Transcript Rehab R&D Center - GRECC Audio Conferences

Assessment and Management of
Urinary Incontinence in the Clinic
Kathryn L. Burgio, PhD
Associate Director for GRECC Research
&
Patricia S. Goode, MD
Associate Director for GRECC Clinical Programs
Birmingham/Atlanta Geriatric Research Education
and Clinical Center – July 27, 2006
Prevalence of Incontinence
Prevalence (%)
Severity
40
35
30
25
20
15
10
5
0
Severe
Moderate
Slight
Unknown
20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+
24 29 34 39 44 49 54 59 64 69 74 79 84
Age
Hannestad et al., 2000
UI - Treatment Seeking
1,104 Community Dwelling Older Adults
with Urinary Incontinence on interview
38%
62%
Reported to
Provider
Not Reported
Burgio, et al: JAGS 42: 208, 1994
Reasons for Not Reporting Incontinence
to Provider
Not
aware that can be treated
Normal part of aging
Personal problem (not medical)
Embarrassed
Fear of nursing home placement
Afraid 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?
Types of Incontinence
Urge
Functional
Stress
Overflow
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
 Habits
medications including OTC
(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 UI
to Treat First
Drugs and Diet
Infection
Atrophic Urethritis
Psychological - Depression, Delirium
Endocrine - Diabetes, Hypercalcemia
Restricted Mobility
Stool Impaction
Contributors to UI
to Treat First
Drugs
Sedatives including alcohol
ACE inhibitors (cough)
Antipsychotics (pseudoparkinsonism)
Diuretics (bad timing)
Alpha Blockers – worsen stress UI
Anticholinergics – incomplete emptying
Contributors to UI
to Treat First
Drugs and Diet – Caffeine & Fluids
Infection
Atrophic Urethritis
Psychological - Depression, Delirium
Endocrine - Diabetes, Hypercalcemia
Restricted Mobility
Stool 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
– generic, Ditropan XL, Oxytrol patch
Tolterodine - Detrol
Solifenacin - VESIcare
Trospium - Sanctura
Darifenacin - Enablex
 Alpha blocker for BPH
Oxybutynin
 Other
treatments
 Behavioral
training – try BEFORE or with drug
Least Invasive – Use First !!
Diet & Fluid
Management
Behavioral
Strategies
PFM Training
and Exercise
Behavioral
Approaches
Bladder Training
Biofeedback
Weight Loss
Bladder
Diaries
Behavioral Treatment:
Multi-component Program
Pelvic
floor muscle training
Home
practice of exercises
Increase
Bladder
duration of contraction/relaxation over time
Control Techniques
Self-Monitoring
w/ bladder diaries
When the Urge Strikes –
Freeze and Squeeze
Stop
and stay still
Squeeze
Relax
pelvic floor muscles
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
Worst
Time
Best
Time
Worst
Time
Calm
Period
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
100
% Reduction
80
81%
60
68%
40
39%
20
0
Behavioral
Drug
Control
Patient Satisfaction with Treatment
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Behavior
Drug
Placebo
78%
49%
28%
Completely satisfied
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
Functional Limitations
Avoid
anticholinergic drugs in pts with dementia
Facilitate functional status
Mobility devices
Physical therapy
Bedside commode
Urinal for men
Prompted 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 PostProstatectomy Incontinence
20
men; 55-87 years old
Average 2 ½ years since surgery
8 weeks of biofeedback-assisted behavioral
training
78.3% decrease in accidents
(range of -12 – 100%)
Burgio, et.al., J Urology, 1989
Behavioral Training for PostProstatectomy Incontinence



Case Series of 27 men with persistent postprostatectomy 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 Training
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
N=125
(p = .032)
prevention
control
0
50
100
150
Time in Days until Continent
200
Burgio, Goode, et al, J Urol, 175:196; 2006
Reduction of Incontinence
%
100
90
80
70
60
50
40
30
20
10
0
p=.090
p=.045
73
52
54
32
Pad Use
Burgio, Goode, et.al., J Urology, 2006
Proportion Dry
Days
Pre-Prostatectomy Muscle Training
 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 Diet
Infection
Atrophic Urethritis
Psychological - Depression, Delirium
Endocrine - Diabetes, Hypercalcemia
Restricted Mobility
Stool Impaction
Urinary Incontinence Treatments
 Behavioral
Treatments
 Pelvic
Floor Muscle
Exercises (Kegel)
 Bladder
 Bladder
Control
Techniques
 Biofeedback
 Pessary
 Pelvic
training
 Timed/Prompted
 Medications
voiding
Floor Electrical
Stimulation
 Magnetic
 Urethral
 Surgery
Chair
Bulking Agents
Current Studies at Bham/ATL GRECC
 MOTIVE
- Combined medication and behavioral therapy
for overactive bladder in men (VA Rehab R&D)
– Behavioral therapy with and without
biofeedback and electrical stimulation for persistent
incontinence in men after radical prostatectomy (NIH)
 ProsTech
 COMBO
- Combined medication and behavioral therapy
for urge incontinence in women (VA Rehab R&D)
– Behavioral therapy or pessary or combined for
stress incontinence in women (NIH)
 ATLAS
 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