Persistent Urinary Incontinence in Older Women

US Pharm. 2006;31(9):20-34.

Urinary incontinence (UI) can have a negative impact  on an individual's quality of life by lowering self-esteem and affecting psychological and physical well-being. According to a study supported in part by the Agency for Healthcare Research and Quality, elderly Americans who are incontinent often experience shame, disgust, embarrassment, and a less active social life, all of which can lead to depression.¹ Furthermore, elderly individuals with UI are more likely than those without it to have symptoms of depression. ¹

According to a recent survey, called What Older Women Want, women ages 55 to 95 rated UI as number 5 among the top 10 unmet health priorities.² This finding is consistent with previous data showing that elderly women express more concerns about living with disabilities than developing common illnesses.² Despite these findings, UI is underdiagnosed and often underreported by patients due to embarrassment or acceptance of the condition as a consequence of aging, although it is not actually caused by aging.^3,4

This article encourages pharmacists to raise awareness of UI, educate patients about the condition, and provide appropriate recommendations for treatment. By approaching UI as a condition with underlying, though sometimes irreversible causes, pharmacists can help manage patients well enough to improve symptoms and minimize complications.⁵

Prevalence
UI affects approximately 17 million Americans, including more than 50% of seniors in hospitals or nursing facilities and 8% to 34% of community-dwelling seniors. ^6,7 It is especially prevalent in women, with a greater than 45% occurrence in those ages 50 to 59.⁸ Overall, data show that 17% to 55% of elderly women versus 11% to 34% of elderly men are affected.⁹ UI leads to decreased quality of life in up to 44% of affected women.² Furthermore, the presence of UI is a predictive factor for nursing home admission.^9,10 One study found that the prevalence of depression was 15.5% in women with UI, compared with only 9.2% in women without UI.¹¹ Management of UI presents a significant financial strain on patients, health care facilities, and industry and government agencies providing health care funding, incurring a direct annual cost of $26.5 billion.¹²

Continence and UI Complications
Normal urination is a complex process, requiring both a bladder that can store and expel urine and a urethra that can close and open appropriately. Normal micturition occurs when bladder contraction is coordinated with urethral sphincter relaxation. Additional factors necessary for continence are related to a patient's cognitive function, dexterity, social awareness, motivation, and locomotive ability. The central nervous system integrates control of the urinary tract. The inability to control urination in a socially appropriate manner is known as UI.

Complications associated with UI include skin rashes, pressure ulcers, and indirectly, falls and fractures. Use of an indwelling catheter is associated with patient discomfort, use of drugs for bladder spasms, and an increased risk of life-threatening infections, bladder stones, and cancer.¹³ Decreases in sleep, social interaction, and self-esteem can affect psychological well-being. In addition, family members and health care facility staff who care for a functionally dependent patients with UI may experience increased levels of stress.

Diagnostic Assessment
Distinguishing which type of UI a patient has is critical for prescribing the appropriate treatment; this begins with determining the cause of UI (TABLE 1). This process comprises a thorough physical examination as well as an evaluation of the patient's medical history. This would include an evaluation of the patient's medication history to rule out reversible medication-related causes of UI. Pharmacists should have an active role in the assessment process, since UI due to anticholinergic, narcotic, and beta-adrenergic drugs can be improved by switching or discontinuing medication or modifying the dosage schedule when appropriate.³ The pharmacist's expertise can prove to be a valuable addition to the team approach of increasing quality of life and decreasing cost of care.¹⁴

The physical exam should assess the patient's medical condition as well as cognition, dexterity, and mobility. An examination of the abdomen, genitals, pelvis, and rectum should also be conducted. Edema and neurologic abnormalities may contribute to UI and, therefore, should be ruled out. Since it may be difficult to correctly diagnose UI, patients should also be examined for urinary tract infection, post-void residual volume, and simple cystometry measures of bladder capacity and stability.³ Detecting potentially reversible causes of UI should always be a priority. Urodynamic instruments such as a uroflowmeter and cystometer should not be used as screening tools, because results of these tests do not differ significantly for continent and incontinent patients; however, using these tools as confirmatory tests may help to determine a therapeutic approach.³

Classifications
There are a number of different types of UI, and more than one type may be present simultaneously or overlap with one another.

Stress Incontinence
Stress incontinence is common among senior women, especially in ambulatory clinic settings. ^15,16 It is usually associated with weakened supporting tissue, which results in hypermotility of the urethra and bladder outlet.¹⁵ Coughing, sneezing, laughing, exercising, or any other physical activity that increases intra-abdominal pressure may cause uncontrolled urination.^15,17 Symptoms can be infrequent, with small amounts of urine and no need for specific treatment, to severe and bothersome, necessitating surgical correction.¹⁶ Vaginal childbirth, estrogen de­ ficiency, obesity, and/or surgery can contribute to stress incontinence. While stress incontinence is rare in men, it can occur in such patients after transurethral surgery and/or radiation therapy for lower urinary tract malignancy (e.g., prostate cancer) when the anatomic sphincters are damaged.¹⁶

Urge Incontinence
The most common type of UI among those age 85 or older is urge incontinence, which is caused by abnormal involuntary detrusor muscle contractions (i.e., detrusor overactivity).^18,19 It is characterized by an abrupt, strong desire to urinate as well as frequent urination (e.g., more than every two hours) and nocturia.¹⁶ Patients may lose urine on their way to the toilet, and some may experience a degree of urinary retention. Causes of urge incontinence include central nervous system disorders (e.g., stroke, dementia, parkinsonism, spinal cord injury) and lower genitourinary conditions (e.g., tumors, stones, diverticula, outflow obstruction).¹⁶ It is possible that symptoms of urge incontinence among the el­ derly may be misinterpreted as agitation related to a behavioral disturbance secondary to dementia.

Overflow Incontinence

Overflow incontinence occurs from distention of the bladder as a result of an inability to empty normally. It is the most common form of incontinence among elderly men. Symptoms include frequent urination, urgency, dribbling, urge incontinence, and stress incontinence. Causes of overflow incontinence vary and include uterine prolapse, urethral strictures, prostate enlargement, diabetes, and spinal cord injury.¹⁸

Mixed Incontinence
Mixed incontinence occurs in 50% to 60% of patients with UI and is characterized by symptoms of both urge incontinence and stress incontinence.²⁰ It is most commonly seen among older women. Mixed incontinence is also commonly seen as a combination of urge and functional incontinence among nursing home residents. ¹⁵

Functional Incontinence
Functional incontinence may be caused by cognitive impairment, psychological impairment, impaired mobility, medications, or dexterity problems that render the patient unable or unwilling to toilet properly.^6,17 For example, delirium promotes incontinence by increasing disorientation and decreasing patient awareness of the need to void. Mobility impairment affects the ability to reach the toilet in time.³ Functional UI may exacerbate other types of persistent incontinence.¹⁵

Complex History of UI
Incontinence associated with pain, hematuria, recurrent infection, pelvic complications (e.g., bladder cancer, bladder stones, prostate cancer), herniated disks, and metastatic tumors is classified as complex history of UI. This type of UI usually requires a specialized management approach.^13,21

Management of UI
Treatment options for the management of UI include both nonpharmacologic and pharmacologic therapy.³

Nonpharmacologic Intervention
Nonpharmacologic therapy is recommended in conjunction with pharmacotherapy. Nonpharmacologic interventions that are helpful in the management of UI include--but are not limited to--behavior modifications such as bladder control training and dietary modification, prompted voiding, and use of absorbent products and catheters.

Behavior modification, used alone or in combination with other treatment modalities, is safe, effective, and the least invasive treatment for UI.^17,22,23 Bladder control training can be useful for managing UI. Kegel exercises, which involve alternating contraction and relaxation of the pubococcygeus muscle, improve pelvic floor muscle tone and help the bladder store urine for longer periods of time. Patients should begin by performing 10 alternating three-second contractions and relaxations per day and gradually increase to 80 to 150 10-second contractions and relaxations per day.² In some cases, biofeedback and electrical stimulation may be recommended in conjunction with pelvic floor exercises to help control urge and overflow incontinence.²⁴ Another method of bladder control training, known as bladder retraining , involves gradually increasing the time between voiding by 15-minute increments each week until voiding occurs every three to four hours.²

Dietary modifications can also be useful for managing UI. Patients should avoid certain foods known to irritate the bladder. These include carbonated or caffeinated drinks, spicy foods, citrus fruits and juices, artificial sweeteners, and diuretics. However, avoiding fluid is not advised, as this may worsen symptoms by irritating the bladder.

Functional incontinence should be managed by using environmental manipulations, scheduled toileting, prompted voiding (e.g., asking the patient "Do you want to use the toilet?"), toilet substitutes (e.g., portable commode), absorbent pads and undergarments, and attention to skin care (e.g., cleansing and drying thoroughly).³ Absorbent products may not only provide overnight protection but also allow residents to resume social activities.¹⁷

In the nursing facility environment, easing restriction on movement while monitoring patient safety may be all the intervention necessary to improve symptoms of UI in some patients.²² For other patients, the use of pessaries, intermittent catheters, or chronic indwelling catheters may be necessary. On June 28, 2005, the Centers for Medicare and Medicaid Services issued interpretive guidelines for the use of indwelling catheters in the treatment of UI. The guidelines redefined UI as any wetness on the skin.²⁵ The new guidance for nursing homes is labeled Tag F315 and contains interpretive guidelines, a new investigative protocol, and compliance and severity guidance.²⁵

Only after other treatments have been tried should surgical intervention (e.g., sling procedure or bladder neck suspension) be recommended to alleviate UI.³

Pharmacologic Intervention
Anticholinergic Agents: Anticholinergic agents (Table 2) are first-line pharmacotherapy for urge incontinence, with recommended titration to tolerability and efficacy. They are associated with adverse reactions (e.g., sedation, constipation, dry mouth, blurred vision, tachycardia, confusion, delirium, an increased risk of heat prostration) and should be used with caution in the elderly when benefit outweighs risk.²⁶ These agents should also be used with caution in patients with urinary obstruction, angle-closure glaucoma (treated), hyperthyroidism, reflux esophagitis, hiatal hernia, heart disease, hypertension, renal or hepatic disease, prostatic hyperplasia, autonomic neuropathy, ulcerative colitis, or intestinal atony. 

Alpha-Adrenergic Agonists: Alpha-adrenergic agonists (e.g., pseudoephedrine) are used for stress incontinence, often in combination with estrogen.¹⁵ Although well tolerated, they may precipitate anxiety, agitation, hypertension, and cardiac arrhythmias and should be used with caution in patients with hyperthyroidism, angina, hypertension, or cardiac arrhythmias.^18,22

Duloxetine: Duloxetine increases urinary sphincter striated muscle tone. While experience with this agent is limited, it appears to be effective for outlet incompetence in stress incontinence.²⁷

Alpha-Adrenergic Antagonists: Alpha-adrenergic antagonists (e.g., prazosin 0.5 to 2 mg twice daily, doxazosin 1 to 8 mg once daily, terazosin 1 to 10 mg once daily, tamsulosin 0.4 to 0.8 mg once daily) are used in conjunction with nonpharmacologic treatments, catheterization, and surgery for patients with overflow incontinence.⁶ Bedtime administration is recommended to minimize the risk of orthostatic hypotension associated with these agents.

Estrogen: Studies have shown that oral estrogen in hormone replacement dosages has no effect on stress incontinence episodes in hypoestrogenemic incontinent women. ¹⁵ In combination with an alpha-agonist, however, estrogen appears to be effective for stress incontinence.¹⁵ Topical estrogen, applied chronically or intermittently (i.e., one- to two-month course), is used to treat urge incontinence or irritative voiding symptoms in women with atrophic vaginitis and urethritis.¹⁵ Therapy usually consists of 0.5 to 1 g of vaginal cream applied nightly for one to two months and then two to three times per week, thereafter. Several months of therapy is usually required to elicit therapeutic benefit.¹⁵ Estrogen delivered via a vaginal ring (inserted every three months), vaginal tablet (inserted two times per week), or transdermal system (e.g., a patch applied two times per week) are also available; however, use of these treatments is generally not preferred in patients with only local symptoms.²⁸ These agents should be used for the shortest duration possible.²⁸ In patients with an intact uterus who are using estrogen, progestin is recommended for 10 to 14 days every four weeks.

Tailored Therapy: Therapeutic interventions for mixed incontinence are focused on the most troublesome symptoms. Treatment for functional incontinence concentrates on improving functional status by discontinuing medications causing UI, treating comorbid medical conditions, and reducing environmental restrictions. If these measures fail, anticholinergics may be effective. Even in patients with severe dementia, bladder training and medications have been shown to improve incontinence.¹³

Botulinum-A Toxin: Studies are reporting the use of botulinum-A toxin injected into the detrusor muscle as a possible treatment option for patients with severe overactive bladder (e.g., traumatic spinal cord injury) resistant to maximal doses of anticholinergic agents and all conventional treatments.^29,30

Conclusion
While UI is common in women, it can be treated and controlled. Inadequate recognition and management of UI can have a significant impact on a patient's quality of life and cost of care. Appropriate treatment can assist with the avoidance of complications and consequences including depression, pressure ulcers, falls, and fractures. Additionally, pharmacologic and nonpharmacologic interventions can help avoid functional dependence associated with UI. The pharmacist's expertise proves a valuable addition to the team approach of decreasing cost of care while increasing quality of life for patients with UI. Pharmacists can help rule out medication-related causes of UI, recommend appropriate medication therapy, and help patients avoid adverse drug reactions.

REFERENCES
1. Dugan E, Cohen SJ, Bland DR, et al. The association of depressive symptoms and urinary incontinence among older adults. J Am Geriatr Soc. 2000;48:413-416.
2. Radcliffe-Branch D, Tannenbaum C. A review of older women's health priorities. Geriatrics Aging. 2006;9:124-128.
3. Rawlins S, Tillmanns AK. Menopause and current management. In: Youngkin EQ, Sawin KJ, Kissinger JF, et al. Pharmacotherapeutics: A Primary Care Clinical Guide. 2nd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2005:281.
4. Johnson TM 2nd, Busby-Whitehead J. Diagnostic assessment of geriatric urinary incontinence. Am J Med Sci. 1997;314:250-256.
5. Levenson S. A tool for managing urinary incontinence. Caring for the Ages . 2006;July:18-19. 
6. Beers MH, Berkow R. The Merck Manual of Geriatrics. 3rd ed. Whitehouse Station, NJ; Merck & Co. 2000: 965-980.
7. National Kidney and Urologic Diseases Advisory Board. Barriers to Rehabilitation of Persons with End-stage Renal Disease. Workshop Summary Report. March 7-9, 1994; Bethesda, MD.
8. Ouslander JG, Shih YT, Malone-Lee J, Luber K. Overactive bladder: special considerations in the geriatric population. Am J Manag Care. 2000;6:S599-S606.
9. Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing.1997;26:367-374.
10. Nuotio M, Tammela TL, Luukkaala T, Jylha M. Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence. J Gerontol A Biol Sci Med Sci. 2003;58:756-762.
11. Vigod SM, Stewart DE. Major depression in female urinary incontinence. Psychosomatics. 2006;47:147-151.
12. Lawrence M, Guay DR, Benson SR, Anderson MJ. Immediate-release oxybutynin versus tolterodine in detrusor overactivity: a population analysis. Pharmacotherapy. 2000;20:470-475.
13. Klusch L. Understanding RAPS. Des Moines, IA: Briggs Corporation; 1998:23-29.
14. Wade WE. Managing dosage alteration needs in the elderly. Clinical Consult Newsletter-American Society of Consultant Pharmacists Vol. 11, No. 10 October 1992.
15. Ouslander JG, Johnson II TM. Incontinence. In: Hazzard WR, Blass JP, Halter JB, et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill, Inc.; 2003:1571-1586.
16. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics . 4th ed. New York: McGraw-Hill, Inc.; 1999:181-230.
17. Couture JA, Valiquette L. Urinary incontinence. Ann Pharmacother. 2000;34:646-655.
18. Nasr SZ, Ouslander JG. Urinary incontinence in the elderly. Causes and treatment options. Drugs Aging.1998;12:349-360.
19. Weinberger MW. Conservative treatment of urinary incontinence. Clin Obstet Gynecol. 1995;38:175-188.
20. Rackley R, Kursh ED. Evaluation and medical management of female urinary incontinence. Compr Ther. 1996;22:547-553.
21. Scientific Committee of the First International Consultation on Incontinence. Assessment and treatment of urinary incontinence. Lancet. 2000;355:2153-2158.
22. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Clinical practice guidelines number 2 (1996 update). March 1996. AHCPR Pub. No. 96-0682.
23. Burgio KL, Locher MA, Goode PS, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women. JAMA. 1998;280:1995-2000.
24. National Institute on Aging. Urinary Incontinence. Available at: www.niapublications.org/ agepages/urinary.asp. Accessed August 2, 2006.  
25. Department of Health & Human Services. Centers for Medicare & Medicaid Services. CMS Manual System. Pub. 100-07 State Operations Provider Certification. Transmittal 8. June 28, 2005. Available at:www.cms.hhs.gov/transmittals/downloads/R8SOM.pdf. Accessed August 25, 2006.
26. Semla TP, Beizer JL, Higbee MD. Geriatric Dosage Handbook. 10th ed. Cleveland: Lexi-Comp, Inc.; 2005.
27. Beers MH, Porter RS, Jones TV. The Merck Manual of Diagnosis and Therapy . 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006:1951-1960.
28. My Epocrates Version 8.00. Available at: www.epocrates.com. Accessed August 23, 2006.
29. Schmid DM, Sauermann P, Werner M, et al. Experience with 100 cases treated with botulinum-A toxin injections in the detrusor muscle for idiopathic overactive bladder syndrome refractory to anticholinergics. J Urol. 2006;176:177-185.
30. Patki PS, Hamid R, Arumugam K, et al. Botulinum toxin-type A in the treatment of drug-resistant neurogenic detrusor overactivity secondary to traumatic spinal cord injury. BJU Int. 2006;98:77-82.
31. Cafiero AC, Rosenberger M, Hajjar ER. Treating urge incontinence: the role of the new pharmacologic agents. Assisted Living Consult. 2006;2:20-23, 30.
32. Urinary Incontinence. Table 6: Potential Medication Interventions by Type of Incontinence. American Medical Directors Association Web site. Available at: www.cpgnews.org/UI/images/table6.jpg. Accessed August 2, 2006.
33. DeMaagd G, Geibig J. An Overview of Overactive Bladder and Its Pharmacological Management with a Focus on Anticholinergic Drugs. P&T. 2006:462-474.

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