Urinary incontinence in women is a neglected problem, but primary care physicians can play a crucial role in treatment, according to Neil M. Resnick, FACP, chief of the division of geriatrics and gerontology and director of the Institute on Aging at the University of Pittsburgh, who spoke on the topic at Internal Medicine 2010.
Incontinence is extremely common, affecting about 20% to 25% of women before menopause and nearly double that after menopause. The associated morbidity is “substantial,” Dr. Resnick said. In younger women, incontinence can lead to sexual dysfunction and is linked to risk for urinary tract infections, while older women with incontinence are at risk for even more serious problems, such as Foley catheter insertion, fractures and institutionalization, he noted.
Cost is also an issue: Incontinence was estimated to cost $26 billion in 1995, exceeding the combined amount spent at the time on dialysis and coronary artery bypass grafting.
Dr. Resnick noted that although many diseases and conditions vie for internists' attention during the office encounter, there's a good reason to be alert for incontinence: “It's treatable,” he said. “Contrary to popular opinion, incontinence is highly treatable at any age.”
Even over the age of 80, he said, one-third of women can be cured, another third can be virtually cured, and the final third can benefit from significant relief of their symptoms.
Workup for incontinence is a multistep process, Dr. Resnick said. At the first office visit, when a patient mentions incontinence, her internist should set her up with a voiding diary and schedule a follow-up visit in a few weeks. Patients should track how much they void, when they void, and when they leak over three consecutive days.
The information in the voiding diary is often enough to help the internist pinpoint the source of the patient's problem. “There are hundreds of cases where the voiding diary tells all,” Dr. Resnick said. “It's really fun to use these to be a Sherlock Holmes.”
He told the story of a 58-year-old woman whose voiding diary revealed that her incontinence always occurred at around 1 a.m. The cause, Dr. Resnick determined, was a generous nightcap she drank before bed.
“She didn't need something for her bladder. She needed to quit drinking,” he said.
The patient wasn't happy with this solution, but she agreed to try it, and even bet Dr. Resnick a case of beer on it. “To this day, I still, once a year, get the case of beer,” Dr. Resnick said. “This is now six years, and she has been completely dry for six years.”
In addition to a review of the diary, the follow-up visit should include a history and physical, a bladder stress test and laboratory tests, Dr. Resnick recommended. To perform a good stress test in the office, he offered the following tips:
- The bladder should be full, at least 150 mL, but the patient should not have an abrupt urge.
- The pelvic muscles should be relaxed (check the gluteal folds).
- The cough should be single and forceful.
With a positive test, leakage will coincide with the onset and cessation of the cough. With a negative test, there will be no leak or a leak that's delayed for 5 to 15 seconds. A delayed leak indicates a bladder spasm triggered by the cough, not a weakness of the sphincter.
“You would not want to send that person for treatment for stress incontinence,” Dr. Resnick said. “That person has urge incontinence. … That's where your stress test helps.”
Dr. Resnick also noted that the test should replicate the symptom or symptoms that led the patient to present for exam.
“You have to make sure that it's not just incidental minor stress incontinence that she's had for years that you focus on, that instead you focus on what brings her in today,” he said.
Lab tests to order include a metabolic survey, a blood urea nitrogen/creatinine level to check for bladder obstruction, a postvoid residual to help decide if the patient has an emptying or storage disorder, and a urinalysis and culture if the patient has symptoms of a urinary tract infection.
When treating incontinence, Dr. Resnick said internists should first address possible transient, reversible causes, illustrated by the DIAPERS mnemonic: delirium, infection, atrophic urethritis or vaginitis, pharmaceuticals, excess excretion, restricted mobility and stool impaction. Treating these will cure incontinence in one-third of patients and ameliorate it in the remainder, he noted.
If the incontinence persists, the next step is to search for an established cause. These include storage problems, such as overactive detrusor and stress incontinence, or emptying problems, such as underactive detrusor and urethral obstruction. “Once the transient causes have been excluded, 90% of female incontinence is in the storage group at any age,” Dr. Resnick said.
Women who may have overflow urinary incontinence, suggested by a postvoid residual of 200 mL or greater, should be referred to a subspecialist. In those with a positive stress test and a postvoid residual of 100 mL of less, the presumed diagnosis is stress incontinence, Dr. Resnick said. Those with a negative stress test and postvoid residual of 100 mL or less may be presumed to have detrusor overactivity.
For urge incontinence caused by detrusor overactivity, “The cornerstone of treatment is behavioral,” Dr. Resnick said. Physicians should assess the voiding diary and start with bladder retraining and urgency suppression methods.
For urgency suppression, the patient needs to be aware of what's happening with her bladder and when a spasm is starting. When she feels one begin, she should “freeze and squeeze,” that is, stop what she's doing, tighten her pelvic floor, and wait for the spasm to recede, Dr. Resnick said. Most involuntary bladder contractions last from under a minute up to a minute and a half, according to Dr. Resnick. Once a contraction is over, the woman can proceed to the bathroom at her own pace.
“That will take care of many women right there,” Dr. Resnick said. “How often does it work? Up to half of women respond to such behavioral treatment alone.”
Anticholinergic bladder relaxants can be used if behavioral therapy proves inadequate, Dr. Resnick said. “The place for medication is after you've done the rest,” he said. Desamino d-arginine vasopressin (DDVAP), he noted, has not been proved to cure incontinence and, given its risks in older women, it should not be used in this group. Intradetrusor injection of botulinum toxin appears to be a promising alternative, but it is still under investigation, he noted.
For stress incontinence, conservative treatment works, he said. Overweight women need to lose only 5% to 10% of their weight to achieve a 50% decrease in urinary leakage, according to a recent New England Journal of Medicine article. Tampons and pessaries can be effective for some women, especially for those with exercise-induced incontinence. Crossing the legs and tightening the pelvic floor before coughing or sneezing can also help, as can Kegels, although women need to do 30 to 50 a day for several months to see results.
Surgery offers the best chance for cure, but patients need to understand that “it doesn't cure everyone and the cure may not be permanent,” Dr. Resnick said. Unfortunately, currently available drugs are of minimal benefit for stress incontinence, he noted.
The bottom line, according to Dr. Resnick, is that although incontinence is common, it's never normal. “And because the causes are multifactorial,” he said, “so too must be the approach. But with a positive, persistent approach, we can cure or help the vast majority of the patients that we see.”