Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate Director for GRECC Clinical Programs Birmingham/Atlanta.

Kathryn L. Burgio, PhDKathryn L. Burgio, PhDAssociate Director for GRECC ResearchAssociate Director for GRECC Research

&&

Patricia S. Goode, MDPatricia S. Goode, MDAssociate Director for GRECC Clinical ProgramsAssociate Director for GRECC Clinical Programs

Birmingham/Atlanta Geriatric Research EducationBirmingham/Atlanta Geriatric Research Education and Clinical Center – July 27, 2006and Clinical Center – July 27, 2006

Assessment and Management of Assessment and Management of Urinary Incontinence in the ClinicUrinary Incontinence in the Clinic

05

10152025303540

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Age

Pre

vale

nce

(%

)

Severe Moderate

Slight Unknown

Hannestad et al., 2000

Prevalence of Prevalence of IncontinenceIncontinence

Severity

UI - Treatment Seeking UI - Treatment Seeking

Reported toProviderNot Reported

1,104 Community Dwelling Older Adults with Urinary Incontinence on interview

Burgio, et al: JAGS 42: 208, 1994Burgio, et al: JAGS 42: 208, 1994

38%38%62%62%

Reasons for Not Reporting Incontinence to Provider

Not aware that can be treatedNormal part of agingPersonal problem (not medical)EmbarrassedFear of nursing home placementAfraid treatment requires surgery

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

Patient Case

75 year old man Goes to the bathroom every 1-2 hours

daytime and 3 times at night. About once a week, on the way to the

bathroom, he can’t make it and wets his clothes.

Evaluation?Diagnosis?Appropriate treatment?

Overflow

Urge Stress

Functional

Types of Incontinence

Work-up of Incontinence

History Physical Urinalysis Post-void Residual

Volume

Incontinence History

Type Do you leak urine during physical activity

such as coughing, sneezing, lifting, or exercising?

Do you get the urge to go and can’t make it without leaking?

Onset

Severity Frequency of leakage Need for absorbent products

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

Medical History

Medical, neurological, history

Surgical history

Prostatectomy

Review medications including OTC

Habits (caffeine, tobacco, alcohol use)

Physical Exam

Brief Neurologic Exam Gait Lower extremity strength Cogwheel rigidity Sphincter tone and voluntary

contraction

Rectal (and Pelvic for women)

Urinalysis

Bacteriuria

Pyuria

Glycosuria

Hematuria

Post-Void Residual Volume

Measure amount of urine left in bladder after voiding.

Ultrasound or catheter

Normal: < 50 ml

Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up

Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation.

Physical: hard stool in vault UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) PVR: 200 mL

Diagnosis? Treatment Options?

Contributors to UIto Treat First

Drugs and DietInfectionAtrophic UrethritisPsychological - Depression, DeliriumEndocrine - Diabetes, HypercalcemiaRestricted MobilityStool Impaction

Contributors to UIto Treat First

DrugsSedatives including alcoholACE inhibitors (cough)Antipsychotics (pseudoparkinsonism)Diuretics (bad timing)Alpha Blockers – worsen stress UIAnticholinergics – incomplete emptying

Contributors to UIto Treat First

Drugs and Diet – Caffeine & FluidsInfectionAtrophic UrethritisPsychological - Depression, DeliriumEndocrine - Diabetes, HypercalcemiaRestricted MobilityStool Impaction

Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up

Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation.

Physical: hard stool in vault UA: 2+ glucose

(and Hgb A1C = 9.8 one month ago) PVR: 200 mL

Patient Case

75 year old man Frequent voiding and weekly urge

incontinence Work up

Hx: Otherwise negative Physical: unremarkable UA: normal PVR: 45 mL

Diagnosis? Treatment options?

First Line Treatments Medications

Anticholinergics Oxybutynin – generic, Ditropan XL, Oxytrol

patch Tolterodine - Detrol Solifenacin - VESIcare Trospium - Sanctura Darifenacin - Enablex

Alpha blocker for BPH

Other treatments Behavioral training – try BEFORE or with drug

PFM Training PFM Training and Exerciseand Exercise

PFM Training PFM Training and Exerciseand Exercise

Weight LossWeight LossWeight LossWeight Loss

Diet & Fluid Diet & Fluid ManagementManagement

Diet & Fluid Diet & Fluid ManagementManagement

Behavioral Behavioral ApproachesApproachesBehavioral Behavioral ApproachesApproaches

Behavioral Behavioral StrategiesStrategies

Behavioral Behavioral StrategiesStrategies

Bladder TrainingBladder TrainingBladder TrainingBladder Training BiofeedbackBiofeedbackBiofeedbackBiofeedback

Bladder Bladder DiariesDiaries

Bladder Bladder DiariesDiaries

Least Invasive – Use First !!

Behavioral Treatment: Multi-component Program

Pelvic floor muscle training

Home practice of exercisesIncrease duration of contraction/relaxation over time

Bladder Control Techniques

Self-Monitoring w/ bladder diaries

When the Urge Strikes –Freeze and Squeeze

Stop and stay still

Squeeze pelvic floor muscles

Relax rest of body

Concentrate on suppressing urge

Wait until the urge subsides

Walk to bathroom at normal pace

Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

When to Void

WorstWorstTimeTime

WorstWorstTimeTime

BestBestTimeTime

CalmCalmPeriodPeriod

Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.

Other Behavioral Strategies

Stress Strategy

Squeeze before you sneeze (or cough or lift)

Post Void Dribbling Strategy

Squeeze after voiding

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

Reduction of Incontinence

81%

39%

68%

0

20

40

60

80

100

Behavioral Drug Control

% R

edu

ctio

n

Patient Satisfaction with Treatment

78%

49%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Completely satisfied

BehaviorDrugPlacebo

Burgio et al. JAMA. 1998; 280:1995-2000

Patient Case

85 year old woman Frequently leaks on the way to the bathroom Work up

Hx: Aricept for dementia Physical: Frail, walks slowly, uses a walker UA: normal PVR: 85 mL

Diagnosis? Treatment Options?

The Patient with The Patient with Functional LimitationsFunctional Limitations

Avoid anticholinergic drugs in pts with dementiaFacilitate functional status

Mobility devicesPhysical therapy

Bedside commodeUrinal for menPrompted voiding – VERY effective

Post-Prostatectomy Incontinence

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 Diagnosis? Treatment Options?

Behavioral Treatment of Post-Prostatectomy

Incontinence

20 men; 55-87 years oldAverage 2 ½ years since surgery8 weeks of biofeedback-assisted behavioral training 78.3% decrease in accidents

(range of -12 – 100%)

Burgio, et.al., J Urology, 1989

Behavioral Training for Post-Prostatectomy Incontinence

Case Series of 27 men with persistent post-prostatectomy UI

Taught pelvic floor muscle exercises without using biofeedback

56.6% reduction in leakage

Meaglia et al. J Urol. 1990;144:674

Post-Prostatectomy Incontinence

65 yo considering

radical prostatectomy Continent Read that 72% of patients reported

incontinence persisting 1 year after surgery

and 40% wearing pads What can he do to help prevent

incontinence?

Stanford, et.al. JAMA, 2000

Pre-Prostatectomy Muscle Pre-Prostatectomy Muscle TrainingTraining

00.10.20.30.40.50.60.70.80.9

1

0 50 100 150 200Time in Days until Continent

prevention

control

(p = .032)

N=125

Burgio, Goode, et al, J Urol, 175:196; 2006

Reduction of Incontinence

3252

73

54

0102030405060708090

100

Pad Use Proportion DryDays

Burgio, Goode, et.al., J Urology, 2006Burgio, Goode, et.al., J Urology, 2006

p=.045p=.090

%

Pre-Prostatectomy Muscle Pre-Prostatectomy Muscle TrainingTraining

Median Time to Continence: Intervention Group - 3.5 months Control Group - > 6 month

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

Summary - Work-up of Incontinence

History

Physical

Urinalysis

Post-void Residual Volume

Summary: Contributors to Incontinence to Treat First

Drugs and DietInfectionAtrophic UrethritisPsychological - Depression, DeliriumEndocrine - Diabetes, HypercalcemiaRestricted MobilityStool Impaction

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

Current Studies at Bham/ATL GRECC

MOTIVE - Combined medication and behavioral therapy for overactive bladder in men (VA Rehab R&D)

ProsTech – Behavioral therapy with and without biofeedback and electrical stimulation for persistent incontinence in men after radical prostatectomy (NIH)

COMBO - Combined medication and behavioral therapy for urge incontinence in women (VA Rehab R&D)

ATLAS – Behavioral therapy or pessary or combined for stress incontinence in women (NIH)

RUBI - Botox injections for refractory urge incontinence in women (NIH)

Contact Information

Patricia Goode, MD [email protected] 205-934-3249 Kathryn Burgio, PhD [email protected] 205-558-7067 Ken Shay, DDS, MS [email protected] 734-222-4325 http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?

id=22318