2. 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

3. Hannestad et al., 2000 Prevalence of Incontinence Severity

4. UI - Treatment Seeking 1,104 Community Dwelling Older Adults with Urinary Incontinence on interview Burgio, et al: JAGS 42: 208, 1994 38% 62%

5. 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

6. Include Incontinence in the Review of Systems for all geriatric patients.

7. 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?

8. Overflow Urge Stress Functional Types of Incontinence

9. Work-up of Incontinence u History u Physical u Urinalysis u Post-void Residual Volume

10. 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

11. 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

12. Medical History  Medical, neurological, history  Surgical history  Prostatectomy  Review medications including OTC  Habits (caffeine, tobacco, alcohol use)

13. 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)

14. Urinalysis  Bacteriuria  Pyuria  Glycosuria  Hematuria

15. Post-Void Residual Volume  Measure amount of urine left in bladder after voiding.  Ultrasound or catheter  Normal: < 50 ml

16. 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?

17. Contributors to UI to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

18. 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

19. Contributors to UI to Treat First Drugs and Diet – Caffeine & Fluids Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

20. 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

21. 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?

22. 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

23. 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 !!

24. 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

25. 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.

26. When to Void Worst Time Best Time Calm Period Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

27. Other Behavioral Strategies u Stress Strategy u Squeeze before you sneeze (or cough or lift) u Post Void Dribbling Strategy u Squeeze after voiding

28. 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

29. Reduction of Incontinence % Reduction

30. Patient Satisfaction with Treatment Burgio et al. JAMA. 1998; 280:1995-2000

31. 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?

32. 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

33. 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?

34. 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

35. 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

36. 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

37. Pre-Prostatectomy Muscle Training (p =.032) N=125 Burgio, Goode, et al, J Urol, 175:196; 2006

38. Reduction of Incontinence Burgio, Goode, et.al., J Urology, 2006 p=.045 p=.090 %

39. 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

40. Summary - Work-up of Incontinence u History u Physical u Urinalysis u Post-void Residual Volume

41. Summary: Contributors to Incontinence to Treat First Drugs and Diet Infection Atrophic Urethritis Psychological - Depression, Delirium Endocrine - Diabetes, Hypercalcemia Restricted Mobility Stool Impaction

42. Urinary Incontinence Treatments  Behavioral Treatments  Pelvic Floor Muscle Exercises (Kegel)  Bladder training  Timed/Prompted voiding  Bladder Control Techniques  Biofeedback  Medications  Pessary  Pelvic Floor Electrical Stimulation  Magnetic Chair  Urethral Bulking Agents  Surgery

43. 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 )

44. Contact Information u Patricia Goode, MD pgoode@aging.uab.edu 205-934-3249 u Kathryn Burgio, PhD kburgio@aging.uab.edu 205-558-7067 u Ken Shay, DDS, MS kenneth.shay@va.gov 734-222-4325 u http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=2 2318