delirium, immobility Polyuria, frequency, urgency Urinary retention, overflow incontinence, fecal impaction, delirium Urinary retention, sedation, fecal impaction Medications that may affect continence

21. Drug Alpha-adrenergic antagonists / blockers Alpha-adrenergic agonists Ca++ channel blockers Diuretics ACE inhibitors Effect on Continence Urethral relaxation (stress incontinence) Urinary retention Polyuria, frequency, urgency Drug-induced cough can lead to stress incontinence Medications that may affect continence

22. Anticholinergic Side Effects “Dry Body” Dry bowels --constipation Dry bladder--urinary retention Dry mouth --xerostomia Dry brain --confusion Dry eyes --xerophalmia

25. Transient Incontinence DIAPPERS mnemonic: D – delirium / confused states I – infection / UTI - symptomatic A – atrophic urethritis / vaginitis P – pharmaceuticals / drugs P – psychosocial, especially depression E – endocrine – hypercalcemia, hyperglycemia R – restricted mobility S – stool impaction

27. Persistent Incontinence Urge Incontinence Stress Incontinence Overflow Incontinence Functional Incontinence Mixed (overlap)

32. Urge Incontinence Characteristics a.k.a. detrusor instability, detrusor hyperreflexia, overactive bladder, irritable bladder Most common cause of incontinence in older persons Abrupt desire to void (urgency) that cannot be suppressed during the day or night Inability to delay voiding Sudden loss of large volume of urine Bladder muscle (detrusor) contracts and intra-vesicular pressure exceeds urethral pressure  incontinence Wet themselves if they don’t get to bathroom immediately “Latch-Key Incontinence” (very little warning) Causes include idiopathic, cystitis, bladder tumor, bladder stones, stroke, Parkinson’s Disease, dementia

34. Urge Incontinence Treatments Anticholinergics / antispasmodics Behavioral therapy (q 2 hour voiding) Medications : Relax detrusor muscle –stop uninhibited contractions OxybutinintidGeneric $60+/month Oxybutinin extended release qd Generic $50/month Brand Ditropan XL $200+/month Oxybutinin transdermal one patch 2x / week– 8 patches per month Generic OTC (Oxytrol for Women)-$30 Brand Oxytrol $300 -667/month-8 patches Tolterodinebid Generic $200/month Brand Detrol $500 /month Tolterodine long acting qd Brand Detrol LA $330/month

35. The transdermal patch formulation of the anticholinergic drug oxybutynin (Oxytrol – Watson) is now available over the counter (OTC) as Oxytrol for Women (MSD) for use in women with overactive bladder (OAB). It is the first treatment for OAB to become available OTC. Oxybutynin remains available only by prescription for men.

36. Oxytrol and Oxytrol for Women both deliver 3.9 mg of oxybutynin per 24 hours and are applied every 4 days, but a box of 8 prescription Oxytrol patches costs $320.32,3 while an 8- patch box of OTC Oxytrol for Women costs only $29.99.4. Sep 16, 2013, The Medical Letter

37. New Antispasmodic Medications trospiumbid Generic $60/month XL$146/mo Brand Sanctura $250 Sanctura XR $150-250/mo solifenacinqd Brand VESIcare $300+/mo flavoxatetid/qid Generic $100+ Brand Urispas d/c in USA darifenacinqd Generic $250+/mo Brand Enablex $300+/mo

38. Myrbetriq- brand Generic: Mirabegron- Daily ER dosing$350+ /month BRAND ONLY NOW Toviaz Brand Generic: Fesoterodine Daily dosing$300/month BRAND ONLY NOW Gelnique brand Generic: Topical Oxybutinin Daily topical dosing of one sachet of gel 30 sachet packets $370 One month supply Anaspaz/ Brand Generic: Hyoscyamine One oral disintergrating tablet q4 hours $45 per 120 tabs— one month supply

39. CONTRAINDICATIONS urinary retention/bladder obstruction gastric retention (slows motility) uncontrolled narrow-angle glaucoma known hypersensitivity Angioedema, rash and anaphylactic reaction have been reported ( SANCTURA XR ®) Uncontrolled HTN(Myrbetriq) Note—many of these drugs interact with alcohol

40. Stress Incontinence Characteristics Most common cause of urinary incontinence in women < 75 years old Increase in abdominal pressure (e.g. Valsalva Maneuver) places “stress” on bladder so pressure in bladder exceeds urethral resistance Persons with stress incontinence leak urine with cough, sneeze, laugh, exercise, sexual activity, arising from chair

41. Stress Incontinence Causes 85% due to hypermobility of bladder outlet/sphincters Hormonal changes Multiple childbirth Hysterectomy Pelvic surgery 15% due to internal sphincter deficiency Pelvic surgery Pelvic radiation Trauma Neurogenic disorders

47. Stress Incontinence Treatment Weight reduction if obese Pelvic floor exercises (Kegels) Pessary for uterine prolapse Estrogens – especially local creams Sympathomimetic (alpha-agonist) medications (increase internal sphincter closure) i.e. pseudoephedrine Urethral collagen injections / implants Surgery if all else fails “bladder suspension ”

54. Overflow Incontinence Characteristics Over distention of bladder causing frequent dribbling Frequent loss of small volume of urine Large volume of residual urine Large distended bladder Frequent nocturia Take a long time to urinate Weak dribbling stream with poor force Urinate small amounts and still feel a sense of bladder fullness and continue to dribble Usual measurement of post-void residual urine by straight cath or bladder scan >200cc

58. Bladder outlet obstruction due to stricture, BPH [(Benign Prostatic Hypertrophy) enlarged prostate gland], rectocele, uterine prolapse, cystocele, fecal impaction Acontractile bladder (detrusor hypoactivity, atonic bladder) due to diabetes, Multiple Sclerosis, lower spinal cord damage, or medications (such as anticholinergic drugs) Overflow Incontinence Characteristics O

59. Treatment of Overflow Incontinence Relieve bladder outlet obstruction via catheterization or surgical approach (i.e. TURP for BPH) Alpha-blocker medication Intermittent catheterization or permanent catheterization

60. Functional Incontinence Characteristics Does not involve pathology of lower urinary tract Due to physical impairment limiting mobility (arthritis stroke, Parkinson’s Disease, restraints) or cognitive impairment (dementia, psychosis, depression)

61. Functional Incontinence Treatment Address mobility issues »Beside commode »Transfer assistance Caregiver assistance »Timed voiding to avoid incontinence Padding incontinence options »Absorbent pads »Adult briefs / diapers »Bed pads (“chux”)

67. A combination of any two or more of above types of persistent incontinence Most common is urge and stress incontinence Typically one type predominates over the other Mixed Incontinence

69. Case Study An 85-year-old woman develops increasing urinary leakage in small amounts. Her medications include lisinopril for hypertension, HCTZ diuretic, sertraline for depression, and calcium supplement Possible explanations of her incontinence include: 1.Acute urinary tract infection 2.Ace inhibitor induced cough causing stress incontinence 3.Diuretic-induced urinary frequency 4.All of the above

70. Case Study A 75-year-old man calls you with significant lower abdominal fullness at 9 p.m. on Superbowl Sunday. He admits to drinking six beers while watching the football game. He notes he has not been able to urinate effectively for 12 hours, except in very small amounts, and yet his underwear is wet from dribbling after urination attempts. He began a new medicine for hypertension last week, but can’t tell you the name. He also took an over-the counter cold medicine for “sniffles” today. This case describes what kind of incontinence: 1.Stress 2.Urge 3.Overflow 4.Functional

71. The medication he began for hypertension most likely is: 1.Ace-inhibitor 2.Alpha-adrenergic blocker 3.Calcium channel blocker

72. The best immediate treatment in this case is to: 1.Arrange prostate resection with the urologist 2.Insert a urinary catheter in the urethra to enable urinary drainage 3.Tell him to stop the new blood pressure pill 4.Advise him to limit himself to two beers during football games

73. You learn that over-the-counter cold medication was: Pseudoephedrine (Sudafed) decongestant This contributed to his overflow incontinence by: 1.Relaxing the detrusor muscle 2.Contracting the detrusor muscle 3.Opening the internal urethral sphincter 4.Closing the internal urethral sphincter

74. Case Study A 79-year-old woman with urge incontinence has symptoms well controlled on oxybutinin XL (Ditropan XL) 10mg po qd. She recently began a cholinergic medicine (donepezil [Aricept]) for Alzheimer’s disease. Her daughter calls you to say her incontinence has recurred. She is wetting four adult diapers daily and beginning to get skin irritation. What is the likely cause of her recurrent incontinence?

75. Case Study A 90-year-old woman with Alzheimer Disease on calcium and iron supplements is troubled with continuous incontinence. Workup failed to delineate any causes of transient incontinence. Her post-void residual urine by straight cath was 10 cc and urinalysis was normal as was serum glucose and calcium level. She and her daughter refused to let you do a pelvic exam. Your next step in management should be: 1.Empiric treatment for urine infection 2.Trial of oxybutynin 3.Estrogen cream nightly to vaginal area 4.KUB abdominal film 5.CT Scan pelvis