Incontinence, Urinary: Nonsurgical Therapies

INTRODUCTION

¡@

Background: Urinary incontinence is defined by the International Continence Society as the involuntary loss of urine that represents a hygienic or social problem to the individual. This author defines urinary incontinence as any involuntary loss of urine. Different types of incontinence exist. They include stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, and functional incontinence. Treatment of urinary incontinence must carefully be tailored to the specific cause of incontinence.

Stress incontinence may be treated with surgery, pelvic floor physiotherapy, and anti-incontinent devices. Urge incontinence may be treated with changes in diet, behavioral modification, pelvic-floor exercises, and/or anticholinergic medications. Mixed incontinence often requires anticholinergics, in addition to surgery. Overflow incontinence is treated with some type of catheter regimen. Functional incontinence is self-limited when the underlying cause is identified and treated in an appropriate fashion.

As a general rule, the first choice for treatment is the least invasive, with the least potential complications for the patient. Examples of noninvasive treatments include medications or exercises; however, the least invasive treatment may not afford the best outcome in certain situations. In specific situations, surgery may be the most effective form of managing urinary incontinence.

¡@

Stress incontinence is urinary incontinence that occurs coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction. In stress incontinence, the bladder outlet has poor resistance to urinary flow. The most common cause of stress incontinence is urethral hypermobility secondary to poor anatomic pelvic support. A less common cause of stress incontinence is an inherent defect in the urethra known as intrinsic sphincter deficiency.

Urge incontinence is involuntary urine loss that occurs due to detrusor overactivity. Urge incontinence may be a result of detrusor myopathy, neuropathy, or a combination of both. When the identifiable cause is unknown, it is termed idiopathic urge incontinence. Symptoms of overactive bladder or urge incontinence in the absence of neurologic causes are known as detrusor instability.

Mixed incontinence is urinary incontinence resulting from a combination of stress and urge incontinence. In mixed incontinence, the bladder outlet is weak and the detrusor is overactive. A classic example of mixed incontinence is a patient with meningomyelocele and an incompetent bladder neck with a hyper-reflexic detrusor; however, a combination of urethral hypermobility and detrusor instability is a more common scenario.

Reflex incontinence occurs as a result of neurologic impairment of the central nervous system. Common neurologic disorders associated with reflex incontinence include cerebrovascular accident (CVA or stroke), Parkinson disease, and brain tumors. Reflex incontinence also occurs in patients with spinal cord injuries and multiple sclerosis. When patients with suprapontine or suprasacral spinal cord lesions manifest symptoms of urge incontinence, this is known as detrusor hyperreflexia.

Overflow incontinence occurs because of overdistention of the detrusor muscle. Overflow incontinence may occur as a result of bladder outlet obstruction, detrusor atony, or neurologic impairment of the urinary bladder. Common causes of bladder outlet obstruction in men include benign prostatic hyperplasia, vesical neck contracture, and urethral strictures. In women, urethral obstruction after anti-incontinence surgery such as pubovaginal sling or bladder neck suspension can result in iatrogenically induced overflow incontinence. Some common neurologic causes of overflow incontinence include herniated lumbar disc, diabetic cystopathy, and peripheral neuropathy. Less common causes of overflow incontinence include AIDS, genital herpes affecting the perineal area, and neurosyphilis. A decompensated detrusor resulting from a neurologic disorder is known as an areflexic detrusor.

Frequency:
¡@

• In the US: Urinary incontinence affects approximately 13 million people in the US, predominantly women. This includes 10-35% of adults and 50% of the 1.5 million residents in the nursing homes. Up to 60% of nursing home patients are incontinent, while 30% of elderly living at home are incontinent.

  Urinary incontinence is an under-diagnosed and under-reported medical problem. An estimated 50-70% of women with urinary incontinence fail to seek medical evaluation and treatment because of social stigma. Only 5% of incontinent individuals in the community and 2% in nursing homes receive appropriate medical evaluation and treatment. Incontinent patients often put up with this condition for 6-9 years before seeking medical therapy.

  Stress incontinence affects 15-60% of women. Stress incontinence is a disorder of the young and the old. Over one fourth of nulliparous young college athletes experience stress incontinence when participating in sports.

Mortality/Morbidity: Chronic urinary incontinence is a major problem in the older population, particularly in patients in nursing homes. Chronic urinary incontinence is a health hazard that affects 10-35% of adults and 50% of the 1.5 million residents in nursing homes.

Urinary incontinence-related morbidities include prolonged hospital admission (35%), urinary tract infections (2%), contact dermatitis (1.6%), and falls (1%). Costs incurred for treating incontinence-related complications approach $2.8 billion compared to $35 million for diagnostic and treatment costs.

• Urinary incontinence is a leading cause of admission to a nursing home when families find it too difficult to care for an incontinent relative. Of nursing home patients, 60% have been reported to be incontinent, while as many as 30% of the older population living at home are incontinent. Afflicted individuals may experience the sudden involuntary loss of urine several times a day.

• Prolonged contact of urine on the unprotected skin causes contact dermatitis and skin breakdown. If left untreated, these skin disorders may lead to pressure sores and ulcers, possibly resulting in secondary infections. For individuals with a decompensated bladder that does not empty well, the elevated postvoid residual urine can lead to overgrowth of bacteria and subsequent urinary tract infection.

• The treatment of urinary incontinence with the use of catheters also poses potential problems. It is well known that indwelling catheters left in the bladder for more than 2 weeks become colonized with bacteria. While asymptomatic bacterial colonization does not cause health hazard, unrecognized bacterial colonization can produce symptomatic bladder infections manifested by symptoms such as purulent urine, fever, bladder spasms, and hematuria.
  
  Thus, chronic indwelling catheters may cause recurrent bladder infections, bladder stones, ascending pyelonephritis, and urethral erosions. The use of intermittent catheterization may result in bladder infections or urethral injury. Chronic suprapubic tubes may cause bladder spasms, bladder stone formation, and bladder infections. Urinary incontinence will continue to be a significant health care problem if left ignored.
  
  Treatment of bladder infections in catheterized patients involves a combination of catheter changes, irrigation with a bacteriostatic/bacteriocidal agents or use of an antibiotic. To minimize symptomatic bladder infections, chronic indwelling catheters should be changed every 3-4 weeks or when drainage is obstructed due to debris or encrustations. Chronic prophylactic antibiotic use is discouraged because of the risk of preferentially selecting resistant organisms.
  
  Catheter-associated urinary tract infection is the most common nosocomial infection. Type of urinary catheter used may impact on the incidence of catheter-related urinary tract infections. Literature suggests the risk with short-term catheterization is 5% per day. However, new urinary catheters impregnated with medications (eg, nitrofurazone or minocycline and rifampin) or coated with a silver alloy-hydrogel significantly reduce the risk of catheter-related UTI for catheterizations not exceeding 2-3 weeks.
  
  Among trials of silver-coated urinary catheters, silver alloy catheters appear to be significantly more effective than silver oxide catheters in preventing UTIs. Although silver alloy catheters cost about $6 more than conventional urinary catheters, they may be worth the extra cost to prevent symptomatic UTIs and urosepsis. This type of catheter may be especially apropos in immunocompromised patients at high risk for infection.

Race: Although the information regarding urinary incontinence in different races is sparse, data are emerging that race may play an important role in the prevalence and likelihood of reporting of incontinence. There also may be effects on prevalence of incontinence due to differences in the anatomic morphology of the urinary sphincter mechanism for different races.

• Older African American women report a lower prevalence of urinary incontinence compared to Caucasian women. Fultz et al reported that 23.02% of the Caucasian women reported incontinence, compared with 16.17% of the African American women.

• Freeman et al reported that African American women were significantly more likely to report that they experienced menopausal symptoms (46% vs. 30%; p < 0.001), urinary incontinence, and vaginal dryness.

• Howard et al reported that functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous African American and white women. African American women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction. Paradoxically, there was a 36% greater bladder neck hypermobility measured with the cotton-swab test (African Americans at 49?vs. whites at 36? P =0.02).

CLINICAL

¡@

History: One popular way to classify urinary incontinence is to define it according to symptom presentation. Although symptom classification is helpful in describing bladder and urethra function, the symptoms of urinary incontinence are not always clear markers for a proper diagnosis. Furthermore, the symptom complex alone does not allow accurate localization of the problem site, such as the bladder, urethra, or both.

Classification of urinary incontinence into types allows the clinician to make an educated guess at a particular anatomic abnormality that warrants further investigation. The 5 major types of urinary incontinence are as follows:

• Stress incontinence: In stress incontinence, a variable amount of urine escapes suddenly with an increase in intraabdominal pressure. The amount of urine lost is not very much, unless the condition is really severe.

• This type of urinary loss is very predictable.

• Irritative voiding symptoms and nocturia typically are absent.

• Urge incontinence: Urge incontinence or symptoms of an overactive bladder are uncontrolled urine loss associated with a strong desire to void, which often is a very sudden and rapid event that occurs without any warning. Urge incontinence is a type of uncontrolled urine loss that cannot be prevented. In this situation, the entire contents of the bladder are lost rather than a few drops of urine.

• Patients with symptoms of an overactive bladder are aware of the intense need to void but are unable to hold back urine. Patients have symptoms of urinary frequency, urgency, nocturia, and urge incontinence.

• Some examples of situations that precipitate urge incontinence include turning a key in the door, washing dishes, or hearing running water. Urge incontinence also may be triggered by drinking too much water or drinking coffee, tea, or alcohol.

• Mixed incontinence: In this type of incontinence, the symptoms of stress incontinence and urge incontinence coexist. With mixed incontinence, the problem is that the bladder is overactive, and the urethra is underactive.

• Affected patients experience mild-to-moderate urine loss with physical activities (stress incontinence). At other times, they will experience acute urine loss without any antecedent warning (urge incontinence). Urinary frequency, urgency, and nocturia complement urge incontinence symptom complex.

• The majority of the time, patients will not be able to distinguish these 2 different symptom complexes. The symptoms of urge incontinence may unwittingly be confused with the symptoms of stress incontinence, and vice versa. In this situation, the symptom complex that is most unbearable is treated first.

• Reflex incontinence: Urinary symptoms of reflex incontinence are the same as those of urge incontinence, but the symptoms of reflex incontinence are particular to women with neurologic disorders.

• Symptoms of urinary frequency, urgency, and nocturia are a rule rather than an exception.

• Common neurologic disorders associated with reflex incontinence include stroke, Parkinson disease, and brain tumor. Reflex incontinence also occurs in patients with spinal cord injuries and multiple sclerosis.

• In this situation, the bladder reflexively empties urine as it fills. Of all the types of urinary incontinence, reflex incontinence probably is the most difficult to treat; however, this condition may be treated with medications, catheters, or augmentation cystoplasty.

• Overflow incontinence: As the term implies, the urine “overflows from the bladder. Overflow incontinence is a condition that results when the bladder is overdistended and has reached its limit of compliance. At this point, the intravesical pressure is greater than the resting urethral closure pressure. Because the intravesical pressure exceeds the resting urethral closure pressure (when the bladder is overdistended), urinary incontinence occurs in spite of the fact there is no detrusor contraction.

  Overflow incontinence may occur in the setting of infravesical bladder outlet obstruction or nonfunctioning detrusor. Causes of bladder outlet obstruction include BPH, urethral stricture, posterior urethral valve, or urethral obstruction after a pubovaginal sling. Causes of nonfunctioning detrusor include detrusor areflexia (sensory or motor paralytic bladder due to underlying neurologic disease) or atonic bladder that has lost its muscular tone (chronic overdistension resulting in decompensated detrusor) in the absence of neurologic cause. Patients complain of a sense of incomplete emptying, slow-flowing urine, and urinary dribbling.

• Symptoms of overflow incontinence may mimic those of mixed incontinence. Patients will lose a small amount of urine when intra-abdominal pressure is increased. Patients who are affected often experience symptoms of frequency and urgency as the detrusor attempts to expel urine.

• Unfortunately, no medications effectively treat this condition. The only way to treat overflow incontinence is with a catheter. This is true whether the bladder has become decompensated as a result of a neurologic insult (areflexic detrusor) or from a mechanical source (atonic detrusor).

• Some patients respond well to temporary continuous Foley catheter drainage. Their bladder capacity returns to normal and voluntary detrusor pressure improves. Return of spontaneous voiding is more likely for patients without neurologic injury. This usually takes at least 1 week of catheter drainage depending on the degree of bladder muscle injury. If it has not resolved after 4 weeks, then the bladder is unlikely to recover on catheter drainage alone. If the underlying cause of the overflow problem can be treated or eliminated, these patients may be able to return to normal voiding. If this is unsuccessful, the intermittent catheterization usually is preferred for long-term therapy if logistically possible. Otherwise, a permanent catheter may need to be considered.

DIFFERENTIALS

¡@

Other Problems to be Considered:

WORKUP

¡@

Lab Studies:
¡@

• Urinalysis and urine culture: Cystitis can produce irritative voiding symptoms and urge incontinence.

• Urine cytology: Patients with carcinoma in situ of the urinary bladder have symptoms of urinary frequency and urgency.

• Chemistry 7 profile: These tests are helpful for patients in whom poor renal function, obstructed ureters, or urinary retention is suggested.

Imaging Studies:
¡@

• Cystogram: A lateral cystogram helps to confirm the presence of stress incontinence, the degree of urethral motion, and the presence of cystocele. These radiographs also may demonstrate intrinsic sphincter deficiency by showing a wide-open urethra on the resting films. Presence of a vesicovaginal fistula also may be documented in this fashion.

• Magnetic resonance imaging (MRI): MRI provides excellent anatomic detail particularly in women with pelvic organ prolapse. MRI may be useful in certain situations requiring complex surgical reconstruction. However, the cost-effectiveness of routine MRI remains controversial.

Other Tests:
¡@

• Voiding diary: A voiding diary is a daily record of the patient's bladder activity and is a useful supplement to the medical history of the patient.

• Pad test: A pad test is a useful adjunct to the patient’s history and physical examination. The pad test is an objective test that determines whether the fluid loss the patient is experiencing is in fact urine. Intravesical methylene blue, oral Pyridium, or Urised may be used as a coloring agent. If the peri-pad changes color, the fluid lost is urine. The pad test may be performed during a 1-hour period or a 24-hour period. The pads may be weighed (1 g = 1 mL) to assess the severity of urine loss.

• Q-tip test: This test is performed by inserting a sterile lubricated cotton swab (Q-tip) into the female urethra. The cotton swab is gently passed into the bladder and then slowly pulled back until the neck of the cotton swab snugs up against the bladder neck. The patient is then instructed to perform a Valsalva maneuver or contract their abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is an important finding for type II stress incontinence. Q-tip excursion angle greater than 35?indicate urethral hypermobility.

• Cough stress test: A critical part of the pelvic examination is direct observation of urine using the cough stress test or Marshall test. Cough stress test is performed by filling the bladder with sterile fluid at least halfway (eg, 250 mL) and instructing the patient to bear down (Valsalva) or cough. Observation of leakage during Valsalva maneuver or cough denotes a positive test.

  Marshall test, otherwise known as Marshall-Bonney test, is performed by placing an index finger and the second finger on either side of the bladder neck. With the bladder relatively full, the patient is instructed to perform Valsalva or cough. Two fingers at the bladder neck serve to support the proximal urethra during Valsalva maneuver. Absence of leakage with bladder neck elevation and presence of leakage with loss of bladder neck support confirms SUI due to urethral hypermobility. However, Marshall test is neither sensitive nor specific enough to diagnose SUI by today's standards. Thus, Marshall test is not widely practiced today.

• Standing pelvic examination: A standing pelvic examination is performed if a pelvic examination fails to demonstrate urine loss or if a pelvic organ prolapse is suspected. If the pelvic prolapse is present, push the prolapsed organ up with a pessary or gauze, and repeat the cough stress test in the standing position.

Procedures:
¡@

• Postvoid residual: The measurement of postvoid residual volume (PVR) is a part of the basic evaluation for urinary incontinence. If the PVR is high, the bladder may be acontractile or the outlet may be obstructed. To determine the postvoid residual urine, either a bladder ultrasound or urethral catheter may be used.

• Uroflow: A useful screening test, uroflow is used mainly to evaluate bladder outlet obstruction. Consistently low flow rates generally indicate a bladder outlet obstruction but may also indicate decreased detrusor contractility. To properly diagnose bladder outlet obstruction, perform pressure-flow studies.

• Filling cystometrogram: A filling cystometrogram (CMG) assesses bladder capacity, bladder compliance, and the presence of phasic contractions. This test may be performed using either gas or liquid to fill the bladder, with different interpretive criteria applying to each. Usually, the patient will feel the first sensation as the bladder begins to fill with 100-200 mL of water. As the bladder begins to get full, 300-400 mL, the patient may begin to feel uncomfortable. True urge to void occurs when the bladder has been filled to capacity. An average adult bladder holds approximately 450-500 mL of urine.

• Abdominal leak point pressure: An important component of multichannel videourodynamics is the determination of the abdominal leak point pressures (ALPP). Abdominal leak point pressures allow women with stress urinary incontinence (SUI) to be classified into urethral hypermobility, intrinsic sphincter deficiency (ISD), or both in combination. An ALPP less than 90 cm H2O is indicative of ISD whereas ALPP greater than 90 cm H2O is reflective of urethral hypermobility.

• Abdominal leak point pressure (also known as Valsalva leak point pressure) is performed by instilling 250 mL of fluid medium into the urinary bladder. The patient is instructed to bear down (Valsalva) in gradients (mild, moderate, severe) to demonstrate leakage. Lowest abdominal pressure (Pabd) required to generate leakage is recorded as abdominal leak point pressure.

• Cough leak point pressure (CLPP) is performed by instilling 250 mL of fluid medium into the urinary bladder. The patient is instructed to cough in gradients (mild, moderate, severe) to demonstrate leakage. Lowest abdominal pressure (Pabd) required to generate leakage is recorded as cough leak point pressure.

• Valsalva leak point pressure (compared to CLPP) appears to be more sensitive in diagnosing ISD since coughing and Valsalva seem to result in a different reaction of the pelvic floor. In addition, progressive bladder filling in 50 mL increments (eg, 250 mL, 300 mL, 350 mL) also appears to increase the sensitivity of leak point pressure testing. Leak point pressures may be performed with or without video (fluoroscopic) capabilities.

• Voiding cystometrogram (pressure-flow study): A pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow. Voiding cystometrogram is the only test able to provide information about bladder contractility and the extent of a bladder outlet obstruction.

• Electromyography: Electromyography (EMG) enables documentation of and distinguishes coordinated voiding (detrusor sphincter synergia) from uncoordinated voiding (detrusor sphincter dyssynergia).

• Cystoscopy: Cystoscopy allows an anatomical assessment of the bladder and the urethra. Bladder lesions, such as stitch in the bladder, tumor, stone, and carcinoma in situ, are identified, which otherwise would remain undiagnosed by urodynamics alone. Cystoscopy also is indicated for patients complaining of persistent irritative voiding symptoms or hematuria. Urethroscopy also can be performed to assess the structure and function of the urethral sphincter mechanism.

TREATMENT

¡@

Medical Care: Stress incontinence may be treated with surgical and nonsurgical means. Urge incontinence may be treated with behavioral modification or with bladder-relaxing agents.

Mixed incontinence may require medications as well as surgery. Overflow incontinence may be treated with some type of catheter regimen. Functional incontinence may be resolved by treating the underlying cause, such as urinary tract infection, constipation, or by simply changing a few drugs.

Do not consider anti-incontinence products to be a cure-all for urinary incontinence; however, judicious use of pads and devices to contain urine loss and maintain skin integrity are extremely useful in selected cases. Absorbent pads and internal and external collecting devices have an important role in the management of chronic incontinence.

The criteria for use of these products are fairly clear-cut, and they are beneficial for women who meet the following conditions: (1) women who fail all other treatments and remain incontinent, (2) women who are too ill or disabled to participate in behavioral programs, (3) women who cannot be helped by medications, (4) women with incontinence disorders that cannot be corrected by surgery, and (5) women who are awaiting surgery.

• Absorbent products: Absorbent products are pads or garments designed to absorb urine to protect the skin and clothing. Available in both disposable and reusable forms, they are a temporary means of keeping the patient dry until a more permanent solution becomes available. By reducing wetness and odor, they help to keep the patient comfortable and allow her to function in normal activities. They may be used temporarily until a definitive treatment has a chance to work or if the treatment yields less than perfect results. Absorbent products are helpful during the initial assessment and workup of urinary incontinence. As an adjunct to behavioral and pharmacologic therapies, they play an important role in the care of persons with intractable incontinence.

  ¡@

  • Do not use absorbent products in place of definitive interventions to decrease or eliminate urinary incontinence. Early dependency on absorbent pads may be a deterrent to achieving continence, giving the wearer a false sense of security. Chronic use of absorbent products may lead to inevitable acceptance of the incontinence condition, which removes the motivation to seek evaluation and treatment. In addition, improper use of absorbent products may contribute to skin breakdown and urinary tract infections. Thus, appropriate use, meticulous care, and frequent pad or garment changes are needed when absorbent products are used.

    ¡@

  • Absorbent products used include underpads, pant liners (shields and guards), adult diapers (briefs), a variety of washable pants and disposable pad systems, or combinations of these products. More than 50% of the members of the National Association For Continence (NAFC), a national support group for incontinent patients (1-800-252-3337), use some form of protective garment to remain dry. In addition, 47% of all elderly men and women use some type of absorbent products. In nursing homes, disposable diapers or reusable pad and pant systems are used.

    ¡@

  • Unlike sanitary napkins, these absorbent products are specially designed to trap urine, minimize odor, and keep the patient dry. Different types of products with varying degrees of absorbency exist. These products may absorb 20-300 mL, depending on the brand and the absorbent material of the product. Absorbent pads and garments that are available include panty shields, pant guards, undergarments, combination pad-pant systems, adult diaper garments, and special bed pads.

    ¡@

  • For occasional minimal urine loss, panty shields (small absorbent inserts) may be used. For light incontinence, guards (close-fitting pads) may be more appropriate. Absorbent guards are attached to the underwear and can be worn under normal clothing. Adult undergarments (full-length pads) are bulkier and more absorbent than guards. They may be held in place by waist straps or snug underwear. Adult briefs are the bulkiest type of protection, offer the highest level of absorbency, and are secured in place with self-adhesive tape. Absorbent bed pads also are available to protect the bed sheets and mattresses at night. They are available in different sizes and absorbencies.

• Urethral occlusive devices: Urethral occlusive devices are artificial devices that may be inserted into the urethra or placed over the urethral meatus to prevent urinary leakage. These devices are palliative measures to prevent involuntary urine loss. Urethral occlusive devices are more attractive than absorbent pads because they tend to keep the patient drier; however, they may be more difficult and expensive to use than pads. Urethral occlusive devices must be removed after several hours or after each voiding. Unlike pads, these devices may be more difficult to change. With device manipulation, patients may soil their hands. The risk that a urethral plug may fall into the bladder or fall off the urethra always exists. Urethral occlusive devices, perhaps, are best suited for an active incontinent woman who does not desire surgery.

• Catheters: Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. The use of catheters for bladder drainage has withstood the test of time. Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence.

  Some patients respond well to temporary continuous Foley catheter drainage. Their bladder capacity returns to normal and voluntary detrusor pressure improves. Return of spontaneous voiding is more likely for patients without neurologic injury. This usually takes at least 1 week of catheter drainage depending on the degree of bladder muscle injury. If it has not resolved after 4 weeks, then the bladder is unlikely to recover on catheter drainage alone.

  If the underlying cause of the overflow problem is bladder outlet obstruction, these patients may be able to return to normal voiding after relief of obstruction. If this is unsuccessful or not feasible, the intermittent catheterization usually is preferred for long-term therapy if logistically possible. Otherwise, a permanent catheter may need to be considered.

  Different types of bladder catheterization include indwelling urethral catheters, suprapubic tubes, and self-intermittent catheterization.

• Indwelling urethral catheters: Commonly known as Foley catheters, indwelling urethral catheters historically have been the mainstay of treatment for bladder dysfunction. If urethral catheters are being used for a long-term condition, they need to be changed monthly. These catheters may be changed at an office, a clinic, or at home by a visiting nurse.

  The standard catheter size for treating urinary retention is 16F or 18F, with a 5-mL balloon filled with 5-10 mL of sterile water. Larger catheters (eg, 22F, 24F) with bigger balloons are used for treating grossly bloody urine found in other urologic conditions or diseases. Increasing the balloon size to treat a catheter that leaks is not appropriate. Treat leakage around a catheter by eliminating the cause of the leakage. (Change or irrigate the catheter if it is blocked. Empty the drainage bag if it is full. Treat any bladder spasms or uninhibited contractions with appropriate anticholinergic medications.) Proper management of indwelling urethral catheters varies somewhat per individual patient.

  The usual practice is to change indwelling catheters once every month. The catheter and bag are replaced on a monthly basis; however, catheters that develop encrustations and problems with urine drainage need to be changed more frequently. All indwelling catheters in the urinary bladder for more than 2 weeks become colonized with bacteria. Bacterial colonization does not mean the patient has a clinical bladder infection.

  Symptoms of bladder infection include foul odor, purulent urine, and hematuria. Fever with flank pain are often present if upper tracts are involved. If a bladder infection occurs, change the catheter and the entire drainage system. The urinary drainage bag does not need to be routinely disinfected to prevent infection. A dilute vinegar solution can be used to dissolve the encrustations that tend to form in the drainage bags. Routine irrigation of catheters is not required. However, some authors favor the use of 0.25% acetic acid irrigation because it is bacteriostatic, minimizes catheter encrustation, and cuts down the odor. When used, 30 mL is instilled into the bladder and allowed to freely drain on a BID basis. Similarly, 30 cc of hydrogen peroxide can be added to the drainage bags immediately before connecting them to the Foley catheter. This supposedly reduces odor and bacterial growth by using a safe, nontoxic, and inexpensive agent.

  Patients do not have to be on continuous antibiotics while using the catheter. As a matter of fact, continuous use of antibiotics while a catheter is used is contraindicated. Prolonged use of antibiotics to prevent infection actually may cause paradoxical generation of bacteria that are resistant to common antibiotics. Indwelling use of a Foley catheter in individuals who are homebound requires close supervision by a visiting nurse and additional personal hygiene care.

  In spite of its seeming advantages, the use of a Foley catheter for a prolonged period of time (eg, months or years) is strongly discouraged. Chronic dependence on these catheters is extremely risky because long-term use of urethral catheters poses significant health hazards. Indwelling urethral catheters are a significant cause of urinary tract infections that involve the urethra, bladder, and kidneys. Within 2-4 weeks after catheter insertion, bacteria will be present in the bladder of most women. Asymptomatic bacterial colonization is common and does not pose a health hazard. However, untreated symptomatic urinary tract infections may lead to urosepsis and death. The death rate of nursing home residents with urethral catheters has been found to be 3 times higher than residents without catheters.

  The use of a urethral catheter is contraindicated in the treatment of urge incontinence. Other problems associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, hematuria, and urethritis. More severe complications include formation of bladder stones, development of periurethral abscess, renal damage, and urethral erosion.

  Another problem of long-term catheterization is bladder contracture, which occurs with urethral catheters as well as suprapubic tubes. Anticholinergic therapy and intermittent clamping of the catheter in combination have been reported to be beneficial for preserving the bladder integrity with long-term catheter use. Individuals who did not use the medication and daily clamping regimen experienced a decrease in bladder capacity and vesicoureteral reflux. For this reason, some physicians recommend using anticholinergic medications with intermittent clamping of the catheter if lower urinary tract reconstruction is anticipated in the future.

  It is important to note that Foley catheter clamping is not a benign procedure. Potential risks include cystitis, pyelonephritis, urosepsis, and bladder perforation. Thus, Foley catheter clamping is not commonly employed except in those rare occasions where bladder reconstruction is being contemplated. The clamping should be performed under strict supervision by monitoring patient comfort and bladder capacity. Coexisting urinary tract infections must be eradicated prior to proceeding with this endeavor.

  Maximum time limit on Foley clamping to expand the bladder should be tailored to the individual but should not exceed 3-4 hours. Patients with small capacity bladders do not tolerate Foley clamping for more than 1 hour. Foley catheter should be unclamped immediately if the patient complains of fever, suprapubic pain, obvious bladder distention, leakage around the Foley catheter, or changes in hemodynamics are noted.

  Restrict the use of indwelling catheters to the following situations: (1) as comfort measures for the terminally ill, (2) to avoid contamination or to promote healing of severe pressure sores, (3) in case of inoperable urethral obstruction that prevents bladder emptying, (4) in severely impaired individuals for whom alternative interventions are not an option, (5) when an individual lives alone and a caregiver is unavailable to provide other supportive measures, (6) for acutely ill persons in whom accurate fluid balance must be monitored, and (7) for severely impaired persons for whom bed and clothing changes are painful or disruptive. However, when long-term use of a urethral catheter is anticipated, a suprapubic catheter is an attractive alternative.

  Some type of catheter bag tubing support usually is recommended to prevent inadvertent pressure on the Foley catheter balloon and bladder neck tissue. Adequate slack should be afforded to allow reasonable, unimpeded leg motion without stretching the Foley catheter. We also recommend the routine use of a water-soluble surgical lubricant to the catheter where it exits the urethra, especially in males because of the soreness that can be produced there. The lubricant affords significant symptomatic relief.

• Suprapubic catheters: A suprapubic tube is an attractive alternative to long-term urethral catheter use. The most common use of a suprapubic catheter is in individuals with spinal cord injuries and a malfunctioning bladder. It can also be used in patients with intractable decompensated bladders or complicated urethral strictures. Both paraplegics and quadriplegics have benefited from this form of urinary diversion. When suprapubic tubes are needed, usually smaller (eg, 14F, 16F) catheters can be placed although some practitioners prefer a larger tube (24F - 28F) especially if they are concerned about the catheter becoming clogged. Like the urethral catheter, change the suprapubic tube at least once a month on a regular basis.

  Many advantages of suprapubic catheters exist. With a suprapubic catheter, the risk of urethral damage is eliminated. Multiple voiding trials may be performed without having to remove the catheter. Because the catheter comes out of the lower abdomen rather than the vaginal area, a suprapubic tube is more patient-friendly. Bladder spasms occur less often because the suprapubic catheter does not irritate the trigone like the urethral catheter. In addition, suprapubic tubes are more sanitary for the individual, and bladder infections are minimized because the tube is away from the perineum.

  Suprapubic catheters are changed easily by either a nurse or a doctor. Unlike the urethral catheter, a suprapubic tube is less likely to become dislodged because the exit site is so small. When the tube is removed, the hole in the abdomen quickly seals itself within 1-2 days.

  Indications for suprapubic catheters include short-term use following gynecologic, urologic, and other types of surgery. Suprapubic catheters may be used whenever the clinical situation requires the use of a bladder drainage device; however, suprapubic catheters are contraindicated in persons with chronic unstable bladders or intrinsic sphincter deficiency because involuntary urine loss is not prevented. A suprapubic tube does not prevent bladder spasms from occurring in unstable bladders nor does it improve the urethral closure mechanism in an incompetent urethra.

  Potential complications with chronic suprapubic catheterization are similar to those associated with indwelling urethral catheters, including leakage around the catheter, bladder stone formation, urinary tract infection, and catheter obstruction. During the initial placement of a suprapubic tube, a potential for bowel injury exists. Although uncommon, bowel perforation is known to occur with first-time placement of suprapubic tubes. Other potential complications include cellulitis around the tube site and hematoma. If the suprapubic tube falls out inadvertently, the exit hole of the tube will seal up and close quickly within 24 hours if the tube is not replaced with a new one. If tube dislodgment is recognized promptly, a new tube can be reinserted quickly and painlessly as long as the tube site remains patent.

  A suprapubic catheter is an alternative solution to an indwelling urethral catheter in women who require chronic bladder drainage. Potential problems unique to suprapubic catheters include skin infection, hematoma, bowel injury, and problems with catheter reinsertion. Long-term management of a suprapubic tube also may be problematic if the health care provider lacks the knowledge and expertise of suprapubic catheters or if the homebound individual lacks quick access to a medical center in case of an emergency. In the right hands, the suprapubic catheter affords many advantages over long-term urethral catheters.

• Intermittent catheterization: Intermittent catheterization or self-catheterization is a mode of draining the bladder at timed intervals, as opposed to continuous bladder drainage. A prerequisite for self-catheterization is the ability of the patient to use their hands and arms; however, in a situation in which the patient is physically or mentally impaired, a caregiver or health professional can perform intermittent catheterization for the impaired individual. Of all 3 possible options (ie, urethral catheter, suprapubic tube, intermittent catheterization), intermittent catheterization is the best solution for bladder decompression of a motivated individual who is not physically handicapped or mentally impaired.

  Many studies of young individuals with spinal cord injuries have shown that intermittent catheterization is preferable to indwelling catheters (ie, urethral catheter, suprapubic tube) for men and women. Intermittent catheterization has become a healthy alternative to indwelling catheters for individuals with chronic urinary retention due to an obstructed bladder, a weak bladder, or a nonfunctioning bladder. Young children with myelomeningocele have benefited from the use of intermittent catheterization. In addition, self-catheterization is recommended by some surgeons for women during the acute healing process after anti-incontinence surgery.

  Intermittent catheterization may be performed using a soft, red, rubber catheter or a short, rigid, plastic catheter. The use of plastic catheters is preferable to red rubber catheters because they are easier to clean and last longer. The bladder must be drained on a regular basis, either based on a timed interval (eg, on awakening, every 3-6 hours during the day, and before bed) or based on bladder volume. Remember that the average adult bladder holds approximately 400-500 mL of urine. Ideally, the amount drained each time should not exceed that amount. This drainage limit may require decreasing the fluid intake or increasing the frequency of catheterizations. So, if catheterization is being performed every 6 hours and the amount drained is 700 mL, increase the frequency of catheterization to, perhaps, every 4 hours to keep the volume drained between 400-500 mL. The idea is to simulate normal voiding. Usually, the average adult empties the bladder 4-5 times a day. Thus, catheterization should occur 4-5 times a day; however, individual catheterization schedules may vary, depending on the amount of fluid taken in during the day.

  Candidates for intermittent catheterization must have motivation and intact physical and cognitive abilities. Anyone who has good use of her hands and arms can perform self-catheterization. Young children and the older population are able to do this every day without any problems. For individuals who are impaired, a home caregiver or a visiting nurse can be instructed to perform intermittent catheterization. Self-catheterization may be done at home, at work, or basically anywhere. Intermittent catheterization may be performed using either a sterile catheter or a nonsterile clean catheter. Intermittent catheterization, using a clean technique, is recommended for young individuals with a bladder that cannot empty who do not have any other available options. Patients should wash their hands with soap and water. Sterile gloves are not necessary. Clean intermittent catheterization results in lower rates of infection than the rates noted with indwelling catheters.

  Studies show that in patients with spinal cord injuries, the incidence of bacteria in the bladder is 1-3% per catheterization and 1-4 episodes of bacteriuria per 100 days of intermittent catheterization, occurring 4 times a day. Furthermore, the infections that do occur usually are managed without complications.

  As a general rule, routine use of long-term suppressive therapy with antibiotics in patients with chronic clean intermittent catheterization is not recommended. The use of chronic suppressive antibiotic therapy in people regularly using clean intermittent catheterization is undesirable because it may result in the emergence of resistant bacterial strains.

  In high-risk populations, such as patients with an internal prosthesis (eg, artificial heart valve, artificial hip) or patients who are immunosuppressed because of age or disease, decide the use of antibiotic therapy for asymptomatic bacteriuria on individual merits. For the older population and individuals with a weak immune system, the sterile technique of intermittent catheterization has been recommended. Persons who are older are at higher risk than younger persons for developing bacteriuria and other complications caused by intermittent catheterization because they do not have a strong defense system against infection. Although the incidence of infection and other complications for patients who are older using sterile versus clean intermittent catheterization is not well established, it appears that sterile intermittent catheterization is the safest method for this high-risk population.

  Potential advantages of performing intermittent catheterization include patient autonomy, freedom from indwelling catheter and bags, and unimpeded sexual relations. Potential complications of intermittent catheterization include bladder infection, urethral trauma, urethral inflammation, and stricture. Concurrent use of anticholinergic therapy will maintain acceptable intravesical pressures and also prevent bladder contracture. Studies have shown that long-term use of intermittent catheterization appears to be preferable to indwelling catheterization (ie, urethral catheter, suprapubic tube), with respect to urinary tract infections, renal failure, and the development of stones within the bladder or kidneys.

Surgical Care: Surgical care for stress incontinence involves procedures that increase urethral outlet resistance. Operations that increase urethral resistance include bladder neck suspension, periurethral bulking therapy, pubovaginal sling, and artificial urinary sphincter. Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity such as detrusor myomectomy or Ingelman-Sundberg procedure. Ingelman-Sundberg procedure is an operation designed to transect the preganglionic pelvic nerves near the inferior surface of the bladder. Additional operations that increase bladder compliance and/or capacity include sacral nerve modulation and bladder augmentation.

Diet: The fact that certain foods in a daily diet can worsen symptoms of urinary frequency and urge incontinence is well known. If a patient's diet contains dietary stimulants, changes in her diet may help in ameliorating incontinence symptoms. Dietary stimulants are substances contained within the food or drink that either cause or exacerbate irritative voiding symptoms. By eliminating or minimizing the intake of dietary stimulants, unwanted bladder symptoms can be improved or possibly cured. Avoidance of dietary stimulants begins with consumer awareness through careful label reading and maintaining a daily diet diary. Experimenting with dietary changes is not for everyone and should be done on an individual basis. Certain food products exacerbate symptoms of urge incontinence.

• Food

  ¡@

  • Foods that contain heavy or hot spices will contribute to urge incontinence. Few medical reports have alluded to the fact that avoiding spicy foods may have a beneficial effect on urinary incontinence. Some examples of hot spices include curry, chili pepper, cayenne pepper, and dry mustard. Foods from specific cultures have a predictable spicy flavor. For example, Tai cuisine contains a lot of chili sauce to make the dishes spicy. Korean dishes tend to be salty and hot. Indian meals are flavored with curry.

    ¡@

  • A second food group that may worsen irritative voiding symptoms is citrus fruit. Fruits and juices that have an acidic pH worsen preexisting urge incontinence. Examples of fruits that have significant acidity include grapefruits, oranges, limes, and lemons.

    ¡@

  • A third food group that may worsen urinary bladder incontinence is chocolate-containing sweets. Chocolate snacks and treats contain caffeine. Caffeine is a bladder-unfriendly agent. Excessive intake of chocolate confectioneries worsens irritative bladder symptoms.

• Water, coffee, tea, and chocolate

• The quantity and quality of refreshments consumed will influence urinary voiding symptoms. An average American adult requires a daily allowance of approximately 6-8 glasses of fluids. Fluids refer to all the beverages a patient consumes in a day, which include water, soda pops, and milk. The human body receives water from beverages drank, water contained in the food ingested, and water metabolized from food eaten. The recommended amount of fluids consumed (all types) in 24 hours totals 6-8 glasses. The benefits of adequate fluid intake include prevention of dehydration, constipation, urinary tract infection, and kidney stone formation.

  ¡@

• Some patients tend to drink water to excess. Some women drink water because they enjoy the taste. Others are on medication that makes their mouth dry, so they drink more water. Some women who are trying to lose weight are on a diet that requires consuming abundant amounts of water. Drinking water to excess actually worsens irritative bladder symptoms. The exact amount of fluid needed per day is calculated based on the patient's lean body mass. Thus, the amount of fluid requirement varies per individual. For an average adult woman with symptomatic urinary incontinence, drinking approximately 6 glasses of liquid per day generally is recommended. In contrast, some older women do not drink enough fluids to keep themselves well hydrated. They minimize their fluid intake to unacceptable levels, thinking if they drink less, they will experience less incontinence. Trying to prevent incontinence by restricting fluids to excess may lead to bladder irritation and actually worsen urge incontinence.

  In addition, dehydration contributes to constipation. If a patient has a problem with constipation, recommend eating a high fiber diet, receiving adequate hydration, and administering laxatives.

  ¡@

• Many drinks contain a common ingredient, caffeine. Caffeine is a natural diuretic and also has a direct excitatory effect on bladder smooth muscle. Thus, caffeine-containing products produce excessive urine and also exacerbate symptoms of urinary frequency and urgency. Caffeine-containing products include coffee, tea, hot chocolate, and colas. Even chocolate milk and many over-the-counter medications contain caffeine. Within this list of caffeine-containing products, coffee contains the most amount of caffeine. Drip coffee contains the most caffeine, followed by percolated coffee and then instant coffee. Even decaffeinated coffee contains a small amount of caffeine. Decaffeinated coffee contains an amount of caffeine similar to the amount in chocolate milk. Persons who consume a large amount of caffeine should slowly decrease the amount of caffeine consumed to avoid significant withdrawal responses such as headache and depression.

• Studies have shown that drinking carbonated beverages, citrus fruits drinks, and acidic juices may worsen irritative voiding or urge symptoms. Consumption of artificial sweeteners also has been theorized to contribute to urge incontinence.

• Nighttime voiding and incontinence are major problems in the older population. Women who have nocturia more than twice a night or experience nighttime bed-wetting may benefit from fluid restriction and the elimination of caffeine-containing beverages from their diet in the evening. Patients should restrict fluids after dinnertime so they can sleep uninterrupted through the night. In some cases, DDAVP can be used to decrease nighttime urine production and help reduce nocturia.

• Finally, individuals who develop edema of the lower extremities during the day experience nighttime voiding because excess fluid from lower extremities returns back to the heart in a recumbent position. This problem may be handled with a behavior technique, support hose, and/or medications.

  Advise these individuals to elevate their lower extremities several hours during the late afternoon or evening to stimulate a natural diuresis and limit the amount of edema present at bedtime. Support hose (Jobst) or intermittent, sequential compression devices (SCDs) used briefly at the end of the day can reduce lower extremity edema and minimize night time diuresis, thus improving sleep.

  Lastly, the judicious use of diuretics has been associated with a decrease in lower-extremity edema and lower nighttime urine volumes. If patients already are taking diuretics, altering the administration time of the diuretics may decrease nighttime voiding and incontinence. Depending on other medical conditions, changing the time of diuretic administration to the morning may prevent large nighttime urinary volumes.

Activity: Anti-incontinence exercises emphasize rehabilitating and strengthening the pelvic floor muscles that are critical in maintaining urinary continence. Pelvic floor muscles also are known as levator ani muscles. They are named levator muscles because they function to levitate or elevate the pelvic organs into their proper place. When levator muscles weaken and fail, pelvic prolapse and stress incontinence result. An anatomic defect of the levator ani musculature requires physical rehabilitation. If aggressive physical therapy does not work, surgery is warranted.

Pelvic muscle exercises may be used alone, augmented with vaginal cones, reinforced with biofeedback therapy, or with electrical stimulation. Burgio et al reported that behavioral treatment is a safe and effective intervention that should be used as a first-line treatment for urge and mixed incontinence. If the patient is using abdominal muscles or contracting their buttocks, they are not doing these exercises properly. If patients have difficulty identifying the levator muscles, biofeedback therapy may be instituted. For selected individuals, electrical stimulation further enhances pelvic muscle rehabilitation therapy.

• Pelvic floor exercise: Pelvic floor exercise refers to strengthening the levator muscles lining the floor of the bony pelvis. The first step in pelvic muscle rehabilitation is to establish a better awareness of the levator muscle function. Pelvic floor exercises, sometimes called Kegels, is a rehabilitation technique used to tighten and tone the pelvic floor muscles (ie, levator ani) that have become weak over time. These exercises empower the external urinary sphincter to prevent stress incontinence and build up the pelvic floor muscles to avert impending pelvic prolapse. In addition, Kegel exercises may be performed to eliminate urge incontinence. Contraction of the external urinary sphincter induces reflex bladder relaxation. Pelvic floor muscle rehabilitation may be used to reprogram the urinary bladder to decrease the frequency of incontinence episodes.

  ¡@

  • Individuals who benefit the most from pelvic floor exercises tend to be young healthy women who can identify the levator muscles accurately. Older adults with weak pelvic tone or women who have difficulty recognizing the right muscles will need adjunct therapy such as biofeedback or electrical stimulation. Pelvic floor exercises work best in mild cases of stress incontinence associated with urethral hypermobility but not intrinsic sphincter deficiency. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence. They also benefit men who develop urinary incontinence following prostate surgery.

    ¡@

  • Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner thigh muscles. Patients should be instructed to squeeze their pelvic floor muscles by performing one of the following techniques: 1) stop the flow of urine during micturition, 2) squeeze the anal sphincter as if to prevent passing gas, 3) tighten perivaginal muscles by squeezing a penis during sexual relations or squeezing a finger inserted into the vagina.

    ¡@

  • For stress incontinence, the recommended exercise programs differ. For beginners, the individual should perform the squeezing exercise 5 times, holding each contraction for a count of 5. Five contractions equal 1 set. Patients should do 1 set every hour while they are awake, whether driving, reading, or watching television. After a while, the patient becomes proficient at this. Pretty soon, the patient may be able to hold each contraction for at least 10 seconds, followed by an equal period of relaxation. The pelvic floor exercises must be performed daily for at least 3-4 months to be effective.

    Another regimen is to perform the exercises for 10 minutes twice a day using an audiocassette tape. The audiocassette coaches the patient to contract the levator ani muscles for a count of 10 seconds and then to relax for a count of 10 seconds, doing 25 repetitions in a row. Twenty-five contractions equal 1 set. Do the first set slowly, followed by a second set done rapidly. In order to gain the most benefit from this program, patients may need to continue this exercise indefinitely. If patients have not significantly improved after a regimented program of 4-6 months, they may need electrical stimulation.

    Another alternate regimen is to suggest that the patient repeat a set of 5 exercises each time they go to the bathroom. Again, this ensures that the exercises are done many times during the day. If patients are unable to perform the exercise for the optimal 5-10 seconds, they may need to start at only 2-3 seconds of "holding" until they are able to do the exercise properly.

    ¡@

  • For urge incontinence, pelvic floor muscle exercises are used to retrain the bladder. When the patient contracts the external urethral sphincter, the bladder automatically relaxes, so the urge to urinate eventually subsides. Strong contractions of the pelvic floor muscles will suppress bladder contractions. Whenever patients feel urinary urgency, they may try to stop the feeling by contracting the pelvic floor muscles. These steps will give the patient more time to walk slowly to the bathroom with urinary control.

    ¡@

  • By regularly training the external sphincter, patients can gradually increase the time between urination from 1-3 hours. Patients should start to see improvement in 3-4 weeks. Thus, this technique may be used for stress and urge symptoms, mixed incontinence.

    ¡@

  • When doing these drills, patients should not contract their abdominal muscles. Contracting the abdominal muscles is counterproductive and merely worsens urinary incontinence. In general, tailor a regimented program of exercises and repetitions to each individual so that the muscle strength increases progressively. Some patients may need more intensive training than others.

    ¡@

  • Patients should practice contracting the levator ani muscles immediately before and during situations when leakage may occur. This will condition the external sphincter instinctively to contract with increases in abdominal pressure or when the need to urinate is imminent. This is known as the “guarding reflex.?By tightening the external urinary sphincter just as the patient is about to sneeze, the involuntary urine loss is thwarted. By squeezing the levator ani muscles when the patient gets the sense of urgency, the sensation of impending bladder contraction will dissipate. By making this maneuver a habit, patients will develop a protective mechanism against stress and urge incontinence.

    ¡@

  • The beneficial effects of pelvic floor muscle exercises alone have been well documented in medical literature. Successful reduction in urinary incontinence has been reported to range from 56-95%. Pelvic floor exercises are effective, even after multiple anti-incontinence surgeries.

• Vaginal weights: Vaginal weight training is an effective form of pelvic floor muscle rehabilitation for stress incontinence in premenopausal women. Vaginal weights are tamponlike special help aids used to enhance pelvic floor muscle exercises. Shaped like a small cone, vaginal weights (identical shape and volume) come in a set of 5, with increasing weights (ie, 20, 32.5, 45, 60, and 75 g). As part of a progressive resistive exercise program, a single weight is inserted into the vagina and held in place by tightening the perivaginal muscles (levator ani muscles) for as many as 15 minutes. As the levator ani muscles become stronger, the exercise may be increased to 30 minutes.

  ¡@

  • This exercise is done twice daily. The intravaginal weight provides the sensory feedback for the desired pelvic muscle contraction. The sustained contraction required to retain the weight within the vagina increases the strength of the pelvic floor muscles.

    ¡@

  • The best results are achieved when standard pelvic muscle exercises (Kegels) are performed with intravaginal weights. In premenopausal women with stress incontinence, the subjective cure or improved continence status was approximately 70-80% after 4-6 weeks of treatment. Vaginal weight training also may be useful for postmenopausal women with stress incontinence; however, vaginal weights are not effective in the treatment of pelvic organ prolapse.

• Biofeedback: Biofeedback therapy is a form of pelvic floor muscle rehabilitation using an electronic device for individuals having difficulty identifying levator ani muscles. Biofeedback therapy is recommended for treatment of stress incontinence, urge incontinence, and mixed incontinence. Biofeedback therapy uses a computer and electronic instruments to relay auditory or visual information to the patient about the status of pelvic muscle activity. These devices allow the patient to receive immediate visual feedback on the activity of the pelvic floor muscles.

  ¡@

  • Biofeedback is an intensive therapy with weekly sessions performed in an office or a hospital by a trained professional and often is followed by a regimen of pelvic floor muscle exercises at home. During a biofeedback therapy, a special tampon-shaped sensor is inserted in the patient's vagina or rectum, and a second sensor is placed on her abdomen. These sensors detect electrical signals from the pelvic floor muscles. The patient is then instructed to contract and relax the pelvic floor muscles upon command. When done properly, the electric signals from the pelvic floor muscles are registered on a computer screen. Biofeedback, using multimeasurement recording, displays the simultaneous measurement of pelvic and abdominal muscle activity on the computer monitor.

    ¡@

  • Biofeedback allows the patient to correctly identify the pelvic muscles that need rehabilitation. The benefit of biofeedback therapy is that it provides the patient with minute-by-minute feedback on the quality and intensity of her pelvic floor contraction. Combining bladder and urinary sphincter biofeedback allows the patient to regulate the pelvic muscle contraction in response to increasing bladder volumes and to monitor the bladder activity. Biofeedback is best used in conjunction with pelvic floor muscle exercises and bladder training.

    ¡@

  • Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with incontinence. The best biofeedback protocol is the one that reinforces levator ani muscle contraction with inhibition of abdominal and bladder contraction. Reports using this method show a 76-82% reduction in urinary incontinence. Biofeedback also has been used successfully in the treatment of men with urge incontinence and intermittent stress incontinence after prostate surgery.

    ¡@

  • Medical studies have demonstrated significant improvement in urinary incontinence in women with neurologic disease and in the frail older population when a combination of biofeedback and bladder training is used. Biofeedback provides a specific reinforcement for pelvic muscle contraction that is isolated from the counterproductive abdominal contraction. Therefore, awareness of levator ani muscle contraction can be achieved more efficiently using biofeedback than vaginal palpation alone.

    ¡@

  • Biofeedback produces a greater reduction in female urinary incontinence, compared to pelvic muscle exercises alone. Overall, the medical literature indicates that pelvic muscle exercises and other behavioral strategies, with or without biofeedback, can cure or reduce incontinence. However, the maximum benefit is derived from any pelvic muscle rehabilitation and education program when ongoing reinforcement and guidance, such as biofeedback therapy, are provided.

• Electrical stimulation: Electrical stimulation is a more sophisticated form of biofeedback used for pelvic floor muscle rehabilitation. This treatment involves stimulation of levator ani muscles using painless electric shocks. Electrical stimulation of pelvic floor muscles produces a contraction of the levator ani muscles and external urethral sphincter while inhibiting bladder contraction. This therapy depends on a preserved reflex arc through the intact sacral micturition center. Like biofeedback, electrical stimulation can be performed at the office or at home. Electrical stimulation can be used in conjunction with biofeedback or pelvic floor muscle exercises.

  ¡@

  • Electrical stimulation therapy requires a similar type of probe and equipment as those used for biofeedback. This form of muscle rehabilitation is similar to the biofeedback therapy, except small electric shocks are used. Nonimplantable pelvic floor electrical stimulation uses vaginal sensors, anal sensors, or surface electrodes. Adverse reactions are minimal.

    ¡@

  • Like biofeedback, pelvic floor muscle electrical stimulation has been shown to be effective in treating female stress incontinence, as well as urge and mixed incontinence. Electrical stimulation may be the most beneficial when stress incontinence and very weak or damaged pelvic floor muscles coexist. A regimented program of electrical stimulation will help these weakened pelvic muscles contract so they can become stronger. For women with urge incontinence, electrical stimulation may help the bladder relax and prevent it from contracting involuntarily.

    ¡@

  • Research indicates that pelvic floor electrical stimulation can reduce urinary incontinence significantly in women with stress incontinence and may be effective in men and women with urge and mixed incontinence. Incidence of urge incontinence secondary to neurologic diseases may be decreased with this therapy. Electrical stimulation appears to be the most effective when augmented with pelvic floor exercises. Long-term data report that the rate of cured or improved patients from electrical stimulation ranged from 54-77%; however, in order to derive significant benefit, perform stimulation for a minimum of 4 weeks, and patients must continue pelvic floor exercises after the treatment. Unfortunately, this treatment does not appear to benefit cognitively impaired patients.

• Bladder training: Bladder training involves relearning how to urinate. This method of rehabilitation most often is used for active women with urge incontinence and sensory urge symptoms. Often, patients find that when they respond to symptoms of urge and return to the bathroom soon after they have voided, they do not urinate that much. In other words, though their bladder is not full, it is signaling for them to void.

  ¡@

  • Bladder training generally consists of self-education, scheduled voiding with conscious delay of voiding, and positive reinforcement. Although bladder training is used primarily for urge incontinence, this program may be used for simple stress incontinence and mixed incontinence. Bladder training requires the patient to resist or inhibit the sensation of urgency and postpone voiding. Patients urinate according to a scheduled timetable rather than the symptoms of urge.

    ¡@

  • Bladder training uses dietary tactics such as adjustment in fluid intake and avoidance of dietary stimulants. In addition, distraction and relaxation techniques allow delayed voiding to help distend the urinary bladder. By using these strategies, patients can induce the bladder to accommodate progressively larger voiding volumes.

    Initially, the interval goal is determined by the patient's current voiding habits and is not enforced at night. Whatever their voiding pattern is, their first voiding interval may be increased by 15- to 30-minute increments. As the bladder becomes accustomed to this delay in voiding, the interval between mandatory voids is progressively increased, with simultaneous distraction or relaxation techniques and dietary modification. The interval goal between each void usually is set between 2 and 3 hours and may be set further apart if desired.

    Another method of bladder training is to keep the prearranged schedule and disregard the unscheduled voids. But patients need to continue to keep the prearranged voiding times. They need to continue this program for several months.

    ¡@

  • Alternatively, bladder ultrasound may be employed. If patients need an objective demonstration that their bladder is relatively empty, a portable bladder scanner may be used. A bladder scanner is a portable ultrasound machine that measures the amount of urine present in a patient's bladder. With this device, patients can void when their bladder fills to a certain volume rather than responding to that sensation of needing to go to the bathroom. When patients feel the need to void, they can check the bladder using the scanner to see how much urine is present. If the bladder is empty, they should ignore that sensation.

• Bladder training has been used primarily to manage urge incontinence; however, it also may be used for stress and mixed incontinence. This form of training is useful in young women but is difficult to implement in cognitively impaired persons. Bladder training may not be successful in frail women who are older. Medical reports demonstrate that bladder training is effective in reducing urinary incontinence. With bladder training, the rate of patients with mixed incontinence that have been cured is reported to be 12%, while the improvement rate was 75% after 6 months.

MEDICATION

¡@

Stress incontinence results from a weak urinary sphincter. The internal sphincter contains high concentrations of alpha-adrenergic receptors. Activation of the alpha-receptors results in contraction of the internal urethral sphincter and increases the urethral resistance to urinary flow. Sympathomimetic drugs, estrogen, and tricyclic agents increase bladder outlet resistance to improve symptoms of stress urinary incontinence. Medical conditions that cause urge incontinence may be neurologic or nonneurologic. The urethra is normal but the bladder is hyperactive or overactive. Pharmacologic therapy for stress incontinence and an overactive bladder may be most effective when combined with a pelvic exercise regimen. The 3 main categories of drugs used to treat urge incontinence include anticholinergic drugs, antispasmodics, and tricyclic antidepressant agents.

All drugs with anticholinergic adverse effects are contraindicated if patients have documented narrow-angle glaucoma. Wide-angle glaucoma is not a contraindication to their use. Urinary retention, bowel obstruction, ulcerative colitis, myasthenia gravis, and severe heart diseases are contraindications for anticholinergic use. These agents may impair the patient's ability to perform hazardous activities, such as driving or operating heavy machinery, because of the potential for drowsiness. Anticholinergic drugs should not be taken in combination with alcohol, sedatives, or hypnotic drugs.

When a single drug treatment does not work, a combination therapy such as Oxybutynin (Ditropan) and Imipramine (Tofranil) may be used. Although their mechanism of action differs, Oxybutynin and Imipramine both work together to improve urge incontinence. Oxybutynin causes direct smooth muscle relaxation of the urinary bladder and also has local anesthetic properties. Imipramine has a direct inhibitory and local anesthetic effect on the bladder smooth muscle, like Oxybutynin; however, Imipramine also increases the bladder outlet resistance at the level of the bladder neck. Thus, the combination of these drugs produces a synergistic effect to relax the unstable bladder to hold in urine and prevent urge incontinence. Potential anticholinergic adverse effects may be additive because both drugs have similar adverse reactions.
¡@

Drug Category: Alpha-adrenergic drugs -- The bladder neck contains a high concentration of receptors that are sensitive to alpha-agonists. Alpha agonists increase bladder outlet resistance by contracting the bladder neck.

Drug Category: Estrogen -- Conjugated estrogen increases the tone of urethral muscle by up-regulating the alpha-adrenergic receptors in the surrounding area, and it enhances alpha-adrenergic contractile response to strengthen the pelvic muscles, which is important in urethral support (prevents urethral hypermobility). Mucosal turgor of periurethral tissue from proper nourishment enhances urethral mucosal coaptation. Result is an improved mucosal seal effect, which is important in urethral function (prevents intrinsic sphincter deficiency). Estrogen supplementation appears to be the most effective in postmenopausal women with mild-to-moderate incontinence. Both types of stress incontinence will benefit from estrogen fortification.

Drug Category: Anticholinergic drugs -- First-line medicinal therapy for women with urge incontinence. Effective in treating urge incontinence because they inhibit involuntary bladder contractions. Useful in treating urinary incontinence associated with urinary frequency, urgency, and nocturnal enuresis. All anticholinergic drugs have similar a performance profile and toxicity. Potential adverse effects of all anticholinergic agents include blurred vision, dry mouth, heart palpitations, drowsiness, and facial flushing. When anticholinergic drugs are used in excess, the bladder may go into acute urinary retention.

Drug Category: Antispasmodic drugs -- They relax the smooth muscles of the urinary bladder. By exerting a direct spasmolytic action on the smooth muscle of the bladder, these medications have been reported to increase the bladder capacity and effectively decrease or eliminate urge incontinence. The adverse effect profile of antispasmodic drugs is similar to that of anticholinergic agents. These drugs may impair the patient's ability to perform activities requiring mental alertness and physical coordination. Drinking alcohol and using sedatives in combination with these antispasmodic drugs is contraindicated.

Drug Category: OBJECT Trial -- Recently, Appell et al conducted an OBJECT trial (Overactive Bladder: Judging Effective Control and Treatment). This was a large double-blind, multicenter, prospective, randomized controlled study that compared the efficacy and tolerability of Ditropan XL (N=160) vs Detrol (N=170) in men and women with symptoms of overactive bladder. The study concluded that Ditropan XL 10 mg was statistically superior to Detrol 2 mg BID in terms of efficacy. However, both drugs had similar adverse effect profile.

Drug Category: Tricyclic antidepressant drugs -- Historically, these drugs were used to treat major depression; however, they have an additional use, treatment of bladder dysfunction. They function to increase norepinephrine and serotonin levels. In addition, they exhibit an anticholinergic and direct muscle relaxant effect on the urinary bladder.

FOLLOW-UP

Section 8 of 11

Further Outpatient Care:
¡@

• Refer to discussion on catheters in the earlier section

Complications:
¡@

• Prolonged contact of urine on the unprotected skin causes contact dermatitis and skin breakdown. If left untreated, these skin disorders may lead to pressure sores and ulcers, possibly resulting in secondary infections. For individuals with a decompensated bladder that does not empty well, the postvoid residual urine can lead to overgrowth of bacteria and subsequent urinary tract infection.

• Chronic indwelling catheters may cause recurrent bladder infection, bladder stones, ascending pyelonephritis, and urethral erosion. The use of intermittent catheterization may result in bladder infections or urethral injury. Chronic suprapubic tubes may result in bladder spasms, bladder stone formation, and bladder infection.

• Potential problems unique to suprapubic catheters include skin infection, hematoma, bowel injury, and problems with catheter reinsertion.

• Complications of intermittent catheterization include bleeding, infection, and urethral injury.

• Untreated urinary tract infections may lead to urosepsis and death.

Prognosis:
¡@

• Prognosis of an incontinent patient is excellent in today's health care. With improvement in information technology, well-trained medical staff, and advances in modern medical knowledge, incontinent patients should not suffer the morbidity and mortality of the past. Although the ultimate well being of an incontinent patient depends on the underlying condition that has precipitated urinary incontinence, urinary incontinence itself is easily treated and prevented by properly trained health care individuals.

MISCELLANEOUS

¡@

Medical/Legal Pitfalls:
¡@

• Failure to diagnose and treat urinary retention may result in adverse consequences.

• Rule out narrow-angle glaucoma prior to prescribing an anticholinergic agent. Note: narrow-angle glaucoma may be converted to open-angle glaucoma by an experienced ophthalmologist.

• When a patient is on an anticholinergic agent, monitor these patients to prevent pharmacologically induced urinary retention.