16. CGA in Primary Care Settings: Patients presenting with urinary incontinence

Types of incontinence

Incontinence can result from:

1. Weakness of the urinary outlet - Stress Incontinence.
2. Failure of the bladder to store urine because of high bladder pressure - Urge Incontinence.
3. A combination of 1 and 2 - Mixed Incontinence.
4. A bladder that is overfull and overflows - Bladder outlet obstruction.
5. Abnormal communications of the urinary tract - Fistulae.
6. Incontinence due to more general impairment e.g. cognitive, functional, affective – Functional Incontinence.

Assessment

Any consultation between an older person and a health care professional should include a screening question about continence issues. If the answer is positive, a full assessment should be offered.

Validated screening questionnaires are also available for selected patients. Several of these have been developed. See the International Consultation on Incontinence Modular Questionnaire (ICIQ).

History

Essentially the symptoms can be divided into problems with storage or voiding. 

Storage: Frequency, Urgency, Stress Incontinence, Urge Incontinence, Nocturia

Voiding: Post micturition dribble, Hesitancy, Terminal dribbling, Incomplete emptying, Intermittent stream

Ask specifically about

• Pain, dysuria and haematuria,- these symptoms need urgent review.
• Urinary symptoms during childhood – for example nocturnal enuresis.
• Bowel function and frequency.
• Systemic symptoms and those symptoms that could be associated with diseases that predispose a patient to urinary incontinence e.g. diabetes.
• Associated co-morbidities (CCF, COPD, DM) and previous surgical procedures, particularly those in or around the pelvis.

Obstetric and gynaecological history are also important in female patients.

Medication review is essential as many drugs can exacerbate urinary incontinence.

Examination

• CVS – look for signs of chronic cardiorespiratory disease.
• Cognition – AMT as a screen for cognitive decline.
• Neuro - assess gait, check dorsiflexion of the toes (S3) and perineal sensation (L1-L2), sensation of the sole (S1) and posterior aspect of the thigh (S3).
• Abdo - palpate for masses or enlarged kidneys, palpate and percuss for a distended bladder.
• Digital Rectal Examination (DRE) should be performed in all patients to assess anal tone, presence of constipation or rectal mass and to assess prostate size in males.
• Pelvis - Inspection may reveal vaginal atrophy or prolapse.

The pelvic floor muscle strength can be assessed during a vaginal examination. 

One grading system is the Oxford classification which is a 6 point scale: 0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good, 5 = strong contraction.

Finally ask the patient to cough or strain to enable demonstration of stress incontinence; repeat this with the patient standing if possible.

Investigations: initial

• Frequency / Volume Chart.
• Urinalysis +/- MSU for MC&S
• Blood tests – FBC, U&E, Calcium, Glucose
• Post-void bladder scan (Other imaging modalities are not routinely indicated unless there are specific indications).

Specialist referral

Refer patients with the following

• Haematuria
• Prolapse beyond the introitus
• Pain associated with the micturition cycle
• Suspicion of prostate cancer.

Consider referral if no improvement with anticholinergic or beta 3 agonist.

General management

Diagnose and manage reversible causes/precipitants of urinary incontinence: delirium, restricted mobility, constipation, UTI, medications, vaginal atrophy, diabetes, CKD

Stress incontinence

Risk Factors: Childbirth, post surgery (e.g. prostactectomy), infection, neurological disease, age, female sex, post hysterectomy, obesity.

Management:

Lifestyle: smoking cessation, weight reduction, managing constipation, reducing alcohol and caffeine.

Medical: duloxetine is NO longer recommended for 1st or 2nd line treatment.

Surgical: mid urethral sling insertion.

MDT: continence advisor referral, pelvic floor exercises, vaginal cone.

Urge incontinence

Causes: 

• Idiopathic: most common and known as Overactive Bladder.
• Neurogenic: associated with neurological conditions e.g. multiple sclerosis, parkinsonism, stroke or spinal cord injury
• Bladder outlet obstruction
• Infective: urinary tract infection, but beware coincidental asymptomatic bacteriuria. Only diagnose infection as a cause of urgency if acute onset and symptoms resolve on first treatment with antibiotics.

Management:

1. Lifestyle: reduce fluid intake, especially in the evening (advise no drinks after 8pm), reduce caffeine and alcohol intake, weight reduction, manage constipation.

2. Medical: antimuscarinic drugs. These are the mainstay of treatment. They act on the M3 receptors on the detrusor muscle to reduce contraction.  They do have common side effects and need to be used with caution in the elderly (the newer agents are said to be more selective for the M3 receptor and therefore have less CNS side effects). Examples include: oxybutynin, tolteridone, darifenacin, trospium, solifenacin and propiverine.

NICE recommended first line agents are:

• Oxybutynin (but not to be used in older adults with frailty or in Parkinson's Disease).
• Tolteridone.
• Darifenacin.

If a first line agent is not tolerated or does not work, then a second agent should be trialed.

• Beta-3-adrenoceptor agonists (Mirabegron)

If there are contraindications, intolerable side effects or poor efficacy to antimuscarinics, a trial of Mirabegron can be considered. Beta-3-adrenoceptors cause the bladder to relax, which helps it to fill and also to store urine.

• Intravaginal oestrogens

NICE recommend their use for women who have vaginal atrophy and symptoms of overactive bladder.

3. MDT: Community continence advisor, bladder retraining, pelvic floor exercises.

Bladder outlet obstruction

Causes: Phimosis, prostate cancer, cervical cancer, colon cancer, BPH, calculi

Management: 

1. Patient education: Bladder Outlet Obstruction (BOO) often coexists with Overactive Bladder (OAB).

2. Medical: there are two medical options for treating BPH:

• Alpha adrenoceptor antagonists (alpha blockers) e.g. doxazocin - these drugs reduce the smooth muscle tone of the prostate.
• 5 alpha reductase inhibitors e.g. finasteride - these drugs reduce prostate volume by blocking the conversion of testosterone to dihydrotestosterone.

Surgical: the surgical management of BOO will depend on the actual cause and will require referral to urology or urogynaecology.

A transurethral prostatectomy (TURP) can be considered in cases of Benign Prostatic Hypertrophy.