Michael J. Koronkowski, Pharm.D.
Spring 1998

Assessment and Management of Urinary Incontinence

1. Introduction - Urinary Incontinence
2. Lower Urinary Tract Anatomy and Function
3. Requirements for Bladder Filling and Urine Storage
4. Requirements for Bladder Emptying
5. Other Factors Required for Continence
6. Iatrogenic Incontinence
7. Treatment Goals for Urinary Incontinence
8. Types of Urinary Incontinence
9. Behavioral Approaches to Urinary Incontinence
10. Drug Therapy for Urinary Incontinence
11. Products for Incontinence
12. Case Study

Assigned Readings:

1. Handout materials.

Suggested Readings:

1. Williams ME, Panill FC. Urinary Incontinence in the Elderly. Ann Intern Med 1982;97:895-907.

Learning Objectives:

1. To understand the pathophysiology of the different types of urinary incontinence.
2. To be able to differentiate between the different types of urinary incontinence.
3. Know the pharmacologic management of urinary incontinence (including doses, mechanisms of action, and adverse effects of drugs).
4. Know the non-pharmacologic methods of management and when to employ them.
5. Be able to use the above information if presented with a case.

World Wide Web Resources:

1. Agency for Health Care Policy Research: On-line clinical practice guidelines on Urinary Incontinence
2. National Institutes of Health: On-line consensus conferences and technology assessment workshops of which urinary incontinence in adults is provided)

I. Introduction - Urinary Incontinence

A. Definition - an objectively proven condition in which involuntary loss of urine is a social and/or hygenic problem

1. Not a disease, but a symptom with many causes

2. Affects young and old people

3. Who is incontinent? Anyone who has regular "accidents" day or night, past the age of 3 years.

B. Prevalence - at least 10 million Americans

1. True prevalence is questionable since not all studies have used the same criteria, settings, data collection methods.

2. effects » 35% of women and 15% of men >60 years old, and 1/5 to 1/2 of institutionalized patients

Hospitalized - 12.9~% to 48% of patients

Community - 1.6~% to 26%

Only 50 % of cases are known to health providers

3. over 70% of people with incontinence can be cured, but only approximately 10% of patients seek help!

C. Risks Factors for Development of Urinary Incontinence

1. neurologic impairment

2. immobility

3. female gender

[NOTE: bacteriuria and advanced age are NOT risk factors]

D. Costs - Urinary Incontinence impacts individual physical and psychological health and has tremendous social and economic consequences.

estimated financial burden = 8 billion dollars annually. This is more than is spent annually on coronary artery bypass graphs and dialysis combined.

E. Morbidity - pressure sores, falls and fractures, urosepsis, rash and excoriation, cellulitis, depression, sexual dysfunction, isolation, and institutionalization.

II. Lower Urinary Tract Anatomy and Function

A. Detrusor Muscle - cholinergic innervation

B. Internal Sphincter - alpha-adrenergic innervation

C. External Sphincter - somatic control

III Requirements for Bladder Filling and Urine Storage

A. ability to accommodate increasing volumes of urine with low intravesicle pressure and appropriate sensation.

B. closed bladder outlet at rest and with increasing pressure

C. absence of involuntary bladder contractions

IV. Requirements for Bladder Emptying

A. coordinated contraction of bladder smooth muscle

B. concomitant lowering of resistance at level of smooth muscle and striated sphincter

C. no anatomic obstruction

V. Other Factors Required for Continence

A. adequate mobility and dexterity to use toilet or toilet substitute and manage clothing

B. adequate cognitive function to recognize toileting needs and find a toilet or toilet substitute

C. motivation to be continent

D. absence of environmental and iatrogenic barriers (i.e. restraints, bed rails, inaccessible toilets, unavailable caregivers, or drug adverse effects).

VI. Iatrogenic Incontinence

A. Caused by drugs or medical treatment

B. Medications that can potentially affect Urinary Incontinence

Medications that can potentially affect Urinary Incontinence

Types of Medication	Potential Effects on Continence
Diuretics	Polyuria, frequency, and urgency
Anticholinergics	Urinary retention, overflow incontinence, impaction
Psychotropics:
Antidepressants	Anticholinergic actions, sedation
Antipsychotics	Anticholinergic actions, sedation, rigidity, immobility
Sedative-Hypnotics	Sedation, delirium, immobility, muscle relaxation
Narcotic analgesics	Urinary retention, fecal impaction, sedation, delirium
Alpha-adrenergic blockers	Urethral relaxation
Alpha-adrenergic agonists	Urinary retention
Beta-adrenergic agonists	Urinary retention
Calcium Channel Blockers	Urinary retention
Alcohol	Polyuria, frequency, urgency, sedation, delirium, immobility

CAUTION: Any drug used to treat incontinence can make it worse if the diagnosis is incorrect or the patient has more than one type of urinary incontinence

VII. Treatment Goals for Urinary Incontinence

A. Maintain Adequate Renal Function

B. Help Patient Become Dry

C. Establish Normal Voiding Pattern

D. Minimize Precipitating Factors (i.e. medications, stress)

E. Establish Realistic Endpoints based on Improvement of Symptoms versus Cure

VIII. Types of Urinary Incontinence

A. Functional Incontinence

Urinary leakage associated with inability to toilet because of impairment of cognitive and/or physical functioning, psychological unwillingness, or environmental barriers. [Common causes: dementia, depression, anger, hostility]

B. Urge Incontinence

Leakage of urine (often large volumes, but variable) because of inability to delay voiding after sensation of bladder fullness is perceived. [Common causes: detrusor instability, CNS disorders, genitourinary conditions]

C. Stress Incontinence

Involuntary loss of urine (usually small amount) with increases in intraabdominal pressure (i.e. cough laugh , or exercise) [weakness & laxity of pelvic musculature and urethral sphincter]

D. Overflow Incontinence

Leakage of urine (usually small amounts) resulting from mechanical forces on an over distended bladder or from other effects of urinary retention on bladder and sphincter function. [anatomic obstruction by prostate or neurologic acontractility secondary to spinal cord injury, diabetes, etc.]

IX. Behavioral Approaches to Urinary Incontinence

A. Functional Incontinence

1. mobility enhancement

2. toileting cues/environmental modification

3. various toileting schedules

B. Urge Incontinence

1. urge suppression

2. relaxation/distraction

3. pelvic floor muscle re-education

1. biofeedback/sphincter EMG
2. electrical stimulation

4. various toileting schedules

C. Stress Incontinence

1. pelvic floor muscle re-education

1. vaginal cones
2. biofeedback/sphincter EMG
3. electrical stimulation

2. various toileting schedules

X. Drug Therapy for Urinary Incontinence

*Attempt to minimize the use of all medications, especially those with anticholinergic, cholinergic, diuretic, and sedative properties.

XI. Products for Incontinence

Pharmacist remain an easily accessible health care provider that the public can turn to when coping with urinary incontinence. Typical products available and commonly used to alleviate incontinence and its consequences are bed dressings, underpads, skin care items, disposable pants and underpants.

References and Selected Readings

1. Williams ME, Panill FC. Urinary Incontinence in the Elderly. Ann Intern Med 1982;97:895-907.
2. Badlani GH, Smith AD. Pharmacotherapy of Voiding Dysfunction in the Elderly. Seminars in Urology 1987;5:120-125.
3. Finkbeiner AE, Bissada NK, Welch LT. Uropharmacology: Part IV Parasympathetic depressants. Urology 1977;10:503-10.
4. Castledon CM, Duffin HM. Guidelines for Controlling Urinary Incontinence Without Drugs or Catheters. Age and Aging 1981;10:l S6.
5. Resnick NM, Yalla SV. Management of Urinary Incontinence in the Elderly. NEJM 1985;313:800-5.
6. Urinary Incontinence in Adults. National Institutes of Health Consensus Development Conference Statement. National Institutes of Health 1988; Vol.7 No. 5.
7. Resnick NM, Yalla SV, Laurino E. The Pathophysiology of Urinary Incontinence Among Institutionalized Elderly Persons. NEJM 1989;1-7.
8. Wein AJ. Receptor Function and Drug Action in the Lower Urinary Tract. Seminars in Neurology 1988;8:121-30.

CASE STUDY:

Mr. A.V. Smith is a 71 y.o. black male who is admitted to your Geriatric Evaluation Unit for assessment and management of his urinary incontinence. His pertinent medical history includes HTN x 30 yrs, CHF x 4 yrs, right-sided cerbralvascular accidents (CVA’S) in 1981 and 1983 with left-sided hemiparesis, and diabetes mellitus x 10 yrs. He describes his incontinence as frequent urination with little warning. He has had little success with a portable urinal because of his partial paralysis. When he is incontinent, he completely saturates the protective undergarments he wears. His present medications include: Furosemide (Lasix) 40mg 1 bid, Digoxin 0.250mg 1 qam, Aspirin 325mg 1 qam, and Insulin NPH 20Units sq qam.

Given the above information, what evidence supports Mr. Smith incontinence being secondary to :

(1) detrusor instability

(2) poor functional status

(3) iatrogenic

Mr. Smith is diagnosed as having detrusor instability and is to treated pharmacologically. You are asked to recommend an appropriate agent, its dose and to counsel the patient about its possible adverse effects. What do you recommend? What will you tell Mr. Smith about his new drug therapy? Describe the mechanism of action of the agent you have recommended.

Key to Case:

Evidence of detrusor instability:

1) the patient has had 2 CVA’s

2) little warning is given prior to urination

3) a neurogenic bladder is one of the long term sequelae of diabetes mellitus

4) large volume of urine is lost (completely saturates his protective undergarment).

Evidence of poor functional status:

1) left-sided hemiparesis

2)admitted difficult with urinal

Evidence of iatrogenic incontinence:

1)Furosemide can cause sudden a frequent urination.

Pharmacologic treatment:

Instruct the patient on the medications directions, how it will benefit him, and what adverse effects to watch out for and how to treat them.

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