Urge Incontinence

Pt age >75 years with h/o cardiovascular disease, heart failure, alcoholism presents with new onset incontinence, urinary frequency, and nocturia. Episodes preceded by intense desire to urinate and pt often loses control of bladder en route to bathroom; this is followed by large volume urine loss. Mediations include diuretics. Minimal, delayed leakage following cough stress test.

  • Variable volume loss noted on 3 day voiding diary

  • Obtain urinalysis with reflex microscopy and urine culture

  • Post void residual <50 mL

  • Comorbid condition management

    • Vaginal atrophy present: Start intravaginal estrogen therapy

    • Pt advised to reduce alcohol consumption

  • Initial therapy

    • Start 3 daily sets of 8 to 12 pelvic floor contractions sustained for 8 to 10 seconds each

    • Start bladder training with timed daily voids occuring at the shortest interval indicated on the 3 day voiding diary

      • Control urgency between voids with relaxation techniques, e.g. deep breathing

      • Increase interval between voids by 15 minutes following each day without incontinence

      • Goal: Timed voids every 3-4 hours

  • Failure of initial therapy

    • Trial of mirabegron 25 mg once daily x8 weeks

    • Mirabegron not covered by insurance and no contraindication to anticholinergic therapy: Start one of the following

      • Oxybutynin immediate-release 5 mg TID

      • Trospium chloride (Sanctura) 20 mg BID

    • Consider referral to pelvic PT

    • Consider referral to urology

Notes

  • Present in ~10% of women age 40-45 years

  • Present in >30% of men and women age >75 years

  • Potential etiologies

    • Detrusor instability: Detrusor overactivity or loss of inhibitory control of bladder contractions

    • Sensory: Urge to urinate caused by local irritation, inflammation, or infection

  • Contraindications to anticholinergic

Stress Incontinence

40 year old F with h/o chronic cough, grand multiparity presents with chronic, small volume urine loss. Urine loss typically occurs when coughing, sneezing, jumping, lifting, or exercising. Episodes have even occured with minimal activity, e.g. rising from chair. Denies nocturia. Medications include alpha-adrenergic agonists and ACE inhibitor. Positive cough stress test on exam.

  • Small volume leakage (<10 mL) on 3 day voiding diary

  • Obtain urinalysis with reflex microscopy and urine culture

  • Post-void residual <50 mL

  • Initial therapy

    • Refer for pessary fitting

    • Consider referral to pelvic PT

    • Consider duloxetine 20 mg twice daily for 2 weeks then 40 mg BID in patients with comorbid depression

  • Failure of initial therapy: Refer for surgical evaluation for mid-urethral sling placement

Notes

  • Epidemiology

    • Present in 30% of women age >30 years

    • May occur in men s/p prostate surgery

  • Etiology: Sphincter and/or pelvic floor weakness

  • Cough stress test

    • Most reliable clinical assessment for stress incontinence

    • Positive if small volume leakage occurs with cough and stops once coughing terminates

    • Negative if no leakage occurs or if leakage occurs >5 seconds after coughing terminates

  • Pelvic floor exercises: 3 daily sets of 8 to 12 pelvic floor contractions sustained for 8 to 10 seconds each

  • Do NOT refer for urodynamic testing 

Overflow Incontinence

Elderly M pt with h/o BPH, DM, multiple sclerosis and alcoholism presents with chronic incontinence. Reports inability to empty bladder, dribbling, hesitancy, and urine loss without sensation of fullness/pressure in lower abdomen. Medications include calcium channel blockers, opioids, muscle relaxants, antidepressants, antiparkinsonian agents, sedatives, and anticholinergics. Bladder distention, peripheral neuropathy, decreased sphincter tone, and enlarged prostate on exam; no leakage noted on cough stress test.

  • No consistent pattern noted in 3 day voiding diary

  • Obtain urinalysis with reflex microscopy and urine culture

  • BMP shows increased serum creatinine

  • Post void residual >200 mL

  • Treatment in men

    • Pt avoid to lose weight and perform daily pelvic floor muscle exercises

    • Start tamsulosin (Flomax) 0.4 mg daily and increase to 0.8 mg daily after 4 weeks

    • Concern for prostate cancer or failure of initial treatment: Refer to urology

  • Pt advised to decrease alcohol intake and adhere to prescribed DM regimen

Notes

  • Leakage is caused by bladder overdistention

  • DM and alcoholism

    • Resulting peripheral neuropathy can lead to overflow incontinence

    • May be indicated by peripheral neuropathy or decreased anal sphincter tone on exam

Functional Incontinence

Elderly pt with h/o cognitive impairment due to CVA/dementia and decreased mobility due to arthritis presents with chronic incontinence. Caregiver reports variable urine leakage, difficulty transporting patient to and from bathroom. Medications include COX-2 selective NSAIDs, sedative-hypnotics, and thiazolidinediones. Negative cough stress test.

  • MOCA <26

  • <50 mL on post-void residual

  • Caregiver counseled that incontinence is most likely related to delayed transport time to toilet and not a physiologic mechanism