Management of Urinary Incontinence
Treatment plans are individualized based upon the classification of UI discovered. First-line management plans include behavioral therapy with lifestyle adjustments followed by pharmacologic therapy. More invasive and surgical therapy is appropriate in selected cases.
Behavioral and Pharmacologic Therapy
Behavioral therapy interventions aim to improve symptoms through education of healthy voiding habits and lifestyle modifications. Behavioral therapy is appropriate for virtually every category of UI.
Timed or scheduled voiding empties the bladder before incontinence can occur and limits the amount of urine in the bladder affected by stress movements. Voiding on a routine schedule, usually every two to three hours, allows the bladder to fill while avoiding distention and resulting UI (Gomelsky & Dmochowski, 2011; Wieder, 2010). Timing of the void can be individualized to best match an individual's habits and schedule. Documentation of personal voiding habits through the use of a bladder diary provides organization and the ability to monitor progress (Nygaard, 2010; Wieder, 2010). While cognitively impaired older adults may have difficulty complying with timed voiding, gentle caregiver prompting and reminders to void lead to decreased incidence of UI (Drennan et al., 2012).
Bladder-training therapies, effective for all categories of urinary incontinence, promote complete bladder contraction and emptying (Wieder, 2010). Techniques such as double voiding facilitate urinary drainage through position changes or a brief period of standing prior to a second void. Another exercise, bladder inhibition, controls urge by implementing strategies, including keeping the body still until the urge subsides, taking slow deep breaths, mentally concentrating on eliminating the urge, distracting to reduce awareness, or toning pelvic floor muscles to inhibit detrusor contraction (Gomelsky & Dmochowski, 2011; Goode et al., 2010).
Pelvic floor muscle training (PFMT), or Kegel exercises, help strengthen the pelvic floor and subsequently improve stress, urgency, and mixed urinary incontinence in both women and men (Abrams et al., 2009). Hay-Smith, Herderschee, Dumoulin, and Herbison (2011) found subjective improvement in individuals performing PFMT with more improvement reported by those in contact with a health care professional. These results emphasize the importance of nurse-driven teaching of proper voiding technique. To perform this exercise, the individual must tighten the pelvic floor muscles as if holding a void, hold this position for 10 seconds, and repeat for three repetitions, three times a day, for six months. With the proper instruction and motivation, results of PFMT can be seen in 6 to 12 weeks.
Adjustments in lifestyle can greatly impact the incidence of UI in adults. Weight loss has shown to improve UI in obese women because extra abdominal weight places greater force on the bladder (Gomelsky & Dmochowski, 2011; Subak et al., 2009). The elimination of certain beverages, such as coffee or alcohol, can decrease urinary leakage symptoms (Gomelsky & Dmochowski, 2011; Jura, Townsend, Curhan, Resnick, & Grodstein, 2011). Smoking tobacco contributes to UI through irritative effects on the bladder and increased abdominal pressure during times of respiratory infections and cough (Buttaro et al., 2013). Balancing fluid intake involves achieving appropriate daily consumption while limiting fluids before bedtime (Buttaro et al., 2013; Wieder, 2010); however, older individuals with UI should not be severely fluid restricted due to risk of dehydration and hypotension (Nygaard, 2010). In some cases, women may use a pessary device to elevate the bladder neck and avoid unwanted surgery (Wieder, 2010).
Transient and Functional Urinary Incontinence
Transient UI can only be resolved through treatment of the underlying instigator. A bedside commode or urinal can greatly reduce incontinence related to limited or restricted mobility. Clothing that can be easily and quickly removed alleviates functional incontinence risk (Klopp, 2002). Awareness of medication side effects and reduction of unnecessary prescriptions reduces polypharmacy associated UI in older adults (Buttaro et al., 2013; Drennan et al., 2012). Additionally, UI diminishes with the resolution of infection and the improvement of chronic medical conditions (Buttaro et al., 2013).
Stress Urinary Incontinence
Lifestyle and behavioral therapies remain first-line management for SUI because pharmacologic treatment options, although available, show only mild benefits. While topical estrogen therapy may be helpful in treating vaginal atrophy in postmenopausal women, there is limited evidence to correlate estrogen and improvement in SUI (Cody, Richardson, Moehrer, Hextall, & Glazener, 2009). Medications with alphaagonistic properties have been shown to mildly increase the tone of the urethral sphincter (Abrams et al., 2009; Smith, Bevan, Douglas, & James, 2013). However, such medications have been used off label because the clinical efficacy of these drugs in SUI is limited (DeMaagd & Davenport, 2012). Such medications must be used with caution in older adults due to their anticholinergic effects and subsequent fall risk (Berardelli et al., 2013; Buttaro et al., 2013). Lastly, serotonin-norepinephrine reuptake inhibitors, such as duloxetine (Cymbalta®), may reduce symptoms of incontinence by 50% by increasing urethral closure forces through its effect on neurotransmitters. Although duloxetine is approved for the treatment of SUI in Europe, it is indicated only for the treatment of depression and neuropathic pain in the U.S. (DeMaagd & Davenport, 2012). Additionally, due to adverse effects of nausea and worsening depression, many patients decline duloxetine as a UI treatment (Goode et al., 2010; Smith et al., 2013).
Urgency and Overflow Incontinence
Anticholinergic medications, which competitively bind to muscarinic cholinergic receptors (M2/M3) on the bladder, de crease the intensity of bladder contractions and urgency. Examples include tolterodine (Detrol®) and oxybutynin (Ditropan®). While these medications improve UI symptoms, inhibition of M receptors outside of the bladder may cause unwanted side effects in the older adult (Rai, Cody, Alhasso, & Stewart, 2012), such as blurry vision, dry eyes, dry mouth, constipation, tachycardia, and cognitive impairment. Therefore, anticholinergic medications should be strictly regulated in the geriatric patient, started at the lowest possible dose and discontinued if poorly tolerated (Buttaro et al., 2013; Wieder, 2010). Mirabegron (Myrbetriq®), a once-daily, beta3-adrenergic agonist, has shown effective and better-tolerated treatment of UUI in the older adult since it was made available in mid-2011 (DeMaagd & Davenport, 2012). While this drug shows minimal anticholinergic side effects, it must be used in caution in hypertensive patients, due to increases in blood pressure and heart rate. Mirabegron is not recommended for use in severe uncontrolled hypertensive patients (defined as systolic blood pressure 180 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater) (Astellas Pharma, 2012).
Overflow incontinence caused by BPH may be treated with alpha-blockers, which work to relax the bladder neck muscles and fibers in the prostate to ease urination. Tamsulosin (Flomax®) or silodosin (Rapaflo®) are often used alone or in combination with 5-alpha reductase in hibitors, finasteride (Proscar®) or dutasteride (Avodart®), as treatment for BPH and associated UI (Wieder, 2010). Jalyn® is a combination of dutasteride and tamsulosin and provides the convenience of one-pill dosing.
When behavioral and pharmacologic therapies are inadequate, discussion regarding more invasive or surgical options may be warranted. SUI is the most common type of UI treated surgically with a sling procedure that lifts and provides support to the bladder neck and urethra (Markland, Richter, Fwu, Eggers, & Kusek, 2011; Smith et al., 2013). Other options include urethral bulking agents and artificial urinary sphincters.
Options for UUI include botulinum toxin injections, neurosacral modulation and bladder augmentation (Nygaard, 2010; Wieder, 2010). Additionally, surgery may be indicated to relieve urethral obstruction caused by BPH, urethral stricture, or organ prolapse. Consultation with a urologist will help to determine the best course of action by considering individual anatomy, urodynamic studies, and patient preferences (Buttaro et al., 2013).
Urol Nurs. 2015;35(2):82-86. © 2015 Society of Urologic Nurses and Associates