Incontinence can hide in middle age

Urinary incontinence can be a debilitating quality-of-life problem for some women, one that curtails their social activities, interrupts their sleep, and causes discomfort and embarrassment. For others, it is an annoyance they tolerate with a few adjustments. Yet many women never mention the problem to their primary care physicians.

An estimated 25% of women age 14 to 21, 44% to 57% of middle-aged and postmenopausal women, and 75% of women age 75 and older experience some form of urinary incontinence, according to a clinical practice guideline from the American College of Physicians about nonsurgical management of urinary incontinence in women.

Older women are less likely to talk about incontinence with their physicians because of embarrassment, said Mary Ann Forciea, MD, FACP, clinical professor of medicine in the Division of Geriatric Medicine at the University of Pennsylvania School of Medicine in Philadelphia. Also, the onset of the condition can be somewhat gradual, and it is so prevalent that many women consider it too common to bother discussing.

“They and all their friends have to go the bathroom more often or they have to get to the bathroom more urgently or they will leak. Many wear protective padding because they don't want to be embarrassed if they are out in public,” she said. She coauthored ACP's recent clinical guideline on nonsurgical management of urinary incontinence in women, published in the Sept. 18, 2014, Annals of Internal Medicine, and said it strongly reaffirms the effectiveness of nonsurgical and nonpharmacologic management as first-line therapy for many women.

But many women may not be aware that urinary incontinence can often be successfully managed. “This is one chronic problem where we can actually do quite a bit to make better and improve the quality of life of women so that they don't have to be reluctant to continue their social activities or go to a wider range of places and not be worried about where the bathroom is,” said Dr. Forciea. She stressed the importance of raising the topic with older women by asking whether they have problems with leaking or sudden urges to urinate, because most women will respond to the question if the problem is bothering them.

“There are increasing pressures in society for pharmacologic treatment of incontinence, with all the ads on TV and in magazines making it seem as if drug treatment is the first thing you would reach for. Many pressures out there have been propelling practices to reach for a medication first,” she said. “[The guideline committee] felt very strongly that that is not what the evidence supports and that the primary response to these problems should be talking to your patients and counseling and education. Only after that fails should you go to a more complicated care or to drug treatment.”

Most women, even older women, are really pleased to know that there is an exercise they could do to make the situation better rather than needing to take another medication when they are already taking so many, she added.

Bladder changes due to aging

Aging does not cause incontinence, but the changes that occur in the bladder, the sphincter, and the urethra of aging women can predispose them to urgency incontinence or to a combination of urgency and stress incontinence, called mixed incontinence. Urgency incontinence is experienced as an intense, urgent, and overwhelming need to urinate.

Older women with incontinence often cannot get to a bathroom without leaking or wetting themselves, according to Neil M. Resnick, MD, FACP, chief of the division of geriatric medicine at the University of Pittsburgh. Some older women try to adapt to urgency incontinence by drinking less liquid, voiding more often, and becoming more attuned to how full their bladder is getting. “They also will know where all the bathrooms are, and if they have good mobility and good mental function, they can avert leakage by employing all those compensatory mechanisms,” he said.

But urgency incontinence can also be due to transient or readily reversible causes that often can have nothing to do with the urinary tract and are easily treated by an internist, Dr. Resnick noted. Internists should begin by asking the patient about any problems with leaking, wetting, or intense urges to urinate and should then screen for several conditions that can be tied to the problem, which can be remembered by the mnemonic DIAPERS:

• delirium, which can also lead to falls or broken bones,
• infection (UTI),
• atrophic urethritis,
• pharmaceuticals, including some of the drugs prescribed for hypertension (such as an alpha-blocker, which impairs contraction of the urethral sphincter) or ones that cause grogginess and over-medication as a side effect,
• excess fluid excretion caused by overconsumption of liquids,
• restricted mobility, such as that caused by ill-fitting shoes, drugs that cause muscle stiffening or orthostasis, or trouble with balance, and
• stool impaction, sometimes related to restricted fluid intake, that can affect the bladder and cause it to overfill and void without warning.

“These causes should be assiduously sought in every older person,” Dr. Resnick said. “They take about 5 to 10 minutes to seek out, are simple to treat, and they readily respond. About 20% of incontinence in older women will be cured by that approach alone. Nothing more fancy in diagnostic testing, no referral.” Even cases that don't completely resolve often improve, he noted, which may then make the patient more amenable to other treatment recommendations.

Diagnosis should also include a urine culture and an inspection of the perineum to assess for any contributing factors, such as prolapse or atrophy of the vaginal tissue, Dr. Forciea said.

Dr. Resnick added that women who have an intense desire to void may also have overflow incontinence, which can lead to leakage when the woman coughs or sneezes.

Internists can diagnose this problem by inserting a catheter into the bladder or by using a portable ultrasound to assess whether excess urine is left in the bladder after the patient has urinated. If those procedures cannot be done in the internist's office, the patient can be referred to a radiologist or urologist, Dr. Resnick said. Overflow incontinence is often linked with constipation and with certain medications, such as opiates or anticholinergics; it can also be due to an intrinsically weak bladder or, less commonly, to urethral obstruction that occasionally follows surgical correction of stress incontinence.

Diagnosing stress incontinence

Stress incontinence, the type most frequently found in younger and middle-aged women, is caused by a weakness in pelvic floor muscles that can produce urine leakage or an instantaneous squirt of urine with coughing, sneezing, bending over, climbing stairs, or any type of physical stress that causes the abdominal muscles to contract and put pressure on the bladder. The instantaneous release of urine can be confirmed by asking the patient to stand over an absorbent pad and cough. If the urine is released at exactly that moment, stress incontinence can be diagnosed.

There are several risk factors for stress incontinence, including pregnancy, chronic constipation, a chronic pulmonary condition, excess weight, and genetic makeup, according to Carol Glowacki, MD, assistant professor of obstetrics and gynecology at Temple University School of Medicine in Philadelphia. She recommends that diagnosis of stress incontinence include questions about the patient's daily fluid intake.

“Most people are under the misconception that they need to drink 8 cups of water or fluid a day, not separating water from tea or coffee or other foods, when in fact they are getting about half the fluids they need each day through food,” Dr. Glowacki said. Some women are drinking much more than 8 cups of fluid each day, because each of their “cups” may actually hold 12 to 24 ounces, she noted.

Diagnosis should also include questions about the patient's frequency of urination, she said. Some patients will need to keep a voiding diary to determine whether they are urinating often enough during the day. “Some people are going to the bathroom only twice a day, so you want to look at their void intervals and have them void more often. Inevitably a bladder can leak; it has its capacity,” she said.

Treatment options

Pelvic floor exercises, also called Kegels or Kegel exercises, are strongly recommended for management of stress incontinence in the ACP guideline and should be the starting point of treatment, Dr. Forciea said. The exercises can lead to a “tremendous improvement if women learn how to do the exercise properly,” she said.

Teaching Kegels takes time and some “cheering on of patients to practice Kegels for 4 to 6 weeks until they begin to see the improvement,” Dr. Forciea said, but although it can be time-consuming, she recommends that internists provide the instruction themselves or delegate the responsibility to another person in their office. “This is an inexpensive solution that has no consequences in terms of interactions, that empowers patients to do something for themselves and to be in control of their own bodies and improve their own lives,” she said.

Older women with urgency incontinence and mixed incontinence should also be encouraged to develop a toileting schedule and work on bladder training, Dr. Forciea said. In a toileting schedule, the woman first determines how long she can comfortably stay dry, then develops a schedule where she voids according to that interval. The next step is setting up a schedule where the woman extends that length of time by about 10 or 15 minutes each week. Doing so improves the muscle performance of the bladder, stretching the muscles slightly so that they have a more normal contract-and-relax pattern, Dr. Forciea said.

“Talk to the patient also about doing deep breathing, meditation, or finding distraction in a crossword puzzle or anything to get their minds off their bladder for 15 minutes,” she recommended.

Pharmaceutical therapy is available for urgency incontinence if Kegel exercises or other changes in the voiding schedule are not providing enough relief. The drugs do have side effects, however, with dry mouth, blurred vision, and constipation among the most common and troubling. There is a high dropoff rate of women who fill an initial prescription for these drugs and then never get a refill because of the side effects, Dr. Forciea said.

The ACP guideline lists effective pharmacologic treatments recommended for urgency incontinence if bladder training has proven unsuccessful, including oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium. For these drugs, Dr. Resnick recommends starting at lower doses than recommended to avoid many of the side effects. For example, he said that in his practice, giving oxybutynin at half doses will often make the treatment more tolerable to older women.

Systemic pharmacologic therapy is not recommended for stress incontinence in the ACP guideline. The guideline does note that patients should also be encouraged to lose weight, if needed; to limit their consumption of caffeine; and to give up smoking to reduce the need to cough. A patient can be referred to a specialist if these methods fail and there has been no significant improvement following fluid intake management or adherence to a voiding schedule.

Conservative management of urinary incontinence is an important starting point for all patients, Dr. Forciea stressed. “Then if a patient does not achieve the quality of life that they want, or can't figure out how to do Kegel exercises, or are really suffering with their incontinence even after doing Kegels and aren't dry enough to lead a fairly normal life, those are the patients to refer to a specialized continence clinic or to a urologist or gynecologist,” she said.