Geriatric rehabilitation: continence promotion in family practice - management of urinary incontinence in elderly

Mei-Ling Tsang 曾美玲, Cheuk-Kwan Tam 譚焯坤, Ho-Pui So 蘇浩培

HK Pract 2005;27:455-467

Summary

Urinary incontinence is a common problem in the elderly with a negative impact on quality of life. Through history taking, targeted examination and relevant investigations, the diagnosis and an appropriate management plan can be made. Reversible conditions should be identified and treated promptly. For management of established incontinence, non-pharmacological options should be considered before pharmacological or surgical treatment. Minimizing the impact of incontinence and restoration of continence should be the aim for every incontinent elderly person.

摘要

小便失禁是常見的老年人問題，對他們的生活質量有很大影響。 通過收集病史、身體檢查和相關檢查研究，可找出病因並給予適當的治療。 可以治療的病人可被確認和盡快得到治療。非藥物治療是首選， 其次才是到藥物和手術治療。目的在於減輕失禁的影響和恢復小便自控能力。

Introduction

Urinary incontinence has been regarded as a geriatric giant because of its common occurrence among the elderly, its complexity and great impact on the elderly and society. It is associated with skin irritation, pressure ulcers, falls and fractures. Psychologically, it leads to anxiety, depression, embarrassment, isolation and poor quality of life.^1,2 Socially, it leads to carer stress and institutionalization.³ It is important that physicians be on the alert to the occurrence of urinary incontinence in the elderly, be knowledgeable of the basic assessment and able to develop an appropriate management plan.

Definition and prevalence of urinary incontinence

Urinary incontinence is defined as the complaint of any involuntary leakage of urine.⁴ (Note: this definition is not applicable in infants and small children.) In US, the prevalence ranges from 3% to 55%, depending on the definition of incontinence used and the age of population studied.⁵ The prevalence of urinary incontinence also increases with advancing age.⁶ In the UK, a survey in 1991 showed that 13.3% of men and 16.8% of women with age >60 years old living in the community had urinary incontinence.2 In Italy, a study in 2001 showed the prevalence of urinary incontinence was 11.2% in men and 21.6% in women with age >65 years old living in the community.⁷ In HK, a study by Hong Kong Continence Society and the Hong Kong College of Family Physicians in 1996 showed that urinary incontinence affected 28.4% of people over 60 years old attending general practitioners.⁸ A study in 1990 revealed that 21.9% of men and 26.3% of women 60 years old or above living in institution had urinary incontinence.⁹

Types of incontinence

Urinary incontinence can be categorized into transient and established incontinence. It can also be classified according to the clinical presentation, including stress, urge, mixed and others. Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency. Urge incontinence can present in different symptomatic forms; for example, as frequent small losses between micturitions or as a catastrophic leak with complete bladder emptying. Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also on exertion, effort, sneezing or coughing. Nocturnal enuresis is the complaint of loss of urine during sleep. Continuous urinary incontinence is the complaint of continuous leakage. The term "Overflow incontinence" is no longer recommended by the International Continence Society (ICS) in 2002. This term is considered confusing and lacking a convincing definition. If used, a precise definition and any associated pathophysiology should be stated.⁴

Transient incontinence

Established incontinence

Established causes of urinary incontinence are summarized in Table 2. It can largely be categorized into 2 groups: Failure of bladder to store urine and failure of bladder to empty urine. However, both conditions are not exclusive and can co-exist. One of the example is "Detrusor Hyperactivity and Impaired Contraction" (DHIC). DHIC is a common form of urinary incontinence in the elderly. It is important to recognise this situation because treatment of urge incontinence with anti-cholinergic agents in patients with DHIC may result in urinary retention.

Evaluation

The objectives of evaluation are to determine the causes of incontinence, identify reversible conditions, evaluate the need for further investigations, assess the patient's environment and available support and resources, and to develop a targeted management plan.

History should focus on the characteristics of urinary incontinence. Going through the lower urinary tract symptoms (LUTS) systematically (Table 3) can help to identify types of urinary incontinence. Identify the frequency, volume and severity of incontinence. Clarify any alternation in bowel habit or sexual function. Record significant past and present medical, surgical, urological, gynaecological and neurological history and previous medical or surgical treatment for incontinence. Check all the medications including non-prescription agents that the patient is taking. Review patient's functional status (mobility, self care ability, mentation and motivation). Assess patient's living condition and social environment. Assess the impact of incontinence on patient and care-giver: their views and attitude, social and psychological impact, effect on hygiene and quality of life, and measures used to contain the leakage.

Physical examination:

Post-void residual (PVR) volume has important diagnostic implications. It gives a valuable guide on the ability of the bladder to empty the urine. PVR is the volume of urine left in bladder at end of micturition. It can be measured by either non-invasive method: use of an ultrasound scanner, or by in-out catheterization. Currently, there is no strong evidence-based PVR value beyond which is considered abnormal. In most settings, PVR < 50ml is empirically considered as acceptable bladder emptying. PVR > 100ml is considered abnormal and justifies further investigation. Urinalysis by dipstick testing of urine is an acceptable screening method. Urine culture should be done to exclude infection.

Bladder chart / continence charts: These are helpful to characterise symptoms and follow response to treatment. It can be in the form of (1) Micturition time chart - this records only the times of micturitions, day and night for at least 24 hours. (2) Frequency volume chart (Figure 1) - this records the volumes and time of each micturition, day and night for at least 24 hours. (3) Bladder diary (Figure 2) - this records times of micturitions, voided volumes, incontinence episodes, pad usage, information such as fluid intake, degree of urgency and degree of incontinence. A 3-day diary is usually adequate for evaluation.

Renal function should be done. Further investigations shall be guided by clinical information obtained.

Urodynamics

Urodynamics are helpful to: (1) establish a diagnosis on which the management plan can be based; (2) provide evidence on management priority for coexisting abnormalities; (3) assess the natural history of lower urinary tract dysfunction; (4) assess the results of treatments designed to affect lower urinary tract function.⁸

Common urodynamic tests include: uroflowmetry; filling and voiding cystometry; videourodynamics; ambulatory urodynamics; urethral pressure profile and neurophsyiological testing.

Cystometry - filling and voiding is a multichannel study. A single channel catheter is inserted into the rectum (records the abdominal pressure). A two channels catheter is inserted into the bladder for saline infusion and intravesicle pressure measurement (detrusor pressure = bladder pressure - abdominal pressure). The bladder is infused with saline and patient is asked to report bladder sensation - the "first" sensation of desire, then the usual "normal" desire and then "strong" desire. Any leakage is noted during the filling phase. When the bladder is full, patient is asked to void. The flow rate and volume voided will be recorded. Figure 3a is the filling and voiding cystometry of a patient with detrusor overactivity. Figure 3b showed a patient with outflow obstruction.

Management

Management can be largely categorised into: (1) Non-pharmacological (Pelvic Floor Muscle Training [PFMT], electrical stimulation, vaginal cones, bladder training); (2) Pharmacological and (3) Surgical interventions.

Non-pharmacological

Pelvic floor muscle training (in female urinary incontinence)

Cochrane systematic review concluded that PFMT is an effective treatment for stress and mixed incontinence.¹⁸ The self reported cure / improvement is significantly higher in those having PFMT than no treatment or placebo treatment.¹⁸ The placebo intervention used in different trials varied and included placebo drug, sham electrical stimulation, and placebo pelvic floor training (i.e. participant perform exercise that will not alter the pelvic floor musculature). There was no significant difference between pelvic floor muscle training alone and other physical therapy regimens, except for a significant

PFMT plus bladder training: A randomized trial compared the efficacy of PFMT (with biofeedback instruction) together with bladder training versus bladder training alone and PFMT alone on urinary incontinence in women with stress incontinence, detrusor instability or both.¹⁹ Bladder training involved a progressive voiding schedule and urge inhibition techniques (e.g. affirmations via self-statements, distraction and relaxation techniques) to avoid voiding off schedule. Immediately after treatment, the combination therapy group had significantly fewer incontinent episodes compared with the other 2 groups. Self reported cure / improvement was better in combined therapy group than either PFMT alone (PFMT 48/64, combined group 55/61) or bladder training alone (bladder training 43/68, combine group 55/61). At 3 months after treatment, no difference was seen in incontinence episodes among the groups. Cure rates increased in the PFMT group from 18% to 20%, while there was slight decrease in the bladder training group (from 18% to 16%) and combined group (from 31% to 27%).¹⁹

PFMT plus anticholinergic drugs: In participants with urge incontinence with or without stress incontinence, the combined subjective cure or improvement rates were marginally better with pelvic floor muscle training (RR, 1.18; 95% CI. 1.01-1.37) and pelvic floor muscle training significantly reduced the number of leakage episodes in 24 hours (weighted mean difference WMD, -0.41;95% CI, -0.79 to -0.03).^12,14,18

PFMT or surgery: Cochrane systematic review compared pelvic floor muscle training to surgery (open retropubic colposuspension, vaginal repair, or a combination) for stress incontinence found no significant difference in the rates of self-reported cure or improvement.¹⁸ However, it did find that pelvic floor muscle training resulted in fewer self-reported cures (PFMT 3/24, Surgery 16/26 ; RR, 0.20; 95% CI, 0.07-0.61). Both groups had a significant reduction in the number of leakage episodes, but surgery group had a significantly greater reduction (P<0.01).¹⁸

Pelvic floor muscle training(in male with post-prostatectomy incontinence)

In a Cochrane review in 2005, it was found that pelvic floor muscle training and biofeedback might help incontinence in the short term after radical prostatectomy. However, there was not enough information about the long-term effects, or the effect in men who had had surgery for benign enlargement of the prostate.¹³

Electrical stimulation

It consists of brief electrical impulses administered via needle or surface electrodes and aims to inhibit detrusor overactivity or to improve pelvic floor musculature. The effectiveness of electrical stimulation may depend on the type of urinary incontinence. A study of 68 participants comparing electrical stimulation with sham stimulation in persons with urge incontinence showed a number needed to treat (NNT) of 5 (95% CI, 3-42) for cure (i.e. no incontinence episodes and no detrusor overactivity on cystometry) and an NNT of 2 (95% CI, 1-4) for improvement (i.e. a reduction in frequency of incontinence by >50% or a cystometric bladder capacity increase >50ml).¹² Electrical stimulation alone or in combination with other therapies was not significantly different from other physical therapy regimes in the treatment of stress incontinence.^12,15

Vaginal cones

Participants with stress incontinence receiving vaginal cones were more likely to be subjectively cured compared with those who received control interventions that did not involve the pelvic floor musculature (RR for failure to cure incontinence, 0.74; 95%CI, 0.03-0.19). However, there were no differences in objective outcomes such as leakage episodes, pad test, or pelvic floor muscle strength. Therapy with vaginal cones appears to be inferior to pelvic floor muscle training.12,15

Bladder training

Bladder training techniques varied between studies, but all involved strategies to increase the time interval between voids using progressive voiding schedules. As outlined above, bladder training was not significantly better than pelvic floor muscle training, and the combination of bladder training with pelvic floor muscle training was more effective than either alone.¹⁹ A randomized placebo-controlled trial with 197 older women aged 55 to 92 years old with diagnosis of urge urinary incontinence or mixed incontinence with urge as the predominant pattern, were included into biofeedback-assisted behavioural treatment, drug treatment (oxybutynin), and placebo control conditioning.20 Biofeedback-assisted behavioural treatment included: pelvic floor muscle training and urge inhibition techniques. Drug treatment or placebo conditioning was double-blinded. Significantly fewer leakage episodes were noted in the behavioural group (P=0.005). Behavioural training resulted in a mean 80.7% improvement, and was significantly more effective than drug treatment (mean improvement - 68.5%; P=0.04) and the control condition (mean improvement - 39.4%; P<0.001). The study also found that drug treatment was more effective than the control condition (P= 0.009).²⁰ More subjects in the behavioural group achieved at least 50% and 75% reductions of incontinence (P=0.002, P<0.001). Highest self perceived improvement / cure was noted in the behavioural group. 96.5% of the behavioural group reported treatment was comfortable enough to continue indefinitely. The study concluded that biofeedback-assisted behavioural training is an effective conservative treatment for urge incontinence. It was more effective than oxybutynin and safe. It was practical for older individuals.²⁰

Pharmacological therapies

(1) For urge incontinence

Anticholinergic drugs: A recent Cochrane review concluded that anticholingerics, as a class, are superior to placebo in treatment of urge incontinence. Another recent review suggested that all of the anticholinergic drugs have similar efficacy.^12,14 The most common side effect was dry mouth, but dysphagia, stomach ulcers, blurred vision, diarrhoea, constipation, abdominal distension, nausea, headache, dizziness, and drowsiness were also reported.¹⁶ Anticholinergic agents may worsen cognitive function and should be used with caution in patients with dementia; limited evidence suggest that tolterodine may have less effect on the central nervous system.¹⁴ Anticholinergic agents are relatively contraindicated in patients with narrow-angle glaucoma, in patients with significant cardiac arrhythmias and bladder outlet obstruction.¹⁶ It is clear that side effects limit the effectiveness of anticholinergic drugs. In direct comparison trials, tolterodine and oxybutynin did not differ in outcomes. However, oxybutynin was more commonly associated with adverse event, in particular, dry mouth.¹²

Calcium channel blockers: No trials have shown their effectiveness on treatment of urge incontinence. A randomised placebo-controlled trial of nimodipine (n = 86) published in 2002 revealed no significant difference in number of incontinent episodes with this medication.¹² Magnesium hydroxide: may be effective by reducing spontaneous detrusor contractions. A randomised placebo-controlled trial of magnesium hydroxide (n=40) published in 1998 for treatment of sensory urgency and detrusor instability found that magnesium hydroxide resulted in subjective improvement of symptoms. The potential adverse reactions are diarrhoea, vomiting, GI tract cramps. The only reported adverse effect was transient diarrhoea.¹²

Tricyclic antidepressant: several antidepressants have been reported to have beneficial effects in patients with detrusor overactivity.^8,17 Imipramine is the drug that has been widely used. Imipramine does not have significant anticholingeric activity on bladder muscle. It may exert its effect on the bladder primarily by direct antispasmodic and local anaesthetic activity.¹⁶ However, the risks and benefits of imipramine in the treatment of voiding disorders do not seem to have been assessed.

(2) For stress incontinence

The pharmacological treatment of stress incontinence aims at increasing alpha-adrenergic input to mediate the contractile response of the smooth muscles in urethra and bladder neck.

Alpha-adrenoceptor agonists: Phenyl-propanolamine was being studied in a double-blind, placebo-controlled trial in women (n=24) with mild to moderate stress incontinence, which showed that treatment group had decreased the number of leaking episodes by 50%. However, because of recent report of severe side effects - including cardiac events and haemorrhagic stroke, it has been removed from the US market.¹⁷

Ephedrine and norephedrine: They have been reported to be effective in stress incontinence. However, these drugs lack selectivity for urethral a-adrenoceptors, and may increase blood pressure. They also can cause sleep disturbances, headache, tremor and palpitations. These drugs may be used on a demand basis in certain situations known to provoke leakage. Long-term experiences with the drugs are lacking.⁸

Imipramine: it inhibits the reuptake of noradrenaline in adrenergic nerve ending, and thus expected to enhance the contractile effects of noradrenaline on urethral smooth muscle. No prospective randomized controlled trials on the effects of imipramine seem to be available.^8,16

Serotonin and norepinephrine reuptake inhibitors - Duloxetine: a large randomized, placebo-controlled trial on 553 women with stress incontinence in 2002, showed that the median number of incontinent episodes decreased markedly in the treatment groups (greatest reduction in women taking the highest dose) versus placebo group. The potential side effects are nausea, diarrhoea, constipation, headache, dizziness and dry mouth.^12,16

Surgery

Surgery has a role in the treatment of stress incontinence. Surgical procedures are designed to correct urethral closure deficiencies and to improve support of the urethrovescial junction. The potential adverse outcomes of surgery include perioperative complications, de novo urgency and urge incontinence, voiding difficulties, recurrent or new pelvic organ prolapse and the need to repeat anti-incontinence surgery. There is insufficient evidence to fully compare surgery with non-surgical interventions. Thus, all patients should be considered for a trial of non-surgical therapy first.¹²

Surgical techniques that have been evaluated include open retropubic colposuspension, bladder neck needle suspension, anterior vaginal repair, laparoscopic retropubic colposuspension, suburethral sling procedure and periurethral injections.

Based on the results from a Cochrane systematic review in 2003, open retropubic colposuspension had lower failure rates, lower rates of repeat anti-incontinence surgery than bladder neck needle suspension, anterior vaginal repair, and laparoscopic retropubic colposuspension. Open retropubic colposuspension was also associated with a lower risk of perioperative complications compared with bladder neck needle suspension and anterior vaginal repair. There was no difference between open retropubic colposuspension and laparoscopic colposuspension in adverse event rates.¹²

Others

Environmental modifications and suitable assistive devices may alleviate or compensate the impairment and thus improve continence, such as bedside commodes, bed pans, urinals. Continence aids and devices such as disposable diaper, disposable minipads (with varying absorbing capacity), male drip collector, absorbent bed protectors, external collecting devices are commercially available to minimize the impact of incontinence. Simple dietary or drug modifications are often helpful to reduce the severity of incontinence.

Conclusion

Urinary incontinence is common in elderly. It has a tremendous impact on their quality of life and function. It should never be regarded as a normal ageing phenomenon. Family physicians have important roles in diagnosis and management of the problem. Questions on continence should always be explored during patient's interview. With the joint effort of the patient, care-giver and doctor, the problem of incontinence can be minimized and restoration to continence can be achieved in majority of patients.

Key messages

1. Urinary incontinence is common in elderly. Always include the bowel and bladder problem during consultation.
2. Proper history, targeted physical examination and simple bed-side and laboratory tests are helpful to establish the diagnosis.
3. Look for causes of transient incontinence - "DIAPERS" and manage accordingly.
4. Bladder chart / diary are valuable tools to characterize symptoms and follow up response to treatment.
5. Non-pharmacological treatment should be attempted before the use of drugs. Surgical interventions are helpful in selected patients.
6. Restoration to continence and minimizing the impact of incontinence should be targeted for every incontinent elderly.