Urinary Incontinence

Aliza Ben-Zacharia, ANP, MSN

The Corinne Goldsmith Dickinson
Center for Multiple Sclerosis
The Mount Sinai Medical Center
aliza.ben-zacharia@mssm.edu
 Anatomy of Micturition
„ Detrusor muscle
„ External and Internal
sphincter
„ Normal capacity 300-
600cc
„ First urge to void 150-
300cc
„ CNS control
„ Pons - facilitates
„ Cerebral cortex - inhibits
„ Parasympathetic -
Bladder contraction
„ Sympathetic - Bladder
Relaxation
„ Sympathetic - Bladder
neck and urethral
contraction
„ Somatic (Pudendal
nerve) - contraction
pelvic floor musculature
Nerves & Micturition
 Prevalence of Urinary Incontinence
„ Urinary incontinence – involuntary loss of urine
sufficient to be a problem
„ Affects 13 million Americans

„ 33% of women >65 have some degree of UI

„ 26% of women>18 experience various degree of SI

„ 15% to 30% of noninstitutionalized older adults

(19% men; 39% women)
„ Prevalence increases with age (not normal aging)

„ 50% of those in nursing facilities

„ Nygaard et al., Obstet Gyneco 2003; 101: 149-56.
„ Thom D. J Am Geriat Society 1998; 46:473-80.
 Urinary Incontinence is Common
Among Older Adults
18 Men
16 Women
Percentage of respondents

14
in each age group

12
10
8
6
4
2
0
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85
Age (years)
This is an example of one woman's idea of
another great use for duct tape.
(She lives in a household with five guys!)
 Economic Costs
„ 10 Billion Dollars – 1987
„ 30 Billion Dollars – 1995
„ Cost of UI in 1995 : $24.3 billion or $3,565 per
incontinent person
„ Cost of UI > Coronary artery bypass surgery + renal
dialysis
„ Cost : Physical, Psychosocial & economic
„ Wagner, Urology 1998; 51:355-61.
„ Resnick, JAMA 1998; 280:2034-5.
„ Hendrix, Disease-A-Month, 2002; 48:622-636.
 Direct Cost of Urinary
Incontinence in the USA

20

16
US $ billion

12

0
1984 1987 1993
 Factors Associated with
Bladder Control Problems
• Age
• Childbirth
• Gender
• Menopausal Status
• Surgery
• Prostate enlargement
• Lifestyle
• Medications
• Concomitant illnesses
 Urinary Incontinence
„ UI is not a normal part
of aging
„ Loss of urine due to a
combination of
„ Genitourinary pathology
„ Age-related changes
„ Comorbid conditions
„ Environmental obstacles
„ Age related changes (BPH,
atrophic vaginitis)
„ Dementia, depression, stroke,
PD, MS
„ Constipation/Fecal
incontinence
„ COPD, or chronic cough
„ Detrusor overactivity &
uninhibited contractions
„ Increased PVR or decreased
capacity
„ Impaired ADLs
„ Obesity
 Types of Incontinence
„ Urge incontinence – strong urge to void Immediately
„ preceded by a sensation of urgent need to urinate, with or without
increased frequency
„ Stress incontinence – increased intra-abdominal
pressure that lead to incontinence
„ On exertion, or sneezing or coughing
„ Overflow incontinence – over-distended bladder
leading to UI / dribbling
„ Functional incontinence – physical / psychological
impairment UI due to inability getting to BR
„ Mixed incontinence – combination of 2 or more
types
 Urge Incontinence
Other Names: OAB, detrusor hyperactivity, detrusor
instability, irritable bladder, spastic bladder

„ Most common cause of UI >75 years of age

„ Abrupt desire to void cannot be suppressed
„ Usually idiopathic
„ Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Multiple
sclerosis, Parkinson’s Disease, dementia
 Overactive Bladder
Urgency

Frequency Urge
incontinence

OVERACTIVE BLADDER
When you got to go, you got to go!
 Stress Incontinence
„ Most common type in women < 75 years old
„ Occurs with increase in abdominal pressure;
cough, sneeze, etc.
„ Hypermotility of bladder neck and urethra;
associated with aging, hormonal changes, trauma of childbirth
or pelvic surgery (85% of cases)
„ Intrinsic sphincter problems; due to
pelvic/incontinence surgery, pelvic radiation, trauma,
neurogenic causes (15% of cases)
 Stress Incontinence
(a) Continent woman (b) Woman with stress
incontinence

External
urethral
sphincter

Sudden increase in intra-abdominal pressure

 Overflow Incontinence
„ Over distention of
bladder
„ Bladder outlet
obstruction; stricture,
BPH, cystocele, fecal
impaction
„ Non-contractile bladder
(hypoactive detrusor or
atonic bladder); Diabetes,
MS, Spinal Injury,
Medications
Functional Incontinence
„ Does not involve lower urinary tract
„ Result of psychological, cognitive or physical
impairment
Mixed Incontinence (older women)
Stress & Urge Incontinence

Sudden increase
in intra-abdominal
pressure

Uninhibited detrusor
contractions
Potentially Reversible Causes
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction
Reversible causes of incontinence
(DRIP Mnemonic)
„ Delirium
„ Restricted mobility
(illness, injury, gait
disorder, restraint)
„ Infection;
Inflammation (atrophic
vaginitis); Impaction of
stool
„ Polyuria (diabetes
mellitus, caffeine intake,
volume overload);
„ Pharmaceuticals
 Other factors causing Incontinence
Antidepressants, sedatives, Sedation, retention (overflow)
antipsychotic
Diuretics Frequency, urgency-OAB
Caffeine Frequency, urgency-OAB
Anticholinergics Retention (overflow)
Alcohol Sedation,frequency-OAB
Narcotics Retention, constipation, sedation
(overflow/OAB)
αAdrenergic blockers Decreased urethral tone
αAdrenergic agonists-Clonidine Increased urethral tone
Calcium Channel Blockers Retention (overflow)
ACE inhibitors Cough (Stress Incontinence)
Why is Treatment of Incontinence Important?

„ Medical complications - skin breakdown,

increased risk of fractures, increased urinary
tract infections
„ Social stigma - leads to social isolation, decline
in function, restricted activities and depression
„ Institutionalization - UI is the second leading
cause of nursing home placement
 Urinary Incontinence is Often
Under-Diagnosed and Under-Treated
„ Only 32% of primary care physicians routinely
ask about incontinence
„ Often not mentioned to physicians
„ 50-75% of patients never describe symptoms
to physicians
„ 80% of urinary incontinence can be cured
or improved
 Taking the History
„ Duration, severity,
symptoms, previous
treatment, medications,
GU surgery
„ 3 P’s
„ Position of leakage
(supine, sitting, standing)
„ Protection (pads per day,
wetness of pads)
„ Problem (quality of life)
„ Voiding Diary
„ Document number of
voids per day
„ Volumes
„ Number of incontinent
episodes
„ Severity of the problem
„ Time of day with
increased incontinence
„ Morning incontinence may
be associated with diuretic
use
 Bladder Diary
Date: Monday 19 March
Time Drinks Amount Did you feel a If leakage occurs,
(types and of urine strong and amount of urine
amount) passed sudden desire to leaked
(ml) urinate (9 if yes)
Small Medium Large
8:00 am Tea, 2 cups

8:30 am 150 ml
9
10:00 am Coffee, 1 mug
9
11:15 am 200 ml

12:00 pm 100 ml

1:00 pm 100 ml

2:00 pm Cola, 1 can

2:30 pm
9
 Urinary Assessment
„ Four questions (Caroline Sampselle, PhD)
„ Are you leaking urine?
„ Do you have trouble making it to the BR or
Do you urinate very frequently?
„ Do you leak urine when you cough, stand,
sneeze?
„ Do you wear a pad for urine leakage?
 Evaluation of Incontinence
„ Medical history: „ Physical
Symptoms examination: Neuro,
associated with abdominal & pelvic &
incontinence rectal examination
„ Surgical history „ Examination
procedures: PVR,
„ Social history
Urodynamics
„ Obstetric &
„ Laboratories: UA,
„ Medications urine culture, blood test
Interpretation of Post-Void Residual
PVR < 50cc - Adequate bladder emptying
PVR > 100cc - Detrusor weakness,
neuropathy or outlet obstruction
PVR > 150cc - Avoid bladder relaxing
drugs
PVR > 200cc - Refer to Urology
PVR > 400cc - Overflow Urinary
Incontinence likely
Bladder Pressure-Volume
Relationship
 Urinary Incontinence
When to refer
„ Failure of initial conservative methods
„ Significant stress urinary incontinence
„ Recurrent urinary tract infections; Hematuria
„ Recent onset of overactive bladder
„ Significant pelvic prolapse
„ Prior incontinence surgery
„ Prior radical pelvic surgery or radiation
 Bladder Irritants
„ Alcoholic beverages „ Milk or milk
„ Carbonated products
beverages „ Coffee or tea
„ Medications with (including decaf)
caffeine „ Citrus juice and fruits
„ Highly spicy food „ Sugar
„ Honey „ Chocolate
„ Tomatoes and „ Corn syrup
tomato paste „ Artificial sweeteners
products
 Treatment pathway
Lifestyle Assess and
Refer
interventions categorise

OAB with or
Stress UI Mixed UI
without urge UI

Urodynamics if appropriate, not routinely for pure stress UI

OAB with or
Stress UI
without urge UI

Behavioral management, Medical approaches,

Medications, Surgical procedures
Behavioral Therapy Techniques
„ Lifestyle „ Bladder Training
Interventions 9 Patient education
9 Fluid & Dietary
9 Scheduled voiding
modifications
regimen
9 Eliminating bladder
9 Urge control
irritants
strategies
9 Constipation
9 Self monitoring
prevention
9 Weight reduction „ Pelvic Floor Muscle
9 Smoking cessation Contractions
 Good Bladder Habits

Step 1:
1 Maintain appropriate
fluid intake
Step 2:
2 Practice good toilet habits
Step 3:
3 Maintain good bowel habits
Step 4:
4 Exercise of pelvic floor
muscles
Pelvic Floor Muscle Exercises
„ Contracting the muscles „ Women will see results
for at least 10 seconds from PFMT after 12-16
„ 30-40 contractions/day weeks
can prevent & treat UI „ May increase sexual
„ Using vaginal cones or pleasure while doing
balls to do pelvic muscle them during intercourse
contractions „ Do them prior to cough
„ Women using devices are or sneeze if has stress
less likely to continue incontinence
PFMT
 Pelvic Floor Exercises

Locate pelvic floor muscles

Squeeze pelvic
Repeat, as floor muscles
as tightly as
recommended possible for a
by physician/ few seconds
continence (maximum of
10 seconds)
advisor

Relax completely for at

least 10 seconds
 Physical therapy & Body
Mechanics
„ Physical therapy
program
„ Strengthening pelvic
floor muscles
„ Controlling spasticity
„ Maintaining posture
& body mechanics
while doing ADLs
Other interventions
Pessaries
 Incontinence Pads and
Protective Equipment
All-in-one briefs

Absorbent pads Reusable underpants

designed to carry
disposable absorbent pads
Dribble pouch

Chair and bed pads

Bladder Catheterization VS
Indwelling Catheter
 Stress Incontinence
Management
„ Behavioral therapy
9 Pelvic floor muscle exercises (Kegel)
9 Exercises with biofeedback
„ Medications
9 Alpha-adrenergic stimulants (urethral closure;
pseudoephedrine)
9 Oral Estrogen - sensitize adrenergic receptors in the
bladder neck
9 Transvaginal Estrogen may be used for atrophic vaginitis
9 Duloxetine (Cymbalta®-SSRI & Norepinephrine reuptake
inhibitor) Increases urethral sphincter contraction
 Stress Incontinence
Management
„ Devices
9 Extracorporeal magnetic innervation (ExMI) chair –
a chair that stimulates pelvic muscles via a low intensity
magnetic field (twice weekly in 20 minutes sessions for 8
weeks)
9 Intravaginal support devices – used in patients with
exercise induced incontinence
9 Pessaries –Used to treat prolapse – support to bladder
neck (long term use requires monitoring for vaginal
infection and ulceration)
9 Pessaries may worsen urge incontinence by reducing
obstruction as a result of the prolapse
 Urge Incontinence
Management
„ Behavioral therapy
9 Bladder training – more effective than oxybutinin &
improves incontinence in more than 50% of patients
9 Dietary manipulations (Fluid intake: 30mL/kg of body
weight, 0.5oz/lb)
9 Kegel exercises – RCT: Patients doing Kegel exercises
had an 81% reduction in incontinence episodes compared
with 69% decrease in oxybutinin patients (statistical
significant)
9 Biofeedback training for learning effective Kegel
technique (does not show increase efficacy)
 Medications for treatment of Urge
Incontinence
„ Anticholinergics „ Side effects: Dry mouth,
„ Inhibit involuntary Constipation, Blurred vision,
Nausea, Dizziness,
bladder contractions Headache, Altered cognitive
function
„ Increase in bladder
capacity „ Transdermal agent
9 Oxybutinin (Oxytrol®)
„ Oral agents 9 One patch twice weekly
9 Oxybutinin (Ditropan®) „ Botox – off label
„ Refractory to oral meds
9 Tolterodine (Detrol®) & neurogenic bladder
9 Short & Long acting
 Urge Incontinence
Management
„ Electrical Therapy
„ Indicated in patients with severe
refractory urge incontinence
„ A generator device that is
inserted into the sq tissue of the
lower back or buttocks
„ The generator powers a lead that
is placed through the sacral
foramen to stimulate the S3
sacral nerve to decrease
detrusor muscle contractions
„ Effective treatment
„ Cost of device-$10,000
(covered by Medicare)
 Overflow Incontinence
Management
„ Urinary retention – ? Bladder emptying
„ Identify the etiology of retention
„ Poor detrusor contraction
9 A trial of betanechol (cholinergic agent)
9 Multiple side effects: flushing, N/V/D, bronchospasm, H/A,
salivation, sweating, & visual changes
9 Intermittent catheterization or a chronic indwelling catheter in
severe detrusor hypo-contractility
„ Bladder outflow obstruction
9 Usually associated with pelvic organ prolapse
9 Referral to a urologist
 Mixed Incontinence
Management
„ Initial treatment of
symptoms
„ Non-invasive behavioral &
rehabilitative therapy
„ Bladder training
„ Eliminating irritants
„ Pelvic muscle exercises
„ Medical treatment options
„ No drugs for SI
„ Surgical therapy for SUI
„ Referral to a urologist
 Functional Incontinence
Management
„ Physical or cognitive
impairments
„ Timed voiding
„ Mobility assist devices
„ Bedside commodes
„ Routine nursing care
 Transient & Continuous
Incontinence Management
„ Transient Incontinence „ Continuous Incontinence -
urinary leakage or dribbling
„ Identification of the
„ Unrelated to stress or
inciting factors for
urgency
transient incontinence
„ Related to an anatomic
„ Treat the reversible causes abnormality
as outlined by the 9 Urethral diverticulum
mnemonic 9 Urinary fistula
DIAPPERS/DRIP „ Referral to a specialist
„ Transient incontinence can „ Further diagnostic evaluation
persist if left untreated „ Surgical correction
Key Clinical recommendations
„ Patients with urge incontinence should be
taught Kegel exercises. Biofeedback does not
improve the efficacy of the exercises
„ Selection of an anticholinergic agent for
treatment of urge incontinence should be
based on a discussion with the patient about
efficacy & side effects
„ Electrical therapy can be considered in
patients with severe refractory urge
incontinence who do not respond to
behavior therapy & medications
 Case Study
„ CC: “I have been having problems over
the past 3 months with losing my urine. I
have leaked a small amount of urine when
I laugh or sneeze. But it is getting worse.
Sometimes when I sit I feel the urge to
urinate. When I urinate at that time I have
large amounts of urine. I have been using
pads to keep myself dry.”
 Case study
„ History (medical, family,
social, meds, ROS)
„ Physical exam
„ Diagnostic tests
9 UA, C&S
9 PVR
9 Urinary diary
9 Labs;chemistry
9 PE; stress test
„ Stress incontinence
„ Urge incontinence
„ Mixed; stress+urge
„ Overflow incontinence
 Case Study - Treatment
„ If UTI – A course of „ Stress I – a sympathetic
antibiotics agonist acts by increasing
„ Education & Non- sphincter tone
pharmacological Tx (pseudoephedrine)
„ Fluid intake issues „ Overflow I with obstruction
„ Hygiene and sexual – a med to increase bladder
tone – bethanechol
„ Avoiding bladder
irritants „ Overactive detrusor – a
„ Urge control by using med to decrease bladder tone
breathing exercises – anticholinergic
„ Kegel’s/PFME can „ * Anticholinergic
be effective medications may cause
urinary retention
 To All Employees:
To maximize productivity and make us more
efficient, we are going to modify all work areas:
It is expected that this change will increase
productivity by approximately 4.58%