Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Urinary Incontinence

Bladder control problems are common.

Prevalence increases with age.

The incidence of female incontinence is : Young adult, 20% to 30%; Middle age, 30% to 40%; Elderly, 30% to 50% (Sandvik H, 1995).

Bothersome lower urinary tract symptoms (LUTS) can occur in up to 30% of men older than 65 (NICE CG97, 2010)

The prevalence of nocturia in older men is about 78% (Boyle P, 2003).

History :

 

The clinical history should include

  • the duration of onset and severity of the lower urinary tract symptoms (LUTS),

  • a subjective assessment of the degree of bother associated with the symptoms,

  • and specific questions around urgency and stress leakage of urine.

 

Symptoms can be divided into problems with storage or voiding.

Urinary Incontinence is one of 4 conditions identified as Geriatric Syndromes 

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Geriatric Syndromes
Geriatric Syndromes
Geriatric Syndromes

Ask about :

  • Pain, dysuria and haematuria - these symptoms need urgent review.

  • Urinary symptoms during childhood – for example nocturnal enuresis.

  • Bowel function and frequency – constipation may lead to incontinence.

  • Systemic symptoms and those symptoms that could be associated with diseases that predispose a patient to urinary incontinence e.g. diabetes.

  • Associated co-morbidities (CCF, COPD, DM) and previous surgical procedures, particularly those in or around the pelvis.

  • Obstetric and gynaecological history.

  • Medication. Many drugs can exacerbate urinary incontinence.

 

 

Examination :

  • CVS – look for signs of chronic cardiorespiratory disease

  • Cognition – AMT as a screen for cognitive decline

  • Neuro - assess gait, check dorsiflexion of the toes (S3) and perineal sensation (L1-L2), sensation of the sole (S1) and posterior aspect of the thigh (S3).

  • Abdo - palpate for masses or enlarged kidneys, palpate and percuss for a distended bladder.

  • Digital Rectal Examination (DRE) should be performed in all patients to assess anal tone, presence of constipation or rectal mass and to assess prostate size in males.

  • Vaginal - Inspection may reveal vaginal atrophy or prolapse.The pelvic floor muscle strength can be assessed during a vaginal examination.

One grading system is the Oxford classification which is a 6 point scale:

0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good, 5 = strong contraction

  • Finally ask the patient to cough or strain to enable demonstration of stress incontinence; repeat this with the patient standing if possible .

 

 

Initial Investigations :

  • Frequency / Volume Chart

  • Urinalysis +/- MSU for MC&S

  • Blood tests – FBC, U&E, Calcium, Glucose

  • Post void bladder scan (Other imaging modalities are not routinely indicated unless there are specific indications)

 

 

Specialist referral :

Refer patients with the following

  • haematuria

  • prolapse beyond the introitus

  • pain associated with the micturition cycle

  • suspicion of prostate cancer

  • consider referral if no improvement with anticholinergic or beta 3 agonist

 

 

General Management :

Diagnose and manage reversible causes/precipitants of urinary incontinence:

  • delirium, restricted mobility, constipation, UTI, medications, vaginal atrophy, diabetes, CKD

INCONTINENCE in WOMEN

 

Treatment for urinary incontinence depends on the type of incontinence, its severity and the underlying cause. A combination of treatments may be needed.

 

 

Bladder diaries :

 

Bladder diaries can be very useful in providing information regarding fluid volume input, type of fluid being drunk, urine output frequency and volume, symptoms of urgency, episodes of incontinence, and pad usage. As such they can enable healthcare professionals and the woman to understand when urgency and leakage occur, and to consider management options.

Bladder diaries may also be used for monitoring the effects of treatment as a comparator.

 

 

Lifestyle changes :

 

Lifestyle changes can significantly improve symptoms in women with UI or overactive bladder (OAB). Giving lifestyle advice to women when they first present means they can benefit from improvements as soon as possible. Lifestyle measures include (NICE CG 171, 2013):

  • a trial of caffeine restriction, which is effective in OAB

  • modification of fluid intake (decrease or increase as appropriate), which is effective in both OAB and stress UI (SUI)

  • weight reduction in women who have UI and a body mass index greater than 30 kg/m2.

 

 

Containment products :


Incontinence products such as pads or toileting aids are not 'treatments' for UI, but are a means of containment and can allow women to continue normal activities of daily living.

They are, however, costly, can cause social embarrassment, and are not a long-term solution to the problem.

They should therefore not be offered unless a full assessment has been conducted or is awaited or if other treatments have failed.

 

 

Behavioral techniques :

 

·Bladder training, to delay urination after getting the urge to go.

                 Start by trying to hold off for 10 minutes with every urge to urinate.

                 The goal is to lengthen the time between trips to the toilet until urinating only every two to four hours.

 

  • Double voiding, to empty the bladder more completely to avoid overflow incontinence.

Double voiding means urinating, then waiting a few minutes and trying again.

 

  • Scheduled toilet trips, to urinate every two to four hours rather than waiting for the need to go.

 

  • Fluid and diet management, to regain control of the bladder.

May need to cut back on or avoid alcohol, caffeine or acidic foods.

Reducing liquid consumption, losing weight or increasing physical activity also can ease the problem.

 

  • Supervised pelvic floor muscle exercises

Also known as Kegel exercises, these techniques are especially effective for stress incontinence but may also help urge incontinence.

Technique :

          Imagine trying to stop your urine flow. Then:

 Tighten (contract) the muscles used to stop urinating and hold for five seconds, and then relax for five seconds. (If this is too  difficult, start by holding for two seconds and relaxing for three seconds.)

          Work up to holding the contractions for 10 seconds at a time.

          Aim for at least three sets of 10 repetitions each day.

 

Women with stress or mixed UI are often given a leaflet on pelvic floor muscle training, but are not given the supervision of an expert to help them.

When women then attend for specialist treatment they have been incorrectly performing pelvic floor muscle training for a significant period of time with no improvement in their symptoms.

There is evidence that supervised pelvic floor muscle training with trained healthcare professionals significantly improves outcomes and can avoid more invasive treatments (NICE QS 77, 2015).

 

 

Electrical stimulation :

 

Electrodes are temporarily inserted into the rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but multiple treatments over several months may be needed.

 

 

Medications :

 

Pharmacotherapy has to be tailored to suit the incontinence subtype and should be carefully balanced according to efficacy and side effects of the drug.

Women with urge incontinence require treatment that relaxes or desensitizes the bladder (antimuscarinics, estrogens, alpha-blockers, beta-mimetics, botulinum toxin A, resiniferatoxin, vinpocetine), whereas women with stress incontinence need stimulation and strengthening of the pelvic floor and external sphincter (alpha-mimetics, estrogens, duloxetine).

Women with overflow incontinence need reduction of outflow resistance (baclofen, alpha-blockers, intrasphincteric botulinum toxin A) and/or improvement of bladder contractility (parasympathomimetics).

If nocturia or nocturnal incontinence are the major complaints, control of diuresis is obtained by administration of the ADH analogue desmopressin.

 

Medications commonly used to treat incontinence in women include:

  • Anticholinergics. These medications can calm an overactive bladder and may be helpful for urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura).

  • Mirabegron (Myrbetriq). Used to treat urge incontinence, this medication relaxes the bladder muscle and can increase the amount of urine your bladder can hold. It may also increase the amount you are able to urinate at one time, helping to empty your bladder more completely.

  • Alpha blockers. In men with urge or overflow incontinence, these medications relax bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), terazosin (Hytrin) and doxazosin (Cardura).

  • Antidepressant medicines, such as imipramine, ( Tofranil)

  • Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas. This may reduce some of the symptoms of incontinence.

 

 

Medical devices :

 

Devices designed to treat women with incontinence include:

  • Urethral insert, a small, tampon-like disposable device inserted into the urethra before a specific activity, such as tennis, that can trigger incontinence.  

     The insert acts as a plug to prevent leakage, and is removed before urination.

  • Pessary, a stiff ring inserted into the vagina and worn all day.

     The device helps hold up the bladder, to prevent urine leakage where incontinence is due to a prolapsed bladder or uterus.

 

 

Indwelling catheters :


Long-term indwelling urinary catheters are associated with increased risk of UTIs and can have damaging effects on the urethra.

Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention causes difficulties, such as incontinence, symptomatic infections, or renal dysfunction, and in whom this cannot otherwise be corrected.

Healthcare professionals should be aware of and explain to women that the use of indwelling catheters in urgency UI may not result in continence as catheters can be associated with 'bypassing' leading to continued urinary leakage.

Long-term indwelling urethral catheters may be indicated for women with UI who:

  • have chronic urinary retention and are unable to manage intermittent self-catheterisation

  • have skin wounds, pressure ulcers, or irritations that are being contaminated by urine until healing occurs

  • experience distress or disruption caused by bed and clothing changes

  • express a preference for this form of management as no other alternatives have been successful.

 

 

Interventional therapies :

 

Interventional therapies that may help with incontinence include:

  •  Bulking material injections. 

A synthetic material is injected into tissue surrounding the urethra.

The bulking material helps keep the urethra closed and reduce urine leakage.

This procedure is generally much less effective than more-invasive treatments such as surgery for stress incontinence and usually needs to be repeated regularly.

  • Botulinum toxin type A (Botox). 

Injections of Botox into the bladder muscle may benefit people who have an overactive bladder.

Botox is generally prescribed to people only if other first line medications haven't been successful.

  •  Nerve stimulators. 

A device resembling a pacemaker is implanted under the skin to deliver painless electrical pulses to the nerves involved in bladder control (sacral nerves). Stimulating the sacral nerves can control urge incontinence if other therapies haven't worked.

The device may be implanted under the skin in the buttock and connected directly to the sacral nerves or may deliver pulses to the sacral nerve via a nerve in the ankle.

 

 

Surgery :

 

In current clinical practice the recommended care pathway for urinary incontinence is to offer conservative and pharmacological interventions as initial treatments within primary care.

The diagnosis of LUTS as stress UI, OAB, or mixed incontinence should inform the initial treatment pathway.

Where the outcomes of these treatments are not optimal in terms of reaching the woman's treatment goals, a range of surgical interventions may be considered.

Almost all of these treatments are offered in secondary care and women would need to be referred from primary care to receive these interventions. The treatment options should be discussed and the multidisciplinary team (MDT) should consider all available options and likelihood of success with the patient (RCOG, 2013).

 

If other treatments aren't working, several surgical procedures can treat the problems that cause urinary incontinence:

  •  Sling procedures. 

This procedure is used to treat stress incontinence

Strips of body's tissue, synthetic material or mesh are used to create a pelvic sling around your urethra and the area of thickened muscle where the bladder connects to the urethra (bladder neck). The sling helps keep the urethra closed, especially when coughing or sneezing.

  •  Bladder neck suspension. 

         This procedure is designed to provide support to urethra and bladder neck It involves an abdominal incision, under general

         or spinal anesthesia.

  •  Prolapse surgery. 

In women with mixed incontinence and pelvic organ prolapse, surgery may include a combination of a sling procedure and prolapse surgery.

LUTS in Men

BPE = Benign Prostatic Hyperplasia

           (cellular proliferation)

           NOT hypertrophy (larger cells)

 

BOO = Bladder Outlet Obstruction

            poor flow rate + high bladder

            pressure (urodynamic study)

            NOT poor flow rate alone (poor

            detrusor contractility)

where BPE or BOO is suspected, check :

-  PSA

-  prostate size (>30ml)

              H x W x L x/6 or W x W x H x/6   (/6 = 0.524)

-  and consider post void residual volume (>200ml)

 

 to evaluate severity and monitor progress :
-  IPSS ( International Prostate Symptom Score ) 

 

to evaluate voiding pattern :

- Frequency/Volume Chart

Modifiable Risk factors :

-  lack of physical activity

-  obesity

-  hyperlipidemia

-  smoking

-  excess alcohol consumption

-  hypertension

-  diabetes

 

 

Lifestyle advice :

-  information on nature and prevalence

-  adjust fluid intake

-  reduce caffeine, artificial sweeteners, alcohol

-  involve the partner

-  review to assess need to progress to drug Rx

Medications

 

Medications commonly used to treat incontinence in women include:

 

Alpha-blockers (first line)

review after 6/52 and 6/12, then yearly

  • alfuzosin (Xatral XL, 10mg once daily)

  • tamsulosin (Flomaxtra XL 0.4mg or generic, once daily).

  • doxazosin (Cardura XL 4mg or generic, requires dose titration)

side fx : postural hypotension

retrograde ejaculation

 

Anticholinergic drugs (second line in storage sx)

where post void residual volume < 200ml

review after 6/52 and 6/12, then yearly

  • fesoterodine (Toviaz 4–8mg once daily),

  • oxybutynin (Lyrinel XL 5–20mg once daily)

  • tolterodine (Detrusitol XL 4mg once daily).

side fx : dry mouth 16%, dizziness 5%, constipation 4%, retention

 

5-alpha reductase inhibitors (second line in voiding sx and post-micturition sx)

where prostate size >30cc

review after 3-6/12, then yearly

expect 25% reduction in prostate size, 50% reduction in PSA

  • dutasteride (Avodart 0.5mg once daily)

when using dutasteride : check PSA after 6/12 and record it as the new baseline (any subsequent increase of this level may indicate prostate cancer)

  • finasteride (generic 5mg once daily) when using finasteride : double the measured PSA levels when evaluating against age appropriate norms

side fx : erectile or ejaculatory dysfunction

 

Combination therapy : Alpha-blockers + 5-alpha reductase inhibitors

  • dutasteride and tamsulosin (Combodart, one capsule daily)

Nocturia :

  • consider furosemide in the late afternoon

  • consider ibuprofen 200mg nocte

 

 

Incontinence :

  • pads (Tena male pads)

  • continence devices

 

 

Other Rx :
 

Nocturia : Desmopressin ( Desmotabs Melt 120-240mcg nocte)

  • can cause fluid retention (care with hypertension),

  • no fluids 1hr before and up to 8 hr after

  • can cause hyponatremia (check Na+ before Rx, 3/7 later, and 1/12 later)

  • not in >65 yrs old

  • stop Rx for one month in six

 

LUTS + Erectile Dysfunction : Phosphodiasterase inhibitors ( Viagra, Cialis, Levitra )

  • approved in USA for LUTS without ED ( not in UK )

 

Where other tretments fail, consider :

  • botox

  • TURP

  • TUVP

  • HoLEP (Holmium Laser Enucleation)

NICE. Urinary incontinence: the management of urinary incontinence in women.

Clinical Guideline 171. (NICE, 2013).

view/access

NICE. Management of lower urinary tract symptoms in men.

Clinical guideline CG97   (Nice, 2010)

view/access

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Urinary Incontinence

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