Fall 2011

No Gender Discrimination: Urinary Incontinence Affects Both Men and Women

By Jaimie Lazare
Aging Well
Vol. 4 No. 4 P. 14

Behavior modification, exercise, medication, and surgery can help treat or improve urinary incontinence in older adult patients.

Urinary incontinence (UI), the involuntary loss of urine common among older adults, creates a tremendous burden on patients and their caregivers. According to the American Urological Association (AUA), 15 million men and women suffer from UI. Specifically, UI affects about 33% of older women, 15% to 20% of older men, 50% of frail elders, and 60% to 80% of nursing home residents.1 One study that looked at the impact of UI on the quality of life of people aged 65 and older showed older adults find that UI affects their quality of life to a greater degree than do chronic conditions such as diabetes and arthritis.2

Types of Urinary Incontinence
There are seven types of UI: urge, stress, overflow, mixed, functional, and transient incontinence, and overactive bladder. Urge incontinence is the involuntary loss of urine in which a patient experiences an uncontrollable urge to urinate that increases in frequency and severity with age and cognitive dysfunction. Stress incontinence, which is due to poor urethral sphincter function, involves the involuntary loss of urine when abdominal pressure is placed on the bladder, such as when coughing or sneezing. Stress incontinence is quite common in the geriatric population, especially among women. Overflow incontinence, which is relatively uncommon, occurs predominantly among men and is marked by the constant dribbling of urine that occurs frequently and in small amounts. Urge and stress incontinence tend to coexist in what is referred to as mixed incontinence among the geriatric population, particularly in women.3

Functional incontinence results from physical limitations or problems with cognition that prevent an individual from reaching a toilet in time. Transient incontinence occurs because of a temporary situation, such as starting a new medication or a urinary tract infection.4 An overactive bladder is caused by nerves that improperly trigger the bladder to contract at the wrong time, resulting in increased frequency and urgency with or without urge incontinence.

Jaspreet S. Sandhu, MD, an assistant attending urologist at Memorial Sloan-Kettering Cancer Center in New York, says that in the geriatric population, “Conditions such as stroke can cause people to become potentially incontinent, and strokes also may result in motor impairments, which could lead to further functional incontinence.”

Although risk factors such as neurologic injury can lead to UI in both men and women, there are special considerations that must be evaluated in treating geriatric patients for UI. More women experience UI than men, and these differences are due to the structure of the female urinary tract, pregnancy, childbirth, and menopause. Approximately 30% of women become incontinent following their first vaginal delivery, and there are many studies that show an episiotomy is not protective against UI.5 Although UI affects women to a greater degree than it does men, the prevalence of UI increases among older adult men.6 And while both men and women share numerous risk factors for UI, about 30% of men experience incontinence due to prostatic diseases and surgery.

Kevin Costello, MD, a geriatrician and hospitalist at Albany Medical College in New York, says because incontinence is multifactorial, like many other geriatric problems, it’s important to look for aggravating factors such as medications and conditions such as dementia. In the case of dementia, patients may not have the cognitive wherewithal to toilet properly or even react to having a full bladder, he says.

Drugs can also play a role in triggering UI in older adults. Annette Sessions, MD, an assistant professor of clinical urology at the University of Rochester Medical Center in New York, says medications such as Flomax and Uroxatral facilitate urinary emptying but at high doses can trigger urinary frequency. Sympathomimetic or anticholinergic drugs can contribute to incomplete bladder emptying that leads to overflow incontinence. Even drugs such as Sudafed can put individuals into urinary retention, she says.

Sequelae of Urinary Incontinence
Sandhu says skin macerations or wet skin caused by UI can lead to ulcers because patients sit on the skin that gets macerated, increasing their risk of pressure ulcers. There is also a risk of increased local infection because of skin maceration although ulceration is more common.

There are psychological issues associated with UI because patients may not want to go out or attend public events, which can lead to decreased exercise and decreased interaction with other people. Such limitations can impact psychosocial well-being.

“Partly a sequela of my practice, I see patients that are postprostatectomy that have been leaking for years and have been told that there’s nothing that can be done for that. Now that’s actually a fixable problem,” Sandhu says. Stress incontinence, which is very common in women, is also common in men postprostatectomy, and it’s reversible with surgery. Patients with stress incontinence are typically treated with a host of medicines and experience no improvements because it typically does not respond well to medical therapy. These patients often see a urologist, and their condition is often improved with surgery. For women, surgical repair would include a sling or urethral bulking agent, and for men, surgery would entail an artificial urinary sphincter or male sling, Sandhu says.

Diagnostic Evaluation
“A lot of people assume that incontinence is a normal part of aging. It’s a common part of aging, but it’s never normal, and it’s not a diagnosis in and of itself. It’s a syndrome that’s due to other things,” says Costello. “We have to ask about incontinence if the patient doesn’t volunteer it because it’s one of those things that may be more embarrassing to patients. But depending on the situation, if they are frustrated by their urinary incontinence, they may come to you specifically for it.”

Sessions suggests asking the following questions during a patient interview: When did your urinary incontinence begin? What provokes it? Do you use any incontinence pads and if so, how many? What fluids do you drink and how much of each do you consume? How are your bowel movements? Are you constipated?

The 2010 Physician Quality Reporting Initiative (PQRI) Specifications for Urologists offers a urinary incontinence assessment approach that can be utilized in practice during an in-office evaluation of patients with a complaint of UI, and the form can be accessed at www.auanet.org/content/legislative-and-regulatory/payment-and-reimbursement/pqri-toolkit/2010PQRIspecifications.pdf.

Sandhu adds that if patients leak with activity such as coughing, sneezing, or exercise, then it’s stress incontinence and they may benefit from surgery. However, patients with leakage they can’t control have urge incontinence, which may respond to medical therapy. So history is a very important component of diagnostics.

The physical exam is also important, particularly in women because the AUA recently updated its guidelines for female stress UI. One indicator critical to the classification of patients with stress UI is the clinician’s noting during a physical exam that a patient leaks with coughing. And similarly in men, if during an in-office evaluation they leak urine while coughing, then that’s pathognomonic for stress incontinence.

Sessions says the physical examination for women involves a vaginal examination including a general assessment of the tone and quality of the pelvic floor muscles. Physicians need to check for a prolapsed uterus, bladder, or rectum as well as testing how well a patient empties her bladder via a postvoid residual urine test, which can be completed using an ultrasound or a catheter, Sessions says. A urine specimen should be sent for culture because bacteria in urine can exacerbate UI. If the test comes back positive for the presence of blood, a cytology screening would be warranted. Although it’s not a perfect test, if it comes back suspicious for cancer, that changes the evaluation, she says.

“In a man the evaluation is similar, but the physical examination also includes an external exam of the genitalia, a digital rectal exam to examine the prostate, and the exam may include a PSA [prostate-specific antigen test] as a screening tool for prostate cancer,” Sessions says. “A subsequent test might also involve a urodynamic evaluation or a uroflow study in which we assess the pressure of the bladder and the responsiveness of the sphincter muscle in the area to bladder filling in urination and the flow rate. I’m only looking at those additional studies if I’m considering surgery, or if I’m concerned about someone having a neurogenic bladder and high bladder pressures that can damage the kidneys over time.”

Management
Sessions notes that before starting patients on any medications, she recommends dietary modifications such as avoiding bladder irritants such as coffee, carbonated beverages, and alcohol. And she asks that patients not drink anything three hours before bedtime if nocturia is the problem. If they are constipated, they need to get on a bowel regimen that will produce soft-formed stool because constipation can trigger overactivity or bladder spasms. Referrals for pelvic floor rehabilitation and physical therapy can also help to improve pelvic floor muscles, she says.

“The first thing that most people do is pelvic floor muscle exercises. Pelvic floor muscle exercises are Kegels, and it helps males and females in both urge and stress urinary incontinence. So if someone comes to see me with urinary incontinence as a chief complaint, the first thing I ask them is if they’ve done a regimen of pelvic floor muscle exercises,” Sandhu says. “We have a protocol that we have our patients follow, which is seven to 10 sets of 10 reps each, and I tell my patients to do this religiously, even if you see no improvement. And two to three months later, the majority of patients do see a pretty dramatic improvement.”

 Costello finds that a toileting schedule helps patients, especially those with functional problems, to empty their bladders routinely, preventing leakage if the bladder starts contracting or is filling up. The schedule should generally start off with short intervals of about a couple of hours and gradually expand to about four hours between voids. By having your patients follow a toileting schedule, physicians can help improve the quality of life not only for the patient but also for their caregivers, he says.

“The largest category of medications associated with the management of bladder incontinence is the anticholinergic, antimuscarinic drugs such as Detrol, VESIcare, and Enablex. Those drugs are for urinary urgency. They have very little significant roles in stress urinary incontinence. Stress urinary incontinence tends to best be treated either by surgery or by off-label use of medications, which are not FDA approved but have some good effects on the bladder that can be helpful in stress urinary incontinence,” Sessions says.

Physicians should make sure their suggestions to patients are practical, Costello says. For example, if your patient has Alzheimer’s disease and you put her on an anticholinergic drug to reduce bladder contractions, it may have a negative effect on her cognition. Although it’s not a contraindication, it is a caution that practitioners should bear in mind when prescribing those medications, he says.

The management of UI requires the application of Kegel exercises as well as working those trigger points in the pelvic floor muscles to correct muscular imbalance and asymmetry. Dietary modifications should be implemented before medications are introduced. If a patient’s UI doesn’t improve, even after administering medications, then surgery may be considered for suitable candidates, Sessions says.

Surgical Considerations
Costello says when evaluating an older patient for surgery, it comes down to a quality-of-life decision as well as a medical decision with respect to a patient’s eligibility and the safety of undergoing surgery. He says when it comes to age, there isn’t a cutoff. Rather, surgical eligibility has more to do with a patient’s physiology and overall functional status.

Sessions recalls the oldest patient she has operated on for UI, who was a healthy woman in her early 90s. Her quality of life was adversely affected by UI because she was soaking through 10 thick pads per day. After trying several different interventions that didn’t work, Sessions discussed surgery with her patient. The risks were significant for someone her age. However, postoperatively the patient’s UI issues improved dramatically, and she was wearing only two pads daily, representing a significant improvement.

While surgery worked in this case, Sessions finds that older patients aren’t interested in undergoing surgery unless it’s absolutely necessary. For the majority of patients, incontinence doesn’t fit the absolutely necessary criterion to undergo surgery, she says.

Unique Possibilities
Sandhu recalls a patient who came to see him after her UI issues got her kicked out of her co-op board meetings because she smelled. Although she was seen by many doctors and was prescribed numerous medications, her problem was difficult to treat because she had severe refractory overactive bladder. She was treated with an injection of botulinum toxin, which is not FDA approved, but it’s a simple intervention. She was able not only to attend her co-op meetings again but also to enjoy activities such as visiting museums.

Researchers are also studying the effects of stem cell treatment for stress urinary incontinence. If it works, it would be a simple way to prevent stress UI in both men and women, Sandhu says.

— Jaimie Lazare is a freelance writer based in Brooklyn, N.Y.

PCP Guideline for Assessing Urinary Incontinence
Evaluating your older patients for urinary incontinence (UI) can be confounded by multiple medications, past surgical history, cognitive deficits, and other issues. It’s important to discuss UI because it can have a devastating effect on patients’ quality of life and lead to social withdrawal and depression. Practice the following for UI patients:

• Acknowledge the impact that UI has on quality of life.

• Assess patients’ history to identify the symptoms and plan treatment goals accordingly.

• Rule out reversible causes of UI such as urinary tract infection or medication.

• Examine patients for neurological disease, abdominal mass, and pelvic organ prolapse to identify the cause of UI.

• Outline patients’ care management, which should include nonsurgical measures as the primary treatment goals.

• Refer patients to a specialist such as a urologist for complex UI cases or unsuccessful treatments.

— Source: Norton P, Brubaker L. Urinary incontinence in women. Lancet. 2006;367(9504):57-67.

References
1. Miu DK, Lau S, Szeto SS. Etiology and predictors of urinary incontinence and its effect on quality of life. Geriatr Gerontol Int. 2010;10(2):177-182.

2. Hawkins K, Pernarelli J, Ozminkowski R, et al. The prevalence of urinary incontinence and its burden on the quality of life among older adults with medicare supplement insurance. Qual Life Res. 2011;20(5):723-732.

3. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician. 1998;57(11):2675-2684.

4. National Kidney & Urologic Diseases Information Clearinghouse. Urinary incontinence in women. Last updated September 2, 2010. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/uiwomen. Accessed August 2, 2011.

5. Norton P, Brubaker L. Urinary incontinence in women. Lancet. 2006;367(9504):57-67.

6. Stothers L, Thom DH, Calhoun EA. Urinary incontinence in men. In: Litwin MS, Saigal CS (eds). Urologic Diseases in America. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, D.C.: U.S. Government Printing Office; 2007; NIH Publication No. 07-5512.