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Incontinence Management Outline

Management of Incontinence in Older Adults*

Urinary incontinence is involuntary loss of urine of sufficient severity to be a social or health problem. There are several types of Objectives UI, but all are characterized by an inability • Identify and treat (UI) to restrain or control urinary voiding. in the older adult • Enhance the utilization of appropriate treatment Definitions measures available to Highmark Medicare Incontinence is common among elderly women and men and Advantage members compromises quality of life (anxiety, reduced socialization). • Prevent the complications of incontinence Incontinence causes burden, cost, and caregiver stress and can precipitate institutionalization.

Key Points Types of Incontinence • Patients may not report incontinence unless asked. • Stress: leakage with activities that increase intra-abdominal • Cause in any individual may be multifactorial. pressure; bladder outlet pressures insufficient to overcome • Cause may be intrinsic to lower urinary tract (sphincter, increased bladder pressures. detrusor dysfunction) and/or extrinsic, for example, • Urge: leakage associated with sensation of uncontrollable diabetes and neurologic disorders, medications. urgency; detrusor muscle hypercontractility. • Assessment in primary care can often identify • Mixed stress and urge; sphincter and detrusor disorder. contributory factors. • Overflow: continual leakage with sensation of incomplete • Management by primary care providers can often reduce emptying; bladder outlet obstruction and/or detrusor severity and burden. hypocontractility. • Behavioral, pharmacologic, and combination of both types of interventions can be implemented in primary care. • Specialists (urologists, gynecologists, and urogynecologists) can conduct more complete assessment, and offer procedural approaches where indicated. Caring for Seniors Primary Care Assessment Assess severity and burden (bother): • How many times a day do you have to change clothes History: Identify the type(s) of incontinence or protection? and look for remediable causes • Have you cut back on leaving the house because of this? Symptoms of (increased frequency, • How bothered would you be if you had to live with this dysuria, change in odor or appearance of urine) for the rest of your life? • Precipitants of stress incontinence (cough, sneeze, laughter) • Are you bothered enough to consider taking medications/ and urge incontinence (arising from chair, entering home, seeing a specialist? running water) • Medication review: diuretics, medications, opiates, adrenergic agonists Management in Primary Care • Substance review: , caffeine Behavioral • Mobility and functional limitations that interfere with • Stress incontinence: crossing legs and tightening pelvic accessing and using toilet floor before cough, sneeze, etc. • Symptoms suggesting myelopathy (leg weakness, • Urge incontinence: scheduled voiding, for example, every saddle sensory loss, ) 3 hours; patients with cognitive impairment will need • Awareness, in women, of pelvic organ prolapse caregiver prompting • History of urinary tract surgery (prostatectomy) Therapy (Dedicated Clinician, e.g., Physical Therapist or Nurse with Training) Physical Examination • Kegel or pelvic floor muscle exercises • Cognitive impairment, acute () or chronic/progressive (dementia) • Urge suppression techniques • Functional impairment (arising from chair, walking, fine motor control for unbuttoning, unzipping) Pharmacologic • Distended bladder (abdominal obesity renders exam • Urge incontinence without increased post void residual: less useful) antimuscarinics such as , ; side effects include dry mouth and constipation • Women: pelvic floor prolapse (cystocele, rectocele, uterine prolapse) • Frequency and urgency in men who do not have increased post void residual: • Men: prostatic enlargement (outlet obstruction can occur without detectable enlargement) –– antagonists such as tamsulosin, silodosin, terazosin: side effects include orthostatic hypotension • Rectal impaction –– alpha-1 reductase inhibitors such as finasteride, • Signs of cord compression (leg weakness, dutasteride: side effects include sexual dysfunction perineal numbness) Note: This class is not particularly effective in reducing symptoms. Diagnostic studies in primary care: • Discontinuing medications which interfere with normal • Urinalysis to check for infection, hematuria bladder and sphincter function: • Post void residual by bladder scan or catheter, especially –– Adrenergic agonists (e.g., decongestants): outlet if is suspected obstruction in men –– Adrenergic antagonists (doxazosin): stress incontinence in women –– (e.g., ) reduced detrusor contractility, constipation –– : reduced detrusor contractility, constipation –– Diuretics: increased urinary volume

2 Incontinence Management Outline Therapeutic Class: Anticholinergic/ (refer to full prescribing information) Drug Recommended Dosing Oxybutinin chloride (Ditropan XL®) (extended release) Start with 5mg orally once daily and may titrate up to 20mg orally once daily

Oxybutynin patch (Oxytrol®) Apply one 3.9mg/day twice weekly (extended release) (every 3–4 days)

Oxybutynin chloride topical gel (Gelnique®) Apply contents of one sachet (100mg/g) topically once daily (10%, 100mg/g packet) to skin on abdomen, upper arms/shoulders, or thighs

Tolterodine tartrate (Detrol® LA) (extended release) Start with 4mg orally once daily and may decrease to 2mg once daily, depending on tolerability

Fesoterodine fumarate (Toviaz™) Start with 4mg once daily and may increase up to 8mg once daily

Darifenacin hydrobromide (Enablex®) Start with 7.5mg orally once daily and titrate as appropriate to 15mg orally once daily (titrate 2 weeks after starting therapy)

Solifenacin succinate (Vesicare®) Start with 5mg orally once daily and may increase up to 10mg/day

Trospium chloride (Sanctura®) 20mg orally twice daily

Trospium chloride (Sanctura XR®) 60mg orally once daily in the morning

Mirabegron (Myrbetriq®) Start with 25mg once daily with or without food and may increase within 8 weeks to 50mg once daily based on efficacy and tolerability

Note: Based on 2017 Prescribing Data.

Incontinence Management Outline 3 Assess Response to Treatment References/Resources

A pre- and post-treatment log of daily incontinence Incontinence episodes may document response. Ask about side effects Markland AD, Vaughan CP, Johnson TM 2nd, Burgio KL, of medications, especially antimuscarinics, which often cause Goode PS. dry mouth, constipation, and blurry vision. Med Clin North Am. 2011 May;95(3):539-54, x-xi. doi: 10.1016/j. mcna.2011.02.006. Review. Urologist or Urogynecologist Referral PMID: 21549877 [PubMed - indexed for MEDLINE] • Markedly increased PVR in men and women, when not acute and/or attributable to medication(s) Benefits and harms of pharmacologic • Stress incontinence not responsive to maneuvers or treatment for urinary incontinence in women: therapy (e.g., such as pessary placement, botox injections, A systematic review. or sling procedure) Shamliyan T, Wyman JF, Ramakrishnan R, Sainfort F, Kane RL. Ann Intern Med. 2012 Jun 19;156(12):861-74, W301-10. doi: 10.7326/0003-4819-156-12-201206190-00436. Review. Medication Issues PMID: 22711079 [PubMed - indexed for MEDLINE] • Antimuscarinics can interfere with cognitive function, directly oppose the activity of the inhibitors Urinary incontinence in frail elderly persons: • If first antimuscarinic is ineffective, a trial of a second Report from the 5th International Consultation member of class may be worthwhile on Incontinence. • Combination of alpha antagonist (e.g., tamsulosin) Wagg A, Gibson W, Johnson T 3rd, Markland A, Palmer MH, and alpha-1 reductase inhibitor (e.g., finasteride) is more Kuchel G, Szonyi G, Kirschner-Hermanns R. effective over time than either class alone in reducing Neurourol Urodyn. 2014 Apr 2. doi: 10.1002/nau.22602. voiding symptoms and need for procedural intervention [Epub ahead of print] in prostatic hyperplasia PMID: 24700771 [PubMed - as supplied by publisher] • Antimuscarinics may be used, with caution, in men with urge incontinence and low PVRs Websites www.AHRQ.gov Conclusion (Agency for Healthcare Research and Quality) Incontinence frequently accompanies aging, but its burden www.NAFC.org can be substantially reduced by feasible and generally safe (National Association for Continence) 800-BLADDER interventions, many of which can be initiated in the primary care setting. Clinical diagnosis for most patients can be www.niddk.nih.gov accomplished with a thorough patient history, physical (National Institute of Diabetes and Digestive and examination, post void residual determination, urinalysis, Diseases) and a few baseline laboratory tests. Treatment can be effective for most of the patients and if urinary incontinence recurs after successful treatment, look for a transient cause.

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