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Patients' fears help keep incontinence in the closet

Bringing up the issue in annual exams and suggesting simple solutions can help patients gain better control

From the March ACP Observer, copyright 2006 by the American College of Physicians.

By Yasmine Iqbal

For Paul F. Speckart, MACP, it's a standard question on every new patient's intake form: "Are you having any trouble with your bladder or noticed any changes in your urine flow?" Nevertheless, the San Diego-based internist knows that many of his elderly patients will be reluctant to check "yes."

"Men are embarrassed to bring up incontinence, and women tend to accept it as a natural part of aging," he explained.

Even when patients get up the nerve to mention it, they rarely express how much it's bothering them, said Neil M. Resnick, MD, chief of the division of geriatric medicine at the University of Pittsburgh School of Medicine. "It's often one of those 'hand on the doorknob' issues that come up at the very tail end of an exam."

As a result, incontinence is underdiagnosed and undertreated, even though it affects millions of American adults. One 2001 study estimated that in community-dwelling adults, 35% of women and 22% of men age 65 or older are affected—and that $16.3 billion is spent every year on incontinence care.

"We don't realize how much this problem cripples people," said Dr. Speckart. "They essentially quit drinking water, they limit themselves to their homes, they stop socializing. And yet, most patients never mention it."

Some say that's because physicians want to focus on conditions like diabetes and heart disease and are concerned that addressing incontinence might distract them. Physicians also may not want to offend patients' sensibilities, noted William J. Hall, MACP, director of the Center for Healthy Aging at the University of Rochester School of Medicine in Rochester, N.Y.

"There was a time when we didn't ask about sexual history or smoking," Dr. Hall said. "This is just another one of those 'taboo' subjects that physicians need to start bringing up."

More often than not, just by asking, physicians remove a burden from their patients' shoulders. "Patients are usually incredibly relieved that you're bringing up the issue, because it shows them that you can actually do something about it," Dr. Hall said. And treatment doesn't have to be complex. Simple behavioral techniques can help immensely, while medications and surgery are effective as well.

Bringing it up

Sometimes, the problem will become obvious during the exam if you notice the patient wearing a pad or you smell urine.

If not, there are several tactful ways to ask about incontinence during an annual exam, noted Michael H. Phillips, MD, a Washington-based urologist. "Ask if patients are having problems with their bladder, if they're leaking with any great regularity or if they're experiencing any increase in the frequency of urination."

Dr. Resnick offered this advice on what not to ask: "Don't ask 'are you incontinent?' because people really don't know what that means," he said. "If they leak but they're managing the problem with pads, they'll accept this as normal and never mention it."

If the incontinence is severe or if it begins suddenly, it might signal an infection, neurological problem or another issue that needs immediate attention. If it doesn't fit these criteria, said Dr. Phillips, the next step is letting patients know that it can be treated and asking if they want to do something about it.

"This is a symptom-driven condition," he said. "One person might be fine with wearing two pads a day; for someone else, this might be misery."

Once incontinence has been diagnosed, a thorough history and physical that includes a pelvic exam, a rectal exam, a urinalysis and a post-void residual test (less than 100 ccs of urine in the bladder after voiding is normal) are key to determining its causes and type. Types include:

  • Urge incontinence. The most common type in older persons, this is usually characterized by a precipitous urge to void followed by small to moderate volume urine loss. Involuntary contractions of the detrusor muscle are usually the cause.

  • Stress incontinence. This occurs when the sphincter fails to remain closed during periods of increased intra-abdominal pressure, such as during sneezing or coughing, and is related to increased urethral mobility and/or poor intrinsic sphincter function.

  • Mixed incontinence. This is a combination of stress and urge incontinence.

  • Overflow incontinence. Symptoms, which are more common in men, include dribbling, weak urinary stream and nocturia, and result from detrusor underactivity, bladder outlet obstruction or both. Benign prostatic hyperplasia or neurological conditions (such as diabetic neuropathy or spinal cord injury) can be the cause.

  • Functional incontinence. This occurs when patients' mobility makes toileting difficult—or when their cognitive status is such that they don't recognize the need to void.

Behavioral treatments help many

First-line treatments should focus on helping patients help themselves. "Behavioral treatments help almost any kind of incontinence, especially if the patient is motivated," said Jayna M. Holroyd-Leduc, ACP Member, assistant professor at the University of Toronto who has started a women's urinary incontinence clinic at Toronto's University Health Network.

Experts recommend the following steps:

  • Set up a voiding schedule. For patients with functional incontinence, setting up a toileting schedule—first thing in the morning, before and after meals, and at bedtime—can help. "A three-day trial can determine if a patient will respond," said Patricia S. Goode, MD, a geriatrician based in Birmingham, Ala.

  • Examine drinking patterns. Simple things may be contributing to the problem. Ask, for instance, how much coffee the patient is drinking. "Remember that two Starbucks' 'venti's' are equivalent to several cups of coffee," Dr. Phillips said. Many patients with urge incontinence improve considerably by tapering off caffeine.

  • Keep a bladder diary. Ask patients to keep a detailed record for at least one week of when they urinate in the toilet or leak urine.

    "It's not uncommon to see symptoms lessen when patients start keeping bladder diaries," said Mary P. Harward, FACP, a geriatrician based in Orange, Calif. "It helps them become more cognizant of the problem, and they learn to do their own behavior modifications." (The American Geriatrics Society offers a downloadable bladder diary.)

  • Teach Kegel exercises. "Kegel exercises, which exercise the entire pelvic floor, have been shown to be very effective in both men and women," said Dr. Goode. "The best way to teach Kegel exercises is to have patients contract the muscles properly during a pelvic exam for women or a rectal exam for men."

    She recommends having patients do Kegels for five minutes, three times a day. Patients with stress incontinence should learn to tense the proper muscles when they feel the urge to sneeze or do anything else that may make them leak.

    "Also, explain to patients with urge incontinence that if they suddenly need to urinate, the worst thing they can do is run to the toilet," she added. "Instead, they should sit still for a minute, focus on controlling the bladder and then walk to the bathroom once the urge subsides. Patients are surprised how well this works because it's counterintuitive."

    Dr. Harward also noted that if patients start doing Kegels before there's a problem, they might be able to head off incontinence or leakage altogether. (See "Diagnosis: Remember DIAPPERS.")

Watch for side effects

Experts agree that medications can be effective for many patients. In randomized controlled trials, for instance, medications decrease urge incontinence by as much as 70%.

Anticholinergic agents, which inhibit parasympathetic nerve impulses and reduce smooth muscle spasms in the bladder, are often used to treat urge incontinence. They include oxybutynin, available in short- and long-acting oral forms (Ditropan and Ditropan XL) and in a transdermal patch (Oxytrol); tolterodine, available in short- and long-acting oral forms (Detrol and Detrol LA); darifenacin (Enablex); trospium (Sanctura); and solifenacin (VESIcare).

"Anticholinergics should be used with caution in the frail elderly and in those with cognitive impairment, due to the potential side effects," said Toronto's Dr. Holroyd-Leduc. While there is not a lot of difference between oxybutynin and tolterodine, she added, patients may experience less side effects with longer-acting formulations or lower doses.

Stress incontinence is less amenable to medications. Alpha-adrenergic agonists, such as Sudafed, might increase the pressure in the muscles of the bladder neck and the urethra, helping the bladder retain urine. But the Food and Drug Administration (FDA) has not approved these medications for incontinence treatment.

Estrogen has also been widely used; the thinking is that estrogen increases urethral vascularity and mucosal thickness and sensitizes alpha-adrenergic receptors in the neck of the bladder, helping improve urethral closure. However, a Women's Health Initiative study published in the Feb. 23, 2005, issue of the Journal of American Medical Association suggested that estrogen therapy actually exacerbated incontinence symptoms.

According to Dr. Harward, all these medications cause side effects, such as blurred vision, dry mouth and constipation. "Unfortunately, the population that these medications are targeted for probably suffers the most side effects."

But she added that newer formulations, such as the transdermal patch, might alleviate these problems. For all medications, she suggested starting patients on a low dose and monitoring them carefully. And "medications work best when they're used in conjunction with non-pharmacologic therapies, such as behavioral modifications and Kegels," said David B. Reuben, FACP, director of the geriatrics program at the University of California, Los Angeles. (See "Further reading and resources.")

Surgical options

Surgery to repair the pelvic floor and other structures may be useful for intractable stress incontinence. According to Dr. Phillips, the following procedures offer good outcomes:

  • Bladder suspension surgeries, such as the Burch procedure, can correct the position of the urethra and bladder by fixing them in place behind the pubic bone.

  • Sling procedures involve placing a supportive hammock (composed of either cadaver or porcine tissue or a synthetic material) directly under the urethra and attaching it to the connective tissue of the abdominal muscles. When the patient strains, the urethra pushes against the sling, which helps close it off. And according to Dr. Goode, newer procedures—including mid-urethral slings, trans-vaginal tape and transobturator tape—are minimally invasive and yield excellent results.

  • Collagen injections can add bulk to the urethral lining, helping it close properly.

  • InterStim therapy is a surgically implanted device that delivers electrical impulses to the sacral nerves, helping control bladder spasms.

Surgeons are also refining techniques for radical prostatectomy, which often causes tissue damage leading to male incontinence. "Robotic surgery has made these procedures much more precise," Dr. Speckart said. "We're learning that the less you muck around down there, the better off you are."

Connect patients to a community

If patients don't respond to behavioral treatments or medications, don't hesitate to refer them to geriatricians, urologists, urogynecologists or pelvic floor specialists, or incontinence clinics.

Ultimately, it's the continued support and long-term management techniques that make the most difference. "We don't see a lot of cures," Dr. Holroyd-Leduc said, "but our patients do learn strategies that help them get back to normal activities. It's all about helping them gain some measure of control."

Yasmine Iqbal is a freelance health and science writer in Philadelphia.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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