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Managing urinary incontinence

Urinary incontinence causes significant impairment in quality of life (QOL).

Contributed by:  Dr. Rebecca Lee and  Dr. Adrian Wagg - View bios

Case

Jane Smith is 78 years old. She presents with a two-year history of gradually worsening urinary incontinence. She passes urine 10-12 times per day and twice overnight. She reports needing to rush to get to the washroom. She is often not able to make it in time and experiences incontinence several times daily as a result.

Her medical history comprises hypertension, diabetes, dyslipidemia, osteoarthritis and depression. Her current medications include ramipril 5mg daily, metformin 500mg BID, simvastatin 40mg daily, aspirin 81mg daily and mirtazapine 15mg at bedtime. She lives alone in a condo. She does not use a gait aid but admits to feeling unsteady when walking. She does not receive any home care. She has not previously discussed her incontinence with a health care provider. She uses 3-4 continence products daily but restricts her social activities because of worries about being at a distance from a toilet or having to visit the toilet embarrassingly frequently.

Issue

Urinary incontinence causes significant impairment in quality of life (QOL). Two thirds of older Canadian women believe incontinence is normal for ageing,1 leading to it being under-recognized and undertreated.2 Appropriate assessment and management can ameliorate urinary incontinence and improve QOL.

Background

The International Continence Society defines urinary incontinence as “involuntary loss of urine.”3 Urgency urinary incontinence occurs when urgency accompanies leakage of urine. Stress urinary incontinence occurs when leakage occurs on effort or physical exertion.3 Disability-associated incontinence occurs when another disease process such as limited mobility prevents an individual from reaching the toilet in time or using it appropriately.

Urinary incontinence is common and increases with age. Estimates of prevalence vary but studies report prevalence between 25-45%.4-6

The prevalence also increases with increasing dependency, with 59-72% of institutionalized elderly people having urinary incontinence.7, 8

Urinary incontinence adversely affects quality of life. It is strongly associated with depression, social isolation, anxiety, sexual dysfunction, physical deconditioning and falls.9-12 It also results in increased caregiver burden.13

Despite this well-recognized toll, individuals often do not report urinary incontinence to their health care provider for reasons, including embarrassment, believing incontinence is not worthy of bothering the clinician or not knowing what might be available to manage the condition.14, 15

Evidence

Mrs. Smith has urgency urinary incontinence. Impaired mobility from her osteoarthritis limits her ability to react to urinary urgency, making subsequent incontinence more likely. Her diabetes may also contribute to incontinence.

Initial management of urgency urinary incontinence consists of behavioral techniques in addition to ensuring correct fluid balance.16, 17 Bladder retraining aims to increase the duration between voids. Urgency suppression aims to suppress the urge to urinate. Pelvic floor muscle therapy facilitates urgency suppression by inhibiting the micturition reflex. Assessment should be done to identify and improve balance and mobility issues.

Review of caffeine intake can be helpful. There is some limited evidence suggesting caffeine may exacerbate urinary urgency and urgency incontinence.18, 19 Based on this, it is reasonable to suggest reducing or eliminating caffeine as a six-week trial.

Management of other medical conditions is important. Diabetes control should be reviewed and optimized as poor glycemic control can result in worsening symptoms of urinary incontinence.20

Pain management should also be reviewed, and simple analgesics recommended as needed for arthritis or other conditions.

Once behavioral strategies and other medical conditions are addressed, specific medications can be considered. Antimuscarinics, such as solifenacin or tolterodine (first line under Alberta Blue Cross regulations), are generally used as first-line agents for urgency urinary incontinence. Potential side effects include dry mouth, constipation and blurred vision.21 Immediate release oxybutynin should be avoided as it has a high rate of discontinuation due to adverse effects.22

The Beta-3 adrenoreceptor agonist mirabegron is available for the treatment of urgency urinary incontinence. Mirabegron has a similar efficacy to antimuscarinics but is more tolerable than antimuscarinic agents.23 It is also associated with fewer anticholinergic side effects. This may be a consideration for patients with a high anticholinergic burden or diseases such as Parkinson’s disease. Adverse effects include headache and urinary tract infection. Mirabegron is contraindicated in uncontrolled hypertension. In order to gain Alberta Blue Cross authorization, patients are required to have failed treatment with either generic solifenacin or extended release tolterodine.

Back to the Case

Mrs. Smith was assessed by a physiotherapist with expertise in pelvic floor conditions. She participated in an incontinence education and exercise program. The physiotherapist arranged for a walker. An occupational therapist completed a home assessment and provided her with a raised toilet seat.

Her glycemic control was reviewed and found to be suboptimal, so her metformin was increased to 1g oral BID with a plan for her family physician to review and follow up.

She practiced bladder retraining and urgency suppression. This improved her symptoms of urgency and reduced the frequency of her urgency urinary incontinence to several times weekly. She was then started on solifenacin 5mg daily, which was later titrated up to 10mg daily with good effect. She noted increased confidence in going to social events and her mood also began to improve.

Recommendations

Urinary incontinence is common and underreported. The management of urinary incontinence is multifactorial and includes both non-pharmacological and pharmacological strategies. Rehabilitation specialists, including physiotherapists and occupational therapists, can play important roles in managing the condition.

References

  1. Shaw C, Rajabali S, Tannenbaum C, Wagg A. Is the belief that urinary incontinence is normal for ageing related to older Canadian women’s experience of urinary incontinence? International urogynecology journal. 2019;30(12):2157.
  2. Penning-Van Beest FJA, Sturkenboom MCJM, Bemelmans BLH, Herings RMC, Demers D. Undertreatment of urinary incontinence in general practice. The Annals of pharmacotherapy. 2005;39(1):17-21.
  3. Foster RT, Sr., Barber MD, Parasio MF, Walters MD, Weidner AC, Amundsen CL. A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse. Am J Obstet Gynecol. 2007;197(1):82 e1-4.
  4. Hunskaar S, Lose G, Sykes D, Voss S. The prevalence of urinary incontinence in women in four European countries. BJU international (Papier). 2004;93(3):324-30.
  5. Abrams P, Cardozo L, Wagg A, Wein A. Incontinence: 6th International Consultation on Incontinence. Abrams P, editor. Paris, France.: International Continence Society; 2017.
  6. Abrams P, Andersson KE, Apostolidis A, Birder L, Bliss D, Brubaker L, et al. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: EVALUATION AND TREATMENT OF URINARY INCONTINENCE, PELVIC ORGAN PROLAPSE AND FAECAL INCONTINENCE. Neurourol Urodyn. 2018;37(7):2271-2.
  7. Jerez-Roig J, Santos MM, Souza DLB, Amaral FLJS, Lima KC. Prevalence of Urinary Incontinence and Associated Factors in Nursing Home Residents. 2016. p. 102-7.
  8. Santos ICRV, dos Santos Júnior JL, da Silva TFL, de Albuquerque NMS, Valença MP, da Silva Filho JC. Urinary incontinence in resident women in nursing homes. International Journal of Urological Nursing. 2019;13(3):99-105.
  9. Vrijens D, Drossaerts J, van Koeveringe G, Van Kerrebroeck P, van Os J, Leue C. Affective symptoms and the overactive bladder - a systematic review. Journal of psychosomatic research. 2015;78(2):95-108.
  10. Felde G, Ebbesen MH, Hunskaar S. Anxiety and depression associated with urinary incontinence. A 10-year follow-up study from the Norwegian HUNT study (EPINCONT). Neurourology and urodynamics. 2017;36(2):322-8.
  11. Radoja I, Degmecic D. Quality of Life and Female Sexual Dysfunction in Croatian Women with Stress-, Urgency- and Mixed Urinary Incontinence: Results of a Cross-Sectional Study. Medicina (Kaunas). 2019;55(6).
  12. Schluter PJ, Arnold EP, Jamieson HA. Falls and hip fractures associated with urinary incontinence among older men and women with complex needs: A national population study. Neurourology and urodynamics. 2018;37(4):1336-43.
  13. Gotoh M, Matsukawa Y, Yoshikawa Y, Funahashi Y, Kato M, Hattori R. Impact of urinary incontinence on the psychological burden of family caregivers. Neurourology and urodynamics. 2009;28(6):492-6.
  14. Dugan E, Roberts CP, Cohen SJ, Preisser JS, Davis CC, Bland DR, et al. Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians. Journal of the American Geriatrics Society. 2001;49(4):462-5.
  15. Shaw C, Tansey R, Jackson C, Hyde C, Allan R. Barriers to help seeking in people with urinary symptoms. Family practice. 2001;18(1):48-52.
  16. Wallace SA. Bladder training for urinary incontinence in adults. Cochrane Database of Systematic Reviews. (1).
  17. Shafik A, Shafik IA. Overactive bladder inhibition in response to pelvic floor muscle exercises. World journal of urology (Print). 2003;20(6):374-7.
  18. Davis NJ, Vaughan CP, Johnson IITM, Goode PS, Burgio KL, Redden DT, et al. Caffeine Intake and its Association with Urinary Incontinence in United States Men: Results from National Health and Nutrition Examination Surveys 2005–2006 and 2007–2008. The Journal of urology. 2013;189(6):2170-4.
  19. Wells MJ, Jamieson K, Markham TCW, Green SM, Fader MJ. The Effect of Caffeinated Versus Decaffeinated Drinks on Overactive Bladder: A Double-Blind Randomized, Crossover Study. Journal of Wound, Ostomy & Continence Nursing. 2014;41(4):371-8.
  20. Lifford KL, Curhan GC, Hu FB, Barbieri RL, Grodstein F. Type 2 diabetes mellitus and risk of developing urinary incontinence. Journal of the American Geriatrics Society. 2005;53(11):1851-7.
  21. Lightner DJ, Gomelsky A, Souter L, Vasavada SP. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment 2019. The Journal of urology. 2019;202(3):558-63.
  22. Veenboer PW, Bosch JLHR. Long-Term Adherence to Antimuscarinic Therapy in Everyday Practice: A Systematic Review. The Journal of urology. 2014;191(4):1003-8.
  23. Chapple CR, Kaplan SA, Mitcheson D, Klecka J, Cummings J, Drogendijk T, et al. Randomized double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron, a β(3)-adrenoceptor agonist, in overactive bladder. European urology. 2013;63(2):296-305.

Published: Jul 8, 2021