The Role of Geriatricians and Family Practitioners in the Treatment of Overactive Bladder and Incontinence

Abstract

Although the prevalence of overactive bladder (OAB) and that of its symptoms (urinary urge incontinence, urgency, and frequency) increase with age, these conditions are not necessarily normal consequences of aging. Patients who present with urinary symptoms should be evaluated and treated, whether they are living on their own or in a residential, assisted-care, or long-term-care environment. Effective treatment for OAB and urinary incontinence (UI) is available and improves quality of life for the elderly. The primary care physician and geriatrician can accomplish a basic evaluation for UI using a systematic approach, as detailed in the following pages.

Urinary incontinence (UI), the involuntary loss of urine sufficient in amount or frequency to be a health or social problem, affects approximately 15 million adults in the United States and will increase as our population ages.¹ It is more prevalent than osteoporosis (10 million),² diabetes mellitus (7 million),³ and Alzheimer’s disease (4 million).⁴ Conservative estimates of UI prevalence among community-dwelling older adults are 38% for women and 19% for men.⁵ Numerous studies estimate 50% of all institutionalized elderly people in the United States suffer from UI, which often has precipitated the decision to institutionalize them. Overactive bladder (OAB), one of the leading causes of UI, is characterized by symptoms of urgency and/or frequency with or without urine leakage. UI and overactive bladder are not distinct disease entities but rather manifestations of an underlying anatomical or functional abnormality, medical problem, or drug-induced disorder.

UI has important economic, medical, and psychosocial implications. Direct costs associated with caring for people with UI total nearly 26 billion dollars annually,⁷ of which 14 billion dollars is directed toward caretaking, pads or briefs, and laundry use. Furthermore, UI and its complications add an estimated $5.2 billion⁸ to nursing facility costs. Medical complications may include urosepsis, perineal rashes, and urinary tract infections.⁹ In addition, urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinence episodes may increase the danger of falling, putting elderly people with osteoporosis at greater risk for bone fractures.¹⁰ Psychosocial complications include depression, isolation, and diminished self-esteem and quality of life. Unfortunately, despite its prevalence, the syndrome is widely underdiagnosed, with fewer than 50% of those affected receiving medical attention.¹¹ Reasons for older adults’ not seeking professional help include embarrassment, fear of surgery, and the perception that the problem is not severe or is a “natural consequence of aging.” In addition, many primary care providers have not received formal education to provide a comfortable understanding of UI and its basic management.

Primary Care Evaluation of Elderly Patients with Symptoms of OAB, with or without UI

All elderly patients (>70 years of age) should be questioned directly about urine loss and symptoms of frequency and urgency even if incontinence is not initially volunteered as a complaint. Questions such as “Do you ever lose urine when you don’t want to?” or “How often are you awakened at night with an urge to urinate?” can initiate a dialogue leading to more specific questions, such as whether coughing or sneezing causes urine loss or whether pads or adult briefs are used to prevent urine from wetting clothing.

History

Seek to identify reversible and persistent conditions to identify an acute (reversible, transient) or a persistent (continuous) problem. Reversible conditions can be remembered by using the acronym “DIAPPERS” (Table 1).¹²

Table 1.

Acute and Potentially Treatable Causes of Urinary Incontinence (DIAPPERS)

D	Delirium/confusion
I	Infection
A	Atrophic vaginitis or urethritis
P	Pharmaceutical agents
P	Psychological factors (eg, depression, dementia)
E	Excess urine output (eg, volume-expanded states, retention overflow)
R	Restricted mobility (eg, musculoskeletal disorders, environmental
	impedance)
S	Stool impaction

A detailed review of the medical and surgical history is necessary to identify preexisting conditions, such as diabetes, spinal cord injury, cerebral vascular accidents, heart failure, urethral sphincter damage, and cancers. Because many elderly patients are on multiple medications, a detailed review of both prescription and over-the-counter agents, caffeine, and alcohol is essential. Drug classifications and potential side effects contributing to UI are included in Table 2.

Table 2.

Drug Classifications and Side Effects Contributing to Urinary Incontinence (UI)

Drug Class	Side Effects
Alcohol	Polyuria, frequency, urgency, sedation,
	delirium
α-agonists, eg, nonprescription	Urinary retention
cold medicines
α-blockers	Urethral relaxation
ACE inhibitors, type I	Diuresis, cough with relaxation of pelvic
	floor
Anticholinergic agents	Urinary retention, overflow UI, stool
	impaction
Antidepressants	Anticholinergic action, sedation
Antiparkinsonism medicines	Urinary urgency; constipation
Antipsychotics	Anticholinergic actions, sedation, rigidity
β-agonists	Urinary retention
Caffeine	Aggravation or precipitation of UI
Calcium-channel blockers	Urinary retention
Diuretics	Polyuria, frequency, urgency
Sedatives/hypnotics	Sedation, delirium, immobility

ACE, angiotensin-converting enzyme.

If a pharmaceutical agent is suspected as the cause of UI, the drug should be discontinued if possible and another medication with a lower side-effect profile substituted. The determination of recent intermittent catheterization or the presence of an indwelling Foley catheter will guide the differential diagnosis toward infection, inflammation, or urinary retention. History of a recent change in functional status, nutrition balance, or fluid intake may be an indication of underlying infection and/or delirium. Complete the history by noting frequency, timing, and precipitants of urinary urgency with or without involuntary loss of urine suggestive of OAB.

Physical Examination

The physical examination begins with a functional assessment of the person’s mobility for getting to the toilet and dexterity in necessary removal of clothing. Determine whether cognition is sufficient to recognize the urge to urinate and whether mood promotes doing so. Relevant cardiovascular examination notations are abnormal rhythm and murmur; varicosities or edema should also be noted. Volume overload states and changes in mental status are critical decision indices in the differential diagnosis. The lungs are examined for abnormal respiratory effort and auscultated for adventitious sounds. Bladder distention, pelvic masses, or tenderness in the suprapubic region suggests overflow incontinence from obstruction. In females, the pelvic examination may identify dry or atrophic labia/vaginal mucosa, prolapses, or vaginal stenosis. Hypoestrogenism is considered a differential factor for atrophic vaginitis or urethritis as well as recurrent cystitis, stress incontinence, and detrusor instability. In males, the glans penis is examined for circumcision or free movability of the foreskin. The scrotum is examined for symmetry of the testicles and for tenderness or enlargement. The prostate is examined for the presence of symmetry or nodularities and for size. Last, the examination of the rectum can ascertain anal tone and identify hemorrhoids or the presence of hard or impacted stool.

The identification of incomplete bladder emptying is an integral part of the physical examination. An astute clinician can palpate the bladder for fullness after emptying, but a more accurate assessment is performed using portable noninvasive ultrasonography or post-void catheterization. The general consensus is that a postvoid residual volume greater than 100 mL or more than 20% of the amount voided is abnormal and may indicate overflow incontinence. Completion of the physical examination allows identification of reversible conditions that can cause or contribute to UI (Table 3).

Table 3.

Conditions Causing Reversible Urinary Incontinence and Their Management

Condition	Management
Impaired ability or willingness
to reach a toilet
Delirium	Diagnosis and treatment of underlying
	cause(s) of acute confusional state
Chronic illness, injury, or restraint	Regular toileting, use of toilet substitutes,
that interferes with mobility	environmental alterations (eg, bedside commode,
	urinal)
Psychological condition	Removal of restraints if feasible; appropriate
	pharmacologic and/or nonpharmacologic
	treatment
Drug side effects (see Table 2)	With all medications, discontinuation or
	change of therapy, as clinically feasible;
	dosage reduction or modification (eg, flexible
	scheduling of rapid-acting diuretics)
Increased urine production
Metabolic disorder
Hyperglycemia	Better control of diabetes mellitus
Hypercalcemia	Therapy depending on underlying cause
Excess fluid intake	Reduction of intake of diuretic fluids
	(eg, caffeinated beverages)
Volume overload
Venous insufficiency with edema	Support stockings, leg elevation, sodium
	restriction, diuretic therapy
Congestive heart failure	Medical therapy
Conditions affecting the lower
urinary tract
Urinary tract infection (with	Antimicrobial therapy
symptoms of frequency, urgency,
dysuria, etc)
Atrophic vaginitis/urethritis	Assess risk / benefit of oral / topical estrogen
Stool impaction	Disimpaction; appropriate use of stool
	softeners, bulk-forming agents, and laxatives
	if necessary

Data from Fantl et al.¹

Developing an Algorithm for Care

A careful history and physical examination allows the primary care physician the opportunity to develop a mental algorithm to guide diagnosis and treatment for the different types of UI. The classifications of UI—urge, stress, overflow, and functional—and their treatment options are detailed elsewhere in this supplement. The algorithm shown as Figure 1 is of use for the primary care physician.

Figure 1.

Algorithm for primary care management of overactive bladder (OAB) with or without incontinence. UI, urinary incontinence; D/C, discontinue; Dx, diagnosis; ADR, adverse drug reaction; BPH, benign prostatic hyperplasia. Adapted from the Omni Care Geriatric Urinary Low Management Program Manual, May 2001.

Following the basic evaluation, all incontinent patients in whom transient (reversible) causes of UI have been detected should be managed appropriately. If UI persists after the transient causes are identified and managed, further evaluation may be helpful before therapy is initiated. Patients requiring further evaluation include those who meet any of the following criteria:

• Uncertain diagnosis and inability to develop a reasonable management plan based on the basic diagnostic evaluation

• Uncertainty in diagnosis due to lack of correlation between symptomatology and clinical findings

• Failure to respond to an adequate therapeutic trial, making the patient a candidate for further therapy

• Hematuria without infection

• Presence of other comorbid conditions, such as incontinence associated with recurrent symptomatic UTIs, severe symptoms of difficult bladder emptying, severe and symptomatic pelvic prolapse, prostate nodule, abnormal postvoid residual urine, or neurological conditions, except for patients for whom further investigation is not feasible.¹

Special Considerations in Managing UI in Long-Term Care

With the “graying of America,” an increasing number of primary care physicians will elect to manage their patients even as they move into nursing-home or assisted-living settings. Untreated UI is not uncommonly the reason elderly patients move along the continuum from home to more restrictive and costlier levels of care. Federal regulations now make at least a basic understanding of UI required for the family practitioner and geriatrician. The Omnibus Budget Reconciliation Act (OBRA), developed in 1987, set forth standards in long-term care stating that facilities “must maximize physical, psychological, and social functioning.”¹³ State surveyors of nursing home facilities have “F Tags” (federal regulatory guidelines) naming the criteria by which to evaluate a facility’s performance in the management of UI. This includes Tag F316, which states, “A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection and to restore as much normal bladder function as possible”.¹⁴ In addition, among a set of 24 quality indicators set forth in the 1999 State Operations Manual of the Health Care Financing Administration, three are directly related to UI: 1) prevalence of bowel or bladder incontinence; 2) prevalence of occasional or frequent urinary or bowel incontinence without a toileting plan; and 3) prevalence of indwelling catheter use.¹⁵ Comparisons of these indicators are then made among nursing home facilities in the state and made available for public review.

Another mandate from OBRA 1987 instituted in 1991 for nursing homes was the standardized Resident Assessment Instrument, a tool consisting of the Minimum Data Set (MDS), resident assessment protocols (RAPs), and “triggered” plans of care. The nursing facility staff, through completion of the MDS, collects data for formation of resident care plans as well as for reporting on quality indicators. There is a specific section (RAP key) relating to UI:

• Incontinent two or more times per week

• Use of external catheter

• Use of indwelling catheter

• Intermittent use of catheter

• Use of pads/briefs

The residents’ attending physician as well as the facility’s medical director is now held accountable for taking an active team role in the evaluation and management of UI in the long-term care setting.

Conclusion

UI can no longer remain the “hidden giant” of medical care. Sadly, the majority of incontinent patients remain untreated, despite the fact that continence can often be significantly improved in the hands of their primary care physicians. Family practitioners and geriatricians who take a stepwise approach to the basic evaluation and management of UI/OAB can significantly improve the quality of life of their patients.

Main Points.

• Approximately 15 million adults in the United States have urinary incontinence (UI); it often precipitates the decision to institutionalize elderly people.

• Although UI is not a direct result of aging, factors more common in older adults (eg, diabetes, heart failure, use of multiple medications) can predispose them to it.

• Possible complications of UI include urosepsis, perineal rashes, and urinary tract infections, but the syndrome is widely underdiagnosed.

• The diagnostic process begins with direct questions about urine loss, frequency, and urgency and goes on to distinguish acute from persistent UI.

• A stepwise approach to basic evaluation and management can determine which of the many possible causes of UI is present so that treatment can be tailored appropriately.