Office management of urinary incontinence among older patients

Case

Mrs M.A. is an 84-year-old lady with mild Alzheimer dementia. She lives at home and is cared for by her 87-year-old husband. They come in together for an appointment, and he comments that his wife’s urinary incontinence (UI) is worsening and is causing increased caregiver stress.

She has had occasional incontinence for more than 5 years, but during the past 6 months she has had at least 3 episodes of urine loss daily, at least 1 of these during the night. He is doing more laundry than before, and they are restricting social activities to minimize embarrassment.

Mrs M.A. minimizes the concern and reports only occasional urine loss. She is independent in self-care but needs assistance with shopping and complex meal preparation. She was started on donepezil 7 months ago and is currently taking 10 mg daily. She also takes 30 mg of extended-release nifedipine daily and 25 mg of hydrochlorothiazide daily for hypertension, 81 mg of enteric-coated acetylsalicylic acid, and 30 mg of oxazepam at bedtime as needed for sleep.

Urinary incontinence is a challenging clinical condition to treat in family medicine. Although it is common, many family physicians have received minimal training in management. Patients underreport the presence of UI and physicians do not commonly ask about it in routine questioning, leading to undertreatment. A survey of family physicians in 20021 found that only 37% of respondents thought they had an organized approach to management, and a similar percentage reported feeling comfortable with management. Almost 50% of respondents managed patients by making referrals, most commonly to urology. Knowledge of resources such as Nurse Continence Advisors was minimal. Despite these concerns, it has been shown that family physicians can improve symptoms and quality of life for those with UI.2

Although UI is not part of “normal aging,” it is common in older patients. Almost 20% of home-care clients in a Canadian sample had incontinence, and this increases to 25% of older hospital patients and up to 50% of nursing home residents.3,4

This paper will focus on management in older, frail patients, although the basic management principles hold true for all patients.

Sources of information

Ovid MEDLINE and the Cochrane database were searched from January 2000 to August 2010 using the terms urinary incontinence, stress incontinence, overactive bladder, urge incontinence, elderly, and geriatrics. Relevant review articles and original research were used when appropriate.

Main message

Assessment in the office

Mrs M.A. describes small-volume urine loss with coughing or laughing, but also reports loss of moderate volumes of urine (enough to drip down her leg) if she “doesn’t get to bathroom right away” (within 2 minutes) when she starts to get the urge. She occasionally wakes up wet and needs to go to the toilet immediately upon awakening. She drinks a cup of coffee in the morning and 3 cups of tea between lunch and bedtime. She does not use alcohol or smoke. During the past month she has substantially restricted her fluid intake, and her husband tries to remind her to go to the bathroom several times throughout the day.

Clinicians should consider whether a patient’s UI is recent or chronic, as the possible causes can differ. A mnemonic used with transient incontinence is presented in Box 1. A UI evaluation is difficult to do in one visit in the office setting, and it might be helpful to break down the evaluation into different visits with older patients who have more difficulty with history and physical examination maneuvers. The Rational Clinical Examination series has reviewed approaches to clarifying the causes of incontinence5 and provides an additional resource for family physicians.

History is not always straightforward, and in the frail elderly it might not correlate well with the causative mechanism. A 3-item questionnaire (3IQ), which asks questions about if, when, and how often patients experience urine leaks, used in combination with a urinalysis has been shown to identify and reasonably accurately categorize UI in middle-aged to elderly women.6 Other questionnaires are available for older patients.7–9 Clarifying obstetrical and surgical history is relevant, especially with stress or overflow UI. Strategies tried by the patient can provide insight into the mechanism and treatment options to use. Questions related to lifestyle, especially caffeine and fluid intake, are important, and use of a bladder diary can help develop management strategies. The Geriatric Interprofessional Interorganizational Collaboration website has a helpful tool kit with many of these resources.10

Concurrent conditions common in older patients, such as Parkinson disease, stroke, heart failure, sleep apnea, and diabetes, can all affect bladder function. Constipation will also impair bladder emptying, and in a frail patient can precipitate overflow incontinence due to retention.11

Physical examination is controversial, and the type of examination required depends on the clinical setting. Older patients’ overall cognitive and functional status is often known to family physicians but can be assessed further by observation and by specific mobility and cognitive assessments. An abdominal examination is relevant, as is examining for conditions affecting fluid redistribution such as venous insufficiency or heart failure. A lower-extremity neurologic examination should be considered, especially in cases of urgency or overflow without clear cause. Perineal sensation and rectal tone should be checked.5,11–13

There is little evidence or clarity on the extent of pelvic examination that is necessary in the family medicine office. Although a full speculum examination with bimanual examination is ideal to check mucosal integrity and degree of prolapse, this is not always possible with frailer patients. The role of the family physician might be more to rule out prolapse that requires obvious surgical consideration. If a more complete pelvic examination is a barrier to providing care in a busy office with a frail patient, then it seems reasonable to visually rule out severe prolapse and atrophy, then do the full pelvic examination or refer the patient if initial management is not helpful.11 Checking for circumvaginal muscle strength is relevant and might guide pelvic floor exercises.12,13

In older patients, prescribed and over-the-counter medications can have considerable effects on bladder function and should be considered an essential part of the evaluation. Table 2 lists common medications and their mechanisms of affecting bladder function.

Mrs M.A. is able to get out of a chair and walk safely with a Timed Up and Go test14 of 3 metres in 12 seconds. She recently scored 22 out of 30 on the Mini-Mental State Examination. Results of her basic physical examination are unremarkable, but a stress maneuver (having the patient cough or do Valsalva maneuver in a supine position with a full bladder) does reveal urine loss. There is moderate atrophy and a small rectocele and circumvaginal strength is weak. Postvoid residual (PVR) urine volume done by in-and-out catheterization is 120 mL. Urine dip results show moderate leukocytes but no blood or nitrites.

Postvoid residual volume is a very important measure in UI assessment, but it can be a challenge to obtain in a family medicine practice. Bladder scanners are convenient but expensive, and their accuracy varies with the experience of the user and with patient characteristics. Bladder scanners might be feasible in group practices or family health teams where they are shared among several physicians. In-and-out catheterization requires training and increases the risk of infection. Some authors suggest that for patients without substantial risk factors, abdominal examination and bladder percussion can suffice, at least initially.11 Our experience is that patients without clear risks sometimes have surprisingly high PVR volumes, especially in hospitals and institutions, and whenever possible measuring the volume is relevant. When it is impossible to obtain the PVR volume, failure to respond to initial therapy should be a cue to seek outside assessment. A normal PVR volume is less than 100 mL,13 but less than 200 mL suggests that retention or overflow incontinence is not a main contributing factor.

Urine dip should be done to look for local irritants causing hematuria and urge incontinence. In the absence of symptoms, routine use of urine culture in older patients with established incontinence is not recommended, and treating otherwise asymptomatic urinary tract infections has been shown to be ineffective (at least among nursing home patients) at improving UI.15

Conclusion

Mrs M.A. stops drinking coffee and takes 1 cup of tea in the morning. Although she still restricts fluids before car trips and after supper, she does not aggressively restrict intake at other times. She continues to take donepezil, as she believes there has been good benefit even with the risk of increasing bladder activity. Her bedtime sedation is minimized, and her nifedipine discontinued in case it contributed to increased PVR volume. Hydrochlorothiazide is switched to an angiotensin-converting enzyme inhibitor. She works hard at Kegel exercises and uses them with moderate success for urge suppression. A trial of long-acting tolterodine results in mild confusion that is frightening for her and is discontinued. Overall, she is pleased with the decrease in frequency of UI episodes (to about 2 per week) and notes she is usually up 1 less time at night.