#53: Urinary Incontinence: Tips and strategies to stay dry.

August 21, 2017 | By Molly Heublein

Get control of urinary incontinence with tips from Internist and Women’s Health Specialist, Dr. Molly Heublein, Assistant Clinical Professor of Medicine at UCSF. This is a must listen if you’re still uncomfortable managing urinary incontinence. We learn nonpharmacologic strategies like pelvic floor muscle therapy, bladder training, timed voiding, foods to avoid, and run through the available medical therapies, their efficacy and side effects. Plus, a brief review of next line therapies like percutaneous tibial nerve stimulation, and botox injections for overactive bladder.

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Case: 79 yo F with at least 10 years of urinary urgency with occasional loss of small amounts of urine and rare full bladder emptying. She drinks 1 cup of coffee every morning and about 2-3 glasses of water per day. She tries to minimize liquids due to her incontinence. She has HTN and takes HCTZ. Has been on oxybutynin for 10 years and wants to try something else.

Clinical Pearls:

1. Prevalence: Varies widely by source for women with stress urinary incontinence (SUI) ~50%, urge urinary incontinence ~17, and mixed UI 34%. About 3-11% of men, mostly urge incontinence (Rev Urol 2001).
2. Questionnaire, 3IQ: Helps classify UI with modest accuracy. During last 3 months have you leaked urine? In what situations did you leak urine? In what situation did you most often leak urine? (see article from AAFP)
3. Additional testing: Evaluate for vaginal atrophy, organ prolapse. Perform neurologic exam. Check a urinalysis. Screen for diabetes if no recent testing.
4. Pelvic floor muscle therapy (PFMT): AKA Kegel exercises. Contract muscles of pelvic floor, hold 10 sec, and repeat 10 reps three times daily. Expect 3 months to improvement. Indication = First line for stress, urge and mixed urinary incontinence (see handout from Stanford).
5. Bladder training: Expect 3 months to improvement. Keep bladder diary and gradually increase time between urge to void and micturition. Time between voids is slowly increased to goal of 2-3 hours. Indication = Adjuvant therapy for overactive bladder, urge, and mixed urinary incontinence (see handout from Stanford).
6. Lifestyle and behavior interventions: Recommend losing 5% body weight if obese. Alter fluid intake to avoid over or under hydration. Trial of diet modifications (see list of irritants below). Regularly scheduled voiding if elderly/limited mobility/cognitive impairment to avoid overly full bladder.
7. Bladder irritants*: Caffeine, alcohol, chocolate, foods that are spicy, or acidic. Very concentrated urine (usually dark yellow/brown). *Weak evidence to support claim
8. Medications associated with urinary incontinence: diuretics, sedatives, hypnotics, antidepressants, and muscle relaxants (source Dynamed Plus).
9. Anticholinergic drugs: Indication: overactive bladder/urge incontinence. Consider if no response to PFMT, bladder training, lifestyle/behavior interventions. Modestly decrease incontinence and improve quality of life. No specific agent is superior so choose by availability/cost. Side effects: dry mouth, tachycardia, confusion, urinary retention, confusion lead to high discontinuation rates.
10. Beta-3 adrenergic agonists: Indication: overactive bladder. Consider if anticholinergic drugs are contraindicated, or fail to improve symptoms. Modestly improve incontinence, and frequency of micturition.
11. Stress urinary incontinence: Leakage with coughing, sneezing, physical activity. Treat with PFMT. Avoid overly full bladder (scheduled voiding). Surgery is effective. Refer for consultation if no response to PFMT.
12. Overactive bladder (OAB) and urge incontinence: OAB can be “dry” meaning urgency without incontinence, or “wet” if leakage occurs. Treat with PFMT, bladder training, lifestyle and behavior interventions. Second line = anticholinergic agents. Third line = beta-3 agonist. Consider next line therapies like percutaneous tibial nerve stimulation, botox injections of the bladder if initial therapy fails.
13. Mixed urinary incontinence: Both stress and urge features present. Treat with combination of therapies for both types.

Goal: Listeners will learn to differentiate between types of urinary incontinence and to apply an evidence based approach to therapy.

Learning objectives:
After listening to this episode listeners will…

1. Classify urinary incontinence (UI) e.g. mixed UI, stress UI, urge UI/overactive bladder (OAB)
2. Identify the potential etiology of UI
3. Recall the 3 incontinence questions
4. Counsel patients on nonpharmacologic measures and lifestyle changes to treat UI
5. Differentiate between pelvic floor muscle therapy and bladder training
6. List the side effects of common drugs used for OAB
7. Counsel patients about risks and benefits of pharmacotherapy for UI
8. Know who and when to refer for “next line” therapies

Disclosures: Dr. Heublein reports no relevant financial disclosures.

Time Stamps
00:00 Intro
01:06 Listener feedback
02:43 Announcements
03:43 Picks of the week
09:07 Getting to know our guest
14:27 Case of urinary incontinence (UI)
15:30 Epidemiology of UI
16:34 Screening for UI
17:30 The 3IQ Questionnaire
18:44 Additional testing in UI
21:23 Classifying UI
24:00 Nonpharmacologic therapy for UI
32:42 Effectiveness of pharmacologic versus nonpharmacologic therapy
34:50 Case continued. Changing medications
37:42 Mirabegron as an alternative to anticholinergics
40:18 More options for stress UI management
41:40 Next line therapies for urge UI, overactive bladder
44:38 Surgery for stress urinary incontinence
45:50 Botox therapy for urge UI, overactive bladder
48:30 Do we need any more fancy diagnostic tests?
50:30 Take home points
55:05 Stuart schools us on urinary incontinence in men and timing of BPH meds
56:40 Outro

Links from the show:

1. The Bechdel Cast (podcast) by Jamie Loftus and Caitlin Durante
2. Pulgasari (1985) North Korean Giant Monster film with english subtitle on YouTube
3. The Life Changing Magic of Tidying Up (book) by Marie Kondo
4. Lifestyle strategies for bladder problems from Mayo Clinic
5. (3IQ: 3 Incontinence Questions) The Sensitivity and Specificity of a Simple Test To Distinguish between Urge and Stress Urinary Incontinence. Ann Int Med 2006
6. Nice article from AAFP discussing utility and limitations of 3IQ
7. Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians. Annals Int Med 2014
8. Handout- Bladder Training from Stanford
9. Handout- Exercising Your Pelvic Muscles from Stanford
10. Behavior Therapy to Enable Drug Discontinuation in the Treatment of Urge Incontinence: A Randomized Controlled Trial. Ann Intern Med 2008
11. Myers DL: Female mixed urinary incontinence: a clinical review. JAMA, 2014 May 21;311(19):2007-14;
12. Gormley, EA. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012
13. Results of a Randomized Phase III Trial of Mirabegron in Patients with Overactive Bladder. J Urol 2013
14. The Prevalence of Urinary Incontinence. Rev Urol 2001