URINARY INCONTINENCE
For Practicing Physicians
TAKE HOME MESSAGES
1. Determine whether the incontinence is transient or persistent.
2. Identify treatable causes, such as infections, delirium, drugs, fecal impaction, and fluid overload.
3. Mixtures of types of persistent incontinence are frequent in the elderly; treatment is best addressed initially with consideration of degree of “nuisance”.
4. Stress and urge incontinence should be approached first with behavioral interventions.
5. It is essential to perform a post void residual to determine retention, as overflow can be confused clinically with urge. Management is totally different in these two types of incontinence.
6. “Overactive bladder syndrome” can occur with and without losses of urine; both forms are treated the same as urge incontinence.
7. Questions of incontinence should be included in review of systems as patients may not report these problems spontaneously.
8. Depression and self-isolation may result from incontinence.
9. Newly occurring incontinence may be a manifestation of other conditions, not necessarily of the GU tract.
10. Physiologic aging changes are in part responsible for the increased prevalence of incontinence in the elderly.
11. Referral of patients with incontinence to specialists should be done selectively, depending on the degree of difficulty of the problem and the level of need of the patient.
12. Continence products are variable in size, capacity, fit and difficulty of use; hence, selection of most suitable products is best done by trial.
TYPES OF URINARY INCONTINENCE
CAUSED OR AGGRAVATED BY MEDICATIONS
Type of Drug Examples Effects
STRESS INCONTINENCEAlpha blockers / doxazosin, prazosin tamsulosin, terazosin / Relax the urinary sphincter and urethra; can cause incontinence when coughing, straining, sneezing, lifting heavy objects, or putting any other pressure on the abdomen (stress incontinence)
Angiotensin-converting inhibitors (ACE-I) / benazepril, captopril, enalapril, lisinopril / Can cause cough and worsen stress incontinence enzyme
OVERFLOW INCONTINENCE
Alpha-adrenergic agonists / nasal decongestants: pseudoephedrine / Tighten the urinary sphincter; can cause containing urine to be retained in the bladder and uncontrollable leakage of small amounts of urine (overflow incontinence)
Antidepressants / amitriptyline doxepin / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
Other highly anticholinergic agents / Amantidine benztropine chlorpheniramine dicyclomine diphenhydramine hydroxyzine phenothiazines promethazine propantheline thioridazine / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence.
Calcium channel blockers (non-dihydropyridines) / diltiazem, verapamil / Interfere with bladder contraction and worsen constipation due to reduced smooth muscle contractility; can cause urine to be retained in the bladder and overflow incontinence
Opioids / morphine, codeine, oxycodone, oxycontin / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
MIXED URGE & FUNCTIONAL INCONTINENCE
Antipsychotics / haloperidol risperidone olanzapine / Can slow mobility (functional incontinence) and cause abrupt urge to urinate followed by uncontrollable loss of urine (urge incontinence)
Sedating Agents / diazepam, flurazepam carisoprodol , chlorzoxazone, metaxalone, cyclobenzaprine orphenadrine / May cause confusion and alter the person’s ability to respond to (functional incontinence) and/or recognize the urge to void.(urge incontinence)
OTHER
Alcohol / beer, wine, liquor / Increases urination by increasing urine production, may also affect a persons awareness of the need to void.
Caffeine / coffee, cola, tea , some nonprescription headache meds / Increases urination by increasing urine production
Diuretics / furosemide, thiazides / Increase urination by increasing urine production. This is particularly relevant in older persons and/or in those with already impaired incontinence.
MEDICATIONS THAT MAY CAUSE OR WORSEN
URINARY INCONTINENCE
Type of Drug Examples Effects
Alcohol / Beer, wine, liquor / Increases urination by increasing urine productionAlpha agonists / Pseudoephedrine, nasal decongestants / Tighten the urinary sphincter; can cause containing urine to be retained in the bladder and uncontrollable leakage of small amounts of urine (overflow incontinence)
Alpha blockers / Doxazosin, prazosin, tamsulosin, terazosin / Relax the urinary sphincter and urethra;
can cause incontinence when coughing, straining, sneezing, lifting heavy objects, or putting any other pressure on the abdomen (stress incontinence)
Angiotensin converting inhibitors (ACE-I) / Benazepril, captopril / Can cause cough and worsen stress incontinence enzyme
Anticholinergics / Benztropine, dicyclomine, loperamide / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
Antidepressants / Amitriptyline, desipramine, nortriptyline / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
Antihistamines / Chlorpheniramine, diphenhydramine / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
Antipsychotics / Haloperidol, risperidone, thioridazine, thiothixene / Can slow mobility and cause abrupt urge to urinate followed by uncontrollable loss of urine (urge incontinence)
Caffeine / Coffee, cola, tea , some nonRx headache remedies / Increases urination by increasing urine production
Calcium channel blockers / Diltiazem, verapamil / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
Diuretics / Furosemide, thiazides / Increase urination by increasing urine production
Opioids / Morphine / Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
Sedatives / Diazepam, flurazepam, lorazepam / Can slow mobility and worsen urge incontinence
VISIT FORM: URINARY INCONTINENCE
Reason for Visit: Bothersome problem with urinary incontinence
History of Present Illness:
YES NO
1. Results of dip UA: 4. Problem using/getting to the toilet……….
Blood: Neg Tr + ++ +++ If yes, explain:______
Leukocyte esterase: Neg Tr + ++ +++ ______
Nitrite: Neg Pos YES NO
5. Prior prostate surgery (if male)……………
2. Duration of symptoms: ______weeks/months/years
6. Prior treatment:
3. Characteristics of voiding: YES NO Timed toileting………………..……………
Sudden urge to void (urge)……………... Medications, specify: ______
Loss with cough/laugh/bend (stress)….. Pelvic/Kegel's exercises (if female)……….
Continuous leakage……………………... Pessary (if female)…………………………
Other, specify: ______Other, specify: ______
Examination: Female Male
1. Genital/ YES NO YES NO
Pelvic: Uterine prolapse………… 1. Prostate: Enlargement…….…….…
Cystocele………………… Mass……………………..
Urine loss with cough……
2. Rectal: Fecal impaction…………. 2. Rectal: Fecal impaction………….
Decreased rectal tone….. Decreased rectal tone…..
Diagnosis/Treatment Plan:
Lab/Tests: Impression: UI, type: Stress Urge Functional Overflow Mixed
Send urine for C&S UI, prostate-related
Bladder US with PVR (Normal <100 ml) Urinary tract infection
Other:______Other: ______
Treatment:
Patient education handout:
“Pelvic exercises”
“Bladder retraining”
Other behavioral treatment: ______
Medication for UI: ______
If behavioral treatment unsuccessful:
For urge/mixed and if PVR <100 ml: For stress:
oxybutynin 2.5-5mg BID-TID, or pseudoephedrine 15-30 mg TID
oxybutynin XL 5-20 mg qd, or
tolterodine 2 mg BID
Medication for UTI: ______x 7-10 days
Gynecology consult
Urology consult
Other:______
Provider’s Signature______Date of Visit______