Rio Bravo qWeek

Episode 177: Urinary Incontinence in Older Adults

Future Dr. Nguyen explains the evaluation and treatment of older adults with urinary incontinence. Dr. Arreaza adds insights into the conservative management of urinary incontinence.

Written by Vy Nguyen, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Definition of urinary incontinence.

The International Continence Society (ICS) defines it as any involuntary urine leakage.

Epidemiology of urinary incontinence.

Data analysis from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 shows that more than 60% of adult women which is equivalent to around 78,000,000 females living in the United States experience urinary incontinence with 32.4% reporting symptoms monthly. More data analysis shows the strongest association with urinary incontinence include age greater than 70, prior vaginal delivery, and BMI of 40 or greater.

Despite urinary incontinence commonly affecting the senior population, this medical condition can also affect the quality of life of younger adult females and males. On top of that, urinary incontinence is often underestimated due to the low report level for various reasons and the obtained data might not accurately reflect the true prevalent rate.

Types and etiology.

Urinary incontinence is divided into 5 categories: stress, urge, mixed, overflow, and functional.

Stress urinary incontinence has the highest prevalence of 37.5% followed by mixed urinary incontinence at 31.3%, urgency at 22%, and unspecified urinary incontinence at 9.2%. Due to time constraints, we will discuss the most prevalent type which is stress urinary incontinence.

In females, stress urinary incontinence is often due to urethral sphincter hypermobility caused by weakened pelvic floor muscles. It can also be caused by dysfunction of the sphincter muscle that is exacerbated by increased intraabdominal pressure from coughing, sneezing, or physical exertion. This type of incontinence is commonly seen in pregnant women, those who experienced childbirth, and young women active in sports.

In males, the most common etiology for stress urinary incontinence in males is prostate surgery such as radical prostatectomy which can damage the external urethral sphincter. Another cause is spinal cord injury or disease that can interfere with sphincter function.

Evaluation.

Urinary incontinence is first evaluated by a thorough history taking that includes inquiries about the type, severity, burden, and duration of incontinence. The initial evaluation includes a voiding diary that can provide clarity and help distinguish between the different types of incontinence or identify the dominating type in the case of mixed incontinence.

Examples of voiding diary can be found on the websites of International Urogynecological Association (IUGA). Medical conditions such as COPD and asthma can induce cough; heart failure can cause volume overload; neurological disorders and musculoskeletal conditions can interfere with bladder emptying and urinary retention and thus should also be investigated. It is also helpful to ask about medication and substance use as the adverse effects can directly or indirectly contribute to urinary incontinence. For our female-identifying patients, a gynecological and obstetrical history such as birth history (vaginal versus c-section), current pregnancy as well as low estrogen (menopause) can contribute to reversible urinary incontinence.

Management.

There are various treatment modalities for stress urinary incontinence ranging from conservative to more invasive surgical management.

Conservative treatment:

-Initial treatment includes pelvic floor strengthening exercises and bladder training with scheduled void.

-Pelvic floor muscle training (PFMT) is very effective, and it is proven to help achieve cure and improve the quality of life in women with ALL types of urinary incontinence.

-For stress urinary incontinence, the median cure rate is around 58.8% for women after 12 months and 78.8% for men at 6 months of supervised pelvic floor muscle training (PFMT).

-Certain behavioral modifications such as fluid intake management (<64 fluid ounces and in smaller portions throughout the day), constipation management, and weight loss can also relieve incontinence.

-According to an AFP article, Cochrane for Clinicians, patients who have obesity may benefit from weight loss, improving the cure rate and improvement of symptoms in any type of urinary incontinence. SOR: B.

-Conservative management should be implemented for 6 weeks before considering other options.

-Supplemental modalities can also be introduced in addition to pelvic floor exercises; those include vaginal weighted cones, biofeedback alone or with electrical stimulation.

-Vaginal cones and electric stimulation are more effective than control at achieving cure or improving symptoms in patients with stress urinary incontinence.

-In the case that initial management does not offer relief, physicians can consider support devices such as pessaries. However, their use is associated with a high incidence of UTIs and doesn’t have long-term efficiency.

Medications.

-In terms of pharmacologic treatments, several medications are being evaluated such as duloxetine and alpha-adrenergic agonists, but the FDA has yet to approve any medications for stress urinary incontinence.

Invasive treatment:

-Lastly, patients without sufficient control of their incontinence via initial management or pessaries should be considered for surgical management.

-Mid-urethral sling procedures have become the standard surgery for stress urinary incontinence due to their minimally invasive approach, rapid recovery, low-risk complications, and high cure rates and thus is the single most investigated procedure with the strongest evidence for its use. Around 53% after 3 years for males who received slings and 84.4% at 12 months for women who received surgical interventions.

-Trans- or periurethral injections of bulking agents are also commonly used given the low invasive nature and rapid recovery.

-Other procedures such as intravesical balloons, and electrical stimulation of pelvic floor can offer some benefits though data remains limited. Response rate often varies depending on the type of incontinence and treatment. Multiple modalities should be explored if symptoms persist.

Conclusion:

-Urinary incontinence affects various physical, mental, and social aspects of our patients’ lives and thus can interfere with work, travel, exercise, and sexual activities. While it is a common presentation in elderly adults, it is imperative to emphasize that it is not part of normal aging. One survey shows almost three out of four women with urinary incontinence hesitate to disclose their symptoms and only 60% of those who tried to address their symptoms receive treatments.

-Our patients might also see us as their sons, daughters, or even grandchildren and are reluctant to share their symptoms due to embarrassment. As we observe and approach our patients with compassion, we can help these individuals understand that many of these symptoms have reversible causes and can be managed to allow for a better quality of life.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

_____________________

References:

1. Patel, Ushma J, et al. Updated Prevalence of Urinary Incontinence in Women: 2015–2018 National Population-Based Survey Data. Female Pelvic Medicine & Reconstructive Surgery 28(4):p 181-187, April 2022.https://journals.lww.com/fpmrs/abstract/2022/04000/updated_prevalence_of_urinary_incontinence_in.1.aspx
2. Tran, Linh and Puckett, Yana. Urinary Incontinence. National Library of Medicine. Last updated Aug 8, 2023.https://www.ncbi.nlm.nih.gov/books/NBK559095/
3. Clemens J, et al. Urinary incontinence in males, Up to Date, last updated: Mar 26, 2024. https://www.uptodate.com/contents/urinary-incontinence-in-males.
4. Lukacz, Emily, et al. Female urinary incontinence: treatment and evaluation, Up to Date, last updated: Apr 2024. https://www.uptodate.com/contents/female-urinary-incontinence-treatment.
5. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.