Urinary Incontinence: Partnering with Patients for Success
Patient profiles should be reviewed for drugs that may cause or exacerbate incontinence.
Patient profiles should be reviewed for drugs that may cause or exacerbate incontinence.
The squirming demeanor, the darting eyes, the awkward shuffle…as women age, they begin to understand “the look.” It’s the look that women get when something—or nothing obvious—causes the urge to void or an accidental urine leakage. Around 25% of young women, 44% to 57% of middle-aged or postmenopausal women, and 75% of older women in nursing homes experience urinary incontinence (UI).1-4 Dissecting “the look” reveals UI’s physical, psychological, and social repercussions. The squirming indicates the bothersome wetness and anxiety. The darting eyes indicate an acute need for the nearest restroom and fear that someone knows, and the shuffle is an attempt to prevent further incontinence.
The International Continence Society defines several types of UI (Table 11,5). UI is associated with depression,6,7 impaired sexual functioning,8,9 an increased risk of falls and fracture in the elderly,10-12 skin ulceration,1,13 and urinary tract infections.14 In the frail elderly, UI often prompts admission to nursing homes and increases medical expenditures.13,15
Risk factors for UI include race (with Caucasians at highest risk), increasing age, family history of incontinence, neurologic conditions (eg, Parkinson’s, stroke, multiple sclerosis), impaired mobility, cognitive impairment, obesity, diabetes mellitus, constipation/fecal impaction, urinary tract infection, multiple vaginal births (especially >4 vaginal births), prior pelvic surgery or radiation, pelvic organ prolapse, and menopause.16
What Women Want
Women want interventions that lead to continence (complete voluntary bladder control), allowing them the freedom to resume their normal activities. Continence is possible, but accurate diagnosis depends on the following1:
- Obtaining a thorough medical history
- Having the patient use a frequency volume chart/bladder diary and interpreting it correctly
- Conducting a cough stress test
- Excluding pathologic causes such as infection or prolapse
Patients who have mild to moderate UI may find that behavioral changes reduce incontinence. Pelvic floor strengthening exercises (eg, Kegel exercises) are effective for treatment of both urge and stress incontinence. It may take weeks to months for exercises to be effective, and they must be done correctly and regularly.1,5,17 Scheduled toileting during waking hours, especially for patients who have mobility issues, can help. Scheduled toileting includes prompting by caregivers, voiding at appointed times, or habit retraining so that accidents are preempted.1,18,19 In addition, weight loss has been shown to reduce symptoms of UI.5
Constipation sometimes exacerbates UI, so treating it can reduce pressure. Note that antimuscarinic and anticholinergic drugs can cause or contribute to constipation.5,20 Some clinicians recommend caffeine elimination, but there is little evidence indicating it helps. Expert panels seem to believe that decreasing caffeine intake decreases fluid intake, and it’s the lessened fluid load rather than the lowered caffeine intake that helps with urgency symptoms.21-23 Many effective absorbent products are available to manage discomfort.
Medication can also cause UI; therefore, pharmacists should review patients’ profiles for drugs that may cause or exacerbate incontinence. Discontinuing medications that could cause cough, constipation, diuresis, or urinary retention is an often overlooked conservative approach (Table 224-26).
Several medications can be employed to treat UI (Online Table 31,8). Anti-cholinergic medications are the treatment of choice for many urinary tract symptoms; these agents block postganglionic muscarinic receptors on the detrusor muscle. Many patients discontinue drug therapy due to anticholinergic side effects (eg, dry eyes, dry mouth, blurred vision, increased heart rate, cognitive impairment). Approximately half of patients report significant improvement, but some authors maintain that achieving complete continence using drugs alone is unlikely.27 Few head-to-head studies have been conducted, so choosing a drug may require trial and error.
Table 3: Medications Used for Urinary Incontinence
Drug or Drug Class
- Systemic estrogen (oral or transdermal) is associated with increased UI or stress UI and is not recommended
Mixed action anticholinergics:
Urinary tract symptoms and urgency UI
- Oxybutynin is available as a topical gel and an OTC patch
- Dry mouth and constipation are frequent side effects; nausea, somnolence, dizziness, fatigue, and diarrhea are also concerns
darifenacin, fesoterodine, solifenacin, tolterodine, trospium
OAB and urgency UI
- Drugs demonstrate similar effectiveness
- Discontinuation due to adverse effects is common
- Compliance rates are traditionally low
Serotonin-noradrenaline uptake inhibitors: duloxetine, imipramine
Stress UI (off-label indication)
- Response is inconsistent, and many women may discontinue the drug due to side effects
Toxins: botulinum toxin
OAB and urgency UI
- Maintenance treatments are required due to waning effects after treatment is discontinued
- Off-label use
- It is a strong hypertensive
OAB = overactive bladder; UI = urinary incontinence. Adapted from references 1 and 8.
Although the extended-release or long-acting formulations have been associated with a lower adverse event burden, the immediate-release doses are often preferred for simple nocturia or for patients who wish to medicate only when necessary (eg, before attending church or social events).28 Flexible dosing is a patient-centered overactive bladder treatment strategy. It involves having patients adjust the drug dose—independently or after calling the prescriber—in increments at preplanned intervals, until patients (1) achieve complete continence, (2) experience side effects they cannot tolerate, or (3) reach the agent’s maximum dose.29-32
Finally, other treatment options include percutaneous nerve stimulation, synthetic midurethral slings, pessaries, and neuromodulation.1,5
Virginia Bartok is a retired pharmacist who lives in eastern Connecticut. Her primary practice was indigent care.
- Shamliyan T, Wyman J, Kane RL. Nonsurgical treatments for urinary incontinence in adult women: diagnosis and comparative effectiveness [published online April 2012]. Agency for Healthcare Research and Quality website. www.ncbi.nlm.nih.gov/books/NBK92960/. Accessed April 30, 2014.
- Milson I, Alrman D, Lapitan MC, Nelson R, Sillen U, Thom D. Committee 1: epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Incontinence. 4th ed. Health Publication Ltd website. www.icud.info/PDFs/Incontinence.pdf. Paris: 4th International Consultation on Incontinence; July 5-8, 2008. Published 2009. Accessed April 30, 2014.
- Carls C. The prevalence of stress urinary incontinence in high school and college-age female athletes in the midwest: implications for education and prevention. Urol Nurs. 2007;27:21-24, 39.
- Kinchen KS, Lee J, Fireman B, et al. The prevalence, burden, and treatment of urinary incontinence among women in a managed care plan. J Womens Health (Larchmt). 2007;16:415-422.
- Abrams P, Andersson L, Birder L, et al. Committee 1: epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Incontinence. 4th ed. Health Publication Ltd website. www.icud.info/PDFs/Incontinence.pdf. Paris: 4th International Consultation on Incontinence; July 5-8, 2008. Accessed April 30, 2014.
- Waetjen LE, Liao S, Johnson WO, et al. Factors associated with prevalent and incident urinary incontinence in a cohort of midlife women: a longitudinal analysis of data: study of women's health across the nation. Am J Epidemiol. 2007:165:309.
- Moghaddas F, Lidfeldt J, Nerbrand C, Jernström H, Samsioe G. Prevalence of urinary incontinence in relation to self-reported depression, intake of serotonergic antidepressants, and hormone therapy in middle-aged women: a report from the Women's Health in the Lund Area study. Menopause. 2005;12:318-324.
- Sand PK, Goldberg RP, Dmochowski RR, McIlwain M, Dahl NV. The impact of the overactive bladder syndrome on sexual function: a preliminary report from the Multicenter Assessment of Transdermal Therapy in Overactive Bladder with Oxybutynin trial. Am J Obstet Gynecol. 2006;195:1730-1735.
- Huang AJ, Stewart AL, Hernandez AL, Shen H, Subak LL. Program to reduce incontinence by diet and exercise. sexual function among overweight and obese women with urinary incontinence in a randomized controlled trial of an intensive behavioral weight loss intervention. J Urol. 2009;181:2235-2242.
- Rapp K, Lamb SE, Büchele G, Lall R, Lindemann U, Becker C. Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial. J Am Geriatr Soc. 2008;56:1092-1097.
- Wenger NS, Roth CP, Shekelle PG, et al. A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia. J Am Geriatr Soc. 2009;57:547-555.
- Johansson C, Hellstrom L, Ekelund P, et al. Urinary incontinence: a minor risk factor for hip fractures in elderly women. Maturitas. 1996;25:21-28.
- Long MA, Reed LA, Dunning K, Ying J. Incontinence-associated dermatitis in a long-term acute care facility. J Wound Ostomy Continence Nurs. 2012;39:318-327.
- Jackson SL, Boyko EJ, Scholes D, Abraham L, Gupta K, Fihn SD. Predictors of urinary tract infection after menopause: a prospective study. Am J Med. 2004;117:903-911.
- Wang SY, Shamliyan TA, Talley KM, Ramakrishnan R, Kane RL. Not just specific diseases: systematic review of the association of geriatric syndromes with hospitalization or nursing home admission. Arch Gerontol Geriatr. 2013;57:16-26.
- Shamliyan T, Wyman J, Bliss DZ, Kane RL, Wilt TJ. Prevention of urinary and fecal incontinence in adults. Evid Rep Technol Assess (Full Rep). 2007;161:1-379.
- O’Neil B, Gilmore D. Approach to urinary incontinence in women: diagnosis and management by family physicians. Can Fam Physician. 2003;49:611-618.
- Palmer MH. Effectiveness of prompted voiding for incontinent nursing home residents. In: Melnyk BM, Fineout-Overholt E, eds. Evidence-Based Practice in Nursing & Healthcare: A Guide to the Best Practice. Philadelphia, PA: Lippincott Williams & Williams; 2005:20-30.
- Ostaszkiewicz J. A clinical nursing leadership model for enhancing continence care for older adults in a subacute inpatient care setting. J Wound Ostomy Continence Nurs. 2006;33:624-629.
- Arnaud MJ. Mild dehydration: a risk factor of constipation? Eur J Clin Nutr. 2003;57(suppl 2):S88-S95.
- Bryant CM, Dowell CJ, Fairbrother G. Caffeine reduction education to improve urinary symptoms. Br J Nurs. 2002;11:560-565.
- Kincade JE, Dougherty MC, Carlson JR, Hunter GS, Busby-Whitehead J. Randomized clinical trial of efficacy of self-monitoring techniques to treat urinary incontinence in women. Neurourol Urodyn. 2007;26:507-511.
- Tomlinson BU, Dougherty MC, Pendergast JF, Boyington AR, Coffman MA, Pickens SM. Dietary caffeine, fluid intake and urinary incontinence in older rural women. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10:22-28.
- Menefee SA, Chesson R, Wall LL. Stress urinary incontinence due to prescription medications: alpha-blockers and angiotensin converting enzyme inhibitors. Obstet Gynecol. 1998;91(5, pt 2):853-854.
- Tsakiris P, Oelke M, Michel MC. Drug-induced urinary incontinence. Drugs Aging. 2008;25:541-549.
- Price N, Currie I. Urinary incontinence in women: diagnosis and management. Practitioner. 2010;254:27-32.
- Staskin DR, MacDiarmid SA. Pharmacologic management of overactive bladder: practical options for the primary care physician. Am J Med. 2006;119(3, suppl 1):24-28.
- Jirschele K, Sand PK. Oxybutynin: past, present, and future. Int Urogynecol J. 2013;24:595-604.
- Wagg A, Khullar V, Marschall-Kehrel D, et al. Flexible-dose fesoterodine in elderly adults with overactive bladder: results of the randomized, double-blind, placebo-controlled study of fesoterodine in an aging population trial. J Am Geriatr Soc. 2013;61:185-193.
- Chapple CR, Martinez-Garcia R, Selvaggi L, et al; the STAR study group. A comparison of the efficacy and tolerability of solifenacin succinate and extended release tolterodine at treating overactive bladder syndrome: results of the STAR trial. Eur Urol. 2005;48:464-470.
- Versi E, Appell R, Mobley D, Patton W, Saltzstein D; The Ditropan XL Study Group. Dry mouth with conventional and controlled-release oxybutynin in urinary incontinence. Obstet Gynecol. 2000;95:718-721.
- Gleason DM, Susset J, White C, Munoz DR, Sand PK; ditropan XL study group. Evaluation of a new once-daily formulation of oxybutynin for the treatment of urinary urge incontinence. Urology. 1999;54:420-423.