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Urinary Incontinence
Urinary Incontinence S. Lawrence Librach
CHAPTER OUTLINE
INTRODUCTION PHYSIOLOGY AND PATHOPHYSIOLOGY TYPES OF URINARY INCONTINENCE Overactive Bladder Syndrome Other Forms of Urgency Incontinence Stress Incontinence Overflow Incontinence Incontinence Secondary to Neurological Dysfunction Incontinence Associated with Cognitive Failure
11 ASSESSMENT MANAGEMENT Behavioral Therapy Pharmacologic Therapy Use of Diapers Skin Care Urinary Urethral Catheters Other Behavioral Techniques PEARLS PITFALLS SUMMARY
INTRODUCTION Urinary incontinence is a relatively common problem seen in patients at the end of life, but the exact prevalence is not clear. Studies of symptom prevalence at the end of life often do not mention urinary incontinence at all (1, 2), yet most patients who receive palliative care are also elderly, and this population is often affected by urinary incontinence. In fact, urinary incontinence affects 15% to 35% of community-dwelling, older adults and more than 50% of nursing home residents (3). There is a general reluctance for patients and families to discuss urinary incontinence. It may be that care providers assume that urinary incontinence is not a symptom in the ordinary sense, but rather a common, although less serious, problem at the end of life. Urinary incontinence can have a significant impact on quality of life. In its various forms, urinary incontinence may limit patients’ mobility and social interactions. Elderly patients with urinary incontinence are more likely to be placed 155
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in a nursing home. Those with limited, economic resources struggle to cope with the costs of seeking investigations and treatment. Urinary incontinence may also lead to depression. The impact of urinary incontinence on the place of care or on other aspects palliative care is not reported. If not properly managed, however, urinary incontinence may add to the suffering of these patients. Neglected urinary incontinence may lead to systemic infections, skin problems, and skin wounds, thus introducing other significant physical morbidity to patients who are already dealing with numerous symptoms at the end of life. One study showed that men are more likely than women to develop sexual dysfunction in association with urinary incontinence (4). Another study indicated that, among heterosexual couples, urinary incontinence correlates with interference of sexual satisfaction (5). Cultural attitudes toward urinary incontinence vary significantly. In North American culture, urinary incontinence is gaining recognition as a medical illness and is discussed more openly, even in television commercials. In other societies, however, urinary incontinence is still traditionally viewed as evidence of selfneglect, being unclean, having poor self-discipline, or being socially incompetent. Patients with urinary incontinence who live in such societies may manage their symptoms in isolation and secrecy (6). The onset of urinary incontinence may adversely affect self-esteem.
PHYSIOLOGY AND PATHOPHYSIOLOGY Micturition, the process of voiding urine from the bladder, is a complex process that involves the interplay of involuntary smooth muscle, voluntary striated muscle, the autonomic and somatic nervous systems, and the brain, as well as a cognitive aspect. The components of the system include the following (7):
The bladder wall is composed of a mesh of smooth muscle fibers. An internal, involuntary sphincter is composed of layers of smooth muscle at the bladder neck that surrounds the urethral orifice, known as the detrusor muscle. The outer layer of this smooth muscle continues in a circular fashion along the full length of the urethra in girls and women and to the distal prostate in boys and men, to forming the involuntary urethral sphincter. An external, voluntary sphincter made up of striated muscle interdigitating with smooth muscle is located between the layers of the urogenital diaphragm. In boys and men, these fibers are concentrated at the distal aspect of the prostate; in girls and women, they are found mainly in relation to the middle third of the urethra.
The innervation of the system is complex. The bladder receives its principal nerve supply from one paired somatic and two paired autonomic nerves. The hypogastric nerves (arising from lumbar spinal segments L1 and 2) mediate sympathetic activity, whereas the pelvic nerves (derived from S2-S4) contain parasympathetic fibers. The pudendal nerves (S2-S4) are primarily somatic fibers innervating the striated, voluntary sphincter. With distention of the bladder wall, stretch receptors trigger
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parasympathetic pelvic nerve fibers that, unless inhibited by higher centers, lead to a parasympathetic motor response and bladder contraction. In micturition, the detrusor muscle contracts, thus drawing the bladder downward, and the external sphincter, under voluntary control, relaxes. Micturition is inhibited by sympathetic nervous system stimulation. All are coordinated by higher centers to initiate or inhibit bladder emptying. Therefore, problems can arise at one or more levels: the physical structure of the bladder, the enervation of the bladder and urethra, and the cognitive function of the patient. Each may result in or may be a factor in urinary incontinence. Other factors may be involved in producing urinary incontinence. Estrogens may be associated with increased prevalence of urinary incontinence. Benzodiazepines and selective serotonin reuptake inhibitors are also associated with an increase in the frequency of urinary incontinence. Another factor in urinary incontinence needs to be mentioned here: urinary incontinence may result from failure by the care provider to manage reversible causes, such as urinary tract infections.
TYPES OF URINARY INCONTINENCE Overactive Bladder Syndrome Overactive bladder (OAB) is characterized by urgency, a sudden compelling desire to pass urine that is difficult to defer. It is usually accompanied by frequency and nocturia, and it may occur with urge urinary incontinence. The exact cause of OAB is not entirely known, but it is both myogenic and neurogenic. OAB affects about 16% of the adult population, and the prevalence increases with age. OAB can have a negative impact on health, ability to function, and quality of life. Elderly patients with urge urinary incontinence are also more likely to be admitted to nursing homes (8). Patients, families, and physicians may treat OAB as a normal consequence of aging, an attitude that results in underdiagnosis and undertreatment of this condition. In the typical population requiring palliative care, namely elderly patients, preexisting OAB can lead to urinary incontinence. As palliative care patients become weaker or have significant pain, it is more difficult for them to reach the washroom in time, and the result is urgency urinary incontinence.
Other Forms of Urgency Incontinence Inflammation of the bladder, tumors at or near the internal urethral orifice, urinary infections, inflammation secondary to radiation, and some neurological disorders may also result in an urgency type of urinary incontinence.
Stress Incontinence Stress urinary incontinence consists of involuntary urethral loss of urine associated with increased intra-abdominal pressure from coughing, sneezing, jumping, laughing, or, in severe cases, even walking. It is associated with faulty urethral support that results in abnormal sphincter function and an inability to resist increased
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bladder pressure. It is more common in women, but it can be present in men, especially those who have had prostate or bladder neck surgery. In female patients, parity, pelvic surgery, obesity, menopause, and smoking are also cofactors in the development of stress urinary incontinence. In palliative care, preexisting stress urinary incontinence may be made worse by symptoms such as poorly controlled coughing or nausea. New stress urinary incontinence may be caused by surgery to the bladder neck, radiation-induced inflammation and fibrosis, tumors external to the bladder that cause increased intravesical pressure, and spinal cord damage.
Overflow Incontinence The continuous urinary leakage seen with overflow urinary incontinence is mostly the result of overflow with chronic urinary retention secondary to urethral stricture or blockage. The bladder remains palpable and percussible, considerable residual urine is present, and the condition is nonpainful. Benign or malignant prostatic disease, spinal nerve damage, and urethral obstruction from tumors are common causes of this problem in palliative care.
Incontinence Secondary to Neurological Dysfunction Spinal cord damage from any cause, sacral tumors, pelvic surgery, and pelvic tumors that invade the nerve supply to the bladder may result in partial or total urinary incontinence.
Incontinence Associated with Cognitive Failure Patients who suffer from significant dementia or delirium are almost always incontinent.
ASSESSMENT An initial evaluation should include the following: 1. A good history. Ask about the following: urinary frequency; the presence of the sensation of urgency; leakage; the influence of activities that increase intra-abdominal pressure; a pattern of urinary incontinence (occasional, continual); neurogenic symptoms such as paresthesia, dysesthesia, anesthesia, motor weakness, or lack of sensation of bladder fullness; pain; and the presence of hematuria or dysuria. 2. A review of the patient’s disease process and treatments. 3. A review of previous imaging to look for sources of neurogenic urinary incontinence and pelvic masses. New imaging may be required, depending on the stage of the patient’s illness and whether this will change management. 4. Patient, caregiver, or care provider monitoring for at least 2 days. Ask for a voiding diary, which should record urinary frequency, urgency, volume of urine, relation to other symptoms (if any), and the presence of pain on urination. 5. A targeted physical examination. Ask for the following: an abdominal examination to exclude a distended bladder; a neurological assessment of the perineum and
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lower extremities; a pelvic examination in women, if warranted; a genital and prostate examination in men, if warranted; and a rectal examination to assess for pelvic masses and anal sphincter tone. This may include a bulbocavernosus reflex. Both are tests of nerve function to the area. 6. Urinalysis. Reagent strip testing of urine is a sensitive and inexpensive screening method that can be supplemented with urine microscopy and culture. 7. Depending on the patient’s illness stage, further investigations such as residual urine determination, urodynamic studies, and cystoscopy may be indicated if they can help with the management of urinary incontinence. Consultation with a urologist can be very helpful.
MANAGEMENT The management of urinary incontinence starts with evaluation for and treatment of reversible causes. Infections should be treated after urine has been obtained for a culture. Some change may need to be made once the organism’s sensitivity to antibiotics is determined. Prostatic obstruction may require surgical intervention, again depending on the stage of the illness. Urethral stricture may require dilation. Obviously, spinal cord compression must be dealt with in the usual fashion. For most palliative care patients, however, the conditions leading to urinary incontinence are not reversible, and a palliative approach must be taken. One of the most important steps in managing patients with nonreversible urinary incontinence is to educate the patient (when possible) and the family about the cause of the urinary incontinence and the various aspects of the treatment. Patients may need counseling to deal with their grief over this particular issue because it is often equated with the need for institutional care. The benefits of appropriate treatment need to be emphasized.
Behavioral Therapy Behavioral therapy includes techniques such as bladder training, timed or prompted voiding, pelvic muscle exercises, and biofeedback. Behavioral therapy may improve bladder control by changing the incontinent patient’s voiding habits and teaching skills for preventing urine loss (9). However, because of the multitude of issues facing palliative care patients, these techniques may be applicable only in the early palliative stages.
Pharmacologic Therapy OVERACTIVE BLADDER First-line therapy of OAB involves the use of anticholinergic drugs aimed at decreasing the urgency from detrusor muscle contractions. Commonly used agents include oral oxybutynin hydrochloride, tolterodine tartrate, and flavoxate hydrochloride. Controlled-release oxybutynin and transdermal oxybutynin are clearly effective in reducing episodes of urinary incontinence and are superior to placebo. Tolterodine, at a dose of at least 2 mg, is similarly effective in reducing episodes of
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urinary incontinence. Direct comparisons between oxybutynin and tolterodine show little treatment effect difference between the two drugs (10). Newer drugs have been marketed for the treatment of OAB. Trospium chloride has efficacy equivalent to twice-daily immediate-release oxybutynin and a lower incidence of dry mouth. Both darifenacin and solifenacin have proven efficacy and are available in once-daily formulations. Whether these agents have a distinct advantage over other anticholinergic drugs has yet to be determined, although they are marketed as having fewer side effects. Tricyclic antidepressant agents, often used as adjuvants for neuropathic pain, may be used for their anticholinergic effects. Pharmacologic treatment is problematic, however. Many patients do not improve much and may experience only a small reduction in episodes of urinary incontinence, and many experience no improvement. Complete continence is rarely achieved. Although this may be important for some patients, if urinary incontinence continues despite treatment, it produces a continued burden and frustration with quality of life. Because the benefits are unpredictable and have not been studied well in the palliative care patient (in whom OAB may be related to tumors and treatments), patients should be offered a brief trial of these anticholinergic agents. The most difficult part of taking these drugs may be the significant, adverse effects associated with their anticholinergic properties. Dry mouth is frequent, often occurring in the majority of patients. Palliative care patients frequently already have dry mouth because of oral candidiasis, chemotherapy and radiation treatments, and other medications, particularly opioids. The addition of further xerostomia from these agents may be intolerable to these patients. Constipation, already a very common problem in palliative care patients, may also be increased. These drugs should be used cautiously in patients with gastric or intestinal hypomotility because they enhance those problems. Anticholinergic drugs should also be avoided in patients with significantly impaired renal or hepatic function. Patients with cardiac arrhythmias cannot take these drugs. Major side effects, such as ventricular arrhythmias or sudden death, are not associated with anticholinergic drugs. Few central nervous system effects are observed in clinical trials of the specific agents, but these drugs may be associated with sedation, hallucinations, and confusion, particularly in elderly patients. Again, palliative care patient populations have not been studied.
STRESS INCONTINENCE a-Adrenergic and b-adrenergic agonists, such as phenylpropanolamine hydrochloride, midodrine, and pseudoephedrine, increase the internal sphincter tone and bladder outflow resistance. b-Adrenergic agonists may also have some effect. a-Adrenergic receptors are widespread in the cardiovascular system, however, which is the mechanism for systemic cardiovascular side effects such as arrhythmia and hypertension. A meta-analysis of the effects of the adrenergic agonist drugs phenylpropanolamine and midodrine suggests that an adrenergic agonist drug is more effective than placebo in reducing the number of pad changes and episodes of urinary incontinence and in improving subjective symptoms (11). Patients who use adrenergic agonists usually experience minor side effects that rarely result in discontinuation of treatment. These include dizziness, palpitations, excitability,
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and sleep disturbance. Rare but serious side effects, such as cardiac arrhythmias and hypertension, may occur. OVERFLOW INCONTINENCE For the overflow urinary incontinence that results from benign prostatic hypertrophy, the relief of outflow obstruction using a-blocker therapy is based on the hypothesis that clinical, prostatic hypertrophy is caused partly by a1-adrenergic– mediated contraction of prostatic, smooth muscle that results in bladder outlet obstruction. Treatment options for symptomatic patients include a-adrenergic antagonists such as alfuzosin, doxazosin, tamsulosin, and terazosin. The data suggest that these agents are equally effective. Data are insufficient to support a recommendation for the use of prazosin hydrochloride. Adverse effects of these drugs include nasal congestion, hypotension, fatigue, ejaculatory problems, cardiac arrhythmias, headaches, and edema (12). The 5-a-reductase inhibitors finasteride and dutasteride are effective for patients who have demonstrable prostatic enlargement, but these are long-term treatments. Patients who have symptomatic prostatic enlargement but no symptoms can be offered a 5-a-reductase inhibitor to retard progression of the disease, but response is limited. The benefit of these drugs in palliative care patients is not clear.
Use of Diapers Diaper or pad technology has advanced rapidly. Diapers are now more absorbent, suppress odors better, and are more fitted, thus reducing the possibility of leakage. The cost may be significant, but it is offset by reduction in care provider time, the need to launder bedding, the ability to keep someone at home, and the reduced stress of family caregivers. Diapers need to be changed frequently. Family members who are caring for the patient at home should be educated about how to apply the diapers so minimal lifting is required. Patients can be dressed and still wear a diaper. Diapers may be problematic in the patient with severe incident pain, however, so urinary catheters should be considered in these patients. Incontinence pads are probably overused and are not very effective in absorbing large quantities of urine.
Skin Care Urinary incontinence that is not adequately treated can lead to skin problems. Skin maceration and irritation can be minimized by frequent diaper changes, the treatment of skin candidiasis and intertrigo, and the use of barrier creams that usually contain silicone or zinc oxide to protect the skin. Skin that is irritated is much more likely to develop wounds, and wound prevention strategies must be employed.
Urinary Urethral Catheters Urinary catheters are often seen as a last resort for patients with urinary incontinence. The major problem with catheters relates to the development of infections
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with long-term use. Although urinary catheters are used with relative frequency in palliative care settings, few reviews have been done. A urinary catheter should be considered for incontinent patients if behavioral changes, nursing care, special clothes, special bed clothes, and medication changes are unsuccessful. Indications for the use of a urinary catheter in palliative care patients include the following (13): 1. Management or prevention of decubitus ulcers and other skin wounds 2. Painful, physical movements that preclude frequent changes of clothes and bed linen 3. A decision by the patient and family that dryness and comfort outweigh the risks of catheterization 4. Overflow urinary incontinence associated with obstruction 5. Urine retention that is not surgically correctable 6. Continuous bladder irrigation in patients with hemorrhage from bladder tumors 7. An explicit request from the patient or family (primarily for patients at the end of life) External, condom catheters have been used for a long time in men. They are poorly accepted by patients, are often difficult to apply and maintain in place, and are uncomfortable. They are associated with skin irritation and ulceration, urinary infections, and (rarely) penile gangrene from inappropriate fitting and neglect. Unless they are preferred by patients, it is probably best to avoid the use of these devices in palliative care. Indwelling urinary catheters can be made of material such as rubber or silicone and may be impregnated with antibacterial chemicals. Complications of indwelling catheters include bladder and urethral infections, pyelonephritis, septicemia, bladder spasm, and hemorrhage from the bladder. It has not been determined whether palliative care patients are more susceptible to these problems because of their cachexia and reduced immune function. Most patients with catheters and asymptomatic bacteriuria should not receive antimicrobial therapy (14). The rationale for this recommendation includes the following: 1. The risk of complications from asymptomatic bacteriuria is low. 2. Treatment does not prevent bacteriuria from recurring. 3. Treatment may lead to the presence of antimicrobial-resistant bacteria that are more challenging to treat. Most experts recommend against using antimicrobial agents to eradicate bacteriuria in asymptomatic patients unless the patient has an abnormal urinary tract or will soon undergo genitourinary tract manipulation or instrumentation. The introduction of the closed-drainage indwelling catheter system is an extremely important advance in the prevention of urinary catheter-related infections. The use of a presealed, urinary catheter junction (as delivered in most catheter sets these days) is important. Aseptic insertion techniques and careful maintenance of the catheter and drainage bag are essential. The collection bag should remain below the level of the bladder to prevent reflux of urine into the bladder, and the drainage tube should be checked for kinking. The drainage bag should be emptied at least
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twice daily. Finally, glove use and proper hand hygiene practices are important in preventing the acquisition of pathogens. Several different types of urethral catheters with anti-infective properties have been developed and evaluated. One such anti-infective catheter uses silver, an effective antibacterial substance, in the form of silver alloy. Results of one meta-analysis indicate that silver alloy catheters are likely to prevent bacteriuria (15), but the effect of these catheters on the more important clinical outcomes (e.g., bacteremia) remains to be determined. Although silver alloy catheters are more expensive, they seem economically efficient when they are used in patients who receive indwelling catheterization for 2 to 10 days (16). Catheters impregnated with antibiotics are now being evaluated, although they may be problematic because of the induction of antibiotic-resistant organisms. Intermittent catheterization is a common method of urinary collection in patients with overflow urinary incontinence, especially from spinal cord damage. Inserting and removing a sterile or clean urinary catheter several times daily may reduce the risk of bacteriuria (compared with an indwelling catheter), and the technique can be taught to patients and family members. Suprapubic catheters may be required in patients with urethral obstruction from tumors.
Other Behavioral Techniques It may be possible to prevent urgency urinary incontinence by prompting the patient to void frequently and to suppress the urge initially by tightening the voluntary sphincter. In institutions, the patient must be brought to toileting facilities before the urge becomes too great. If the patient is bed bound, ready access to urine bottles for men or to slipper-type bedpans for women may avoid embarrassing urinary incontinence. Reduced cognitive abilities may, however, make these interventions ineffective.
PEARLS
Urinary incontinence has important negative effects on quality of life. Careful assessment to determine the type of urinary incontinence may lead to specific but limited pharmacologic treatment. Indwelling urinary catheters can be used effectively in palliative care patients when indicated.
PITFALLS
Ignoring urinary incontinence will increase patients’ suffering and will decrease quality of life. Unless managed properly with aseptic technique, indwelling catheters can become a source of infection.
SUMMARY Urinary incontinence is a relatively frequent occurrence in palliative care patients, and it is a sensitive issue for patients and family. Management requires
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careful assessment, education and counseling, and a variety of medications. It often requires instrumentation such as catheters, especially in the last few days of life.
References 1. Kutner JS, Kassner CT, Nowels DE: Symptom burden at the end of life: Hospice providers perceptions. J Pain Symptom Manage 2001;21:473–480. 2. Solano JP, Gomes B, Higginson IJ: A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006;31:58–69. 3. Diokno AC: The epidemiology of urinary incontinence. J Gerontol Med Sci 2001;56:3–4. 4. Temml C, Haidinger G, Schmidbauer J, et al: Urinary incontinence in both sexes: Prevalence rates and impact on quality of life and sexual life. Neurourol Urodynam 2000;19:259–271. 5. Barber MD, Visco AG, Wyman JF, et al: Continence Program for Women Research Group: Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002;99:281–289. 6. Wilson MG: Urinary incontinence: A treatise on gender, sexuality, and culture. Clin Geriatr Med 2004;20:565–570. 7. Madersbacher H, Madersbacher S. Men’s bladder health: Part I. Urinary incontinence in the elderly. J Mens Health Gender 2005;2:31–37. 8. Thom DH, Haan MN, Van Den Eeden SK: Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing 1997;26:367–374. 9. Lavelle JP, Karam M, Chu FM, et al: Management of incontinence for family practice physicians. Am J Med 2006;119(Suppl 3A):37–40. 10. Thomas DR: Pharmacologic management of urinary incontinence. Clin Geriatr Med 2004; 20:511–523. 11. Alhasso A, Glazener CM, Pickard R, N’Dow J: Adrenergic drugs for urinary incontinence in adults. Cochrane Database Syst Rev 2003;2CD001842. 12. American Urological Association Practice Guidelines Committee: AUA Guideline on Management of Benign Prostatic Hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170:530–547. 13. Fainsinger R, Bruera E: Urinary catheters in palliative care. J Pain Symptom Manage 1991;6:449–451. 14. Saint S, Chenoweth CE: Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003;17:411–432. 15. Saint S, Elmore JG, Sullivan SD, et al: The efficacy of silver alloy coated urinary catheters in preventing urinary tract infection: A meta-analysis. Am J Med 1998;105:236–241. 16. Plowman R, Graves N, Esquivel J, Roberts JA: An economic model to assess the cost and benefits of the routine use of silver alloy coated urinary catheters to reduce the risk of urinary tract infections in catheterized patients. J Hosp Infect 2001;48:33–42.
CHAPTER OUTLINE
INTRODUCTION PHYSIOLOGY AND PATHOPHYSIOLOGY TYPES OF URINARY INCONTINENCE Overactive Bladder Syndrome Other Forms of Urgency Incontinence Stress Incontinence Overflow Incontinence Incontinence Secondary to Neurological Dysfunction Incontinence Associated with Cognitive Failure
11 ASSESSMENT MANAGEMENT Behavioral Therapy Pharmacologic Therapy Use of Diapers Skin Care Urinary Urethral Catheters Other Behavioral Techniques PEARLS PITFALLS SUMMARY
INTRODUCTION Urinary incontinence is a relatively common problem seen in patients at the end of life, but the exact prevalence is not clear. Studies of symptom prevalence at the end of life often do not mention urinary incontinence at all (1, 2), yet most patients who receive palliative care are also elderly, and this population is often affected by urinary incontinence. In fact, urinary incontinence affects 15% to 35% of community-dwelling, older adults and more than 50% of nursing home residents (3). There is a general reluctance for patients and families to discuss urinary incontinence. It may be that care providers assume that urinary incontinence is not a symptom in the ordinary sense, but rather a common, although less serious, problem at the end of life. Urinary incontinence can have a significant impact on quality of life. In its various forms, urinary incontinence may limit patients’ mobility and social interactions. Elderly patients with urinary incontinence are more likely to be placed 155
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in a nursing home. Those with limited, economic resources struggle to cope with the costs of seeking investigations and treatment. Urinary incontinence may also lead to depression. The impact of urinary incontinence on the place of care or on other aspects palliative care is not reported. If not properly managed, however, urinary incontinence may add to the suffering of these patients. Neglected urinary incontinence may lead to systemic infections, skin problems, and skin wounds, thus introducing other significant physical morbidity to patients who are already dealing with numerous symptoms at the end of life. One study showed that men are more likely than women to develop sexual dysfunction in association with urinary incontinence (4). Another study indicated that, among heterosexual couples, urinary incontinence correlates with interference of sexual satisfaction (5). Cultural attitudes toward urinary incontinence vary significantly. In North American culture, urinary incontinence is gaining recognition as a medical illness and is discussed more openly, even in television commercials. In other societies, however, urinary incontinence is still traditionally viewed as evidence of selfneglect, being unclean, having poor self-discipline, or being socially incompetent. Patients with urinary incontinence who live in such societies may manage their symptoms in isolation and secrecy (6). The onset of urinary incontinence may adversely affect self-esteem.
PHYSIOLOGY AND PATHOPHYSIOLOGY Micturition, the process of voiding urine from the bladder, is a complex process that involves the interplay of involuntary smooth muscle, voluntary striated muscle, the autonomic and somatic nervous systems, and the brain, as well as a cognitive aspect. The components of the system include the following (7):
The bladder wall is composed of a mesh of smooth muscle fibers. An internal, involuntary sphincter is composed of layers of smooth muscle at the bladder neck that surrounds the urethral orifice, known as the detrusor muscle. The outer layer of this smooth muscle continues in a circular fashion along the full length of the urethra in girls and women and to the distal prostate in boys and men, to forming the involuntary urethral sphincter. An external, voluntary sphincter made up of striated muscle interdigitating with smooth muscle is located between the layers of the urogenital diaphragm. In boys and men, these fibers are concentrated at the distal aspect of the prostate; in girls and women, they are found mainly in relation to the middle third of the urethra.
The innervation of the system is complex. The bladder receives its principal nerve supply from one paired somatic and two paired autonomic nerves. The hypogastric nerves (arising from lumbar spinal segments L1 and 2) mediate sympathetic activity, whereas the pelvic nerves (derived from S2-S4) contain parasympathetic fibers. The pudendal nerves (S2-S4) are primarily somatic fibers innervating the striated, voluntary sphincter. With distention of the bladder wall, stretch receptors trigger
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parasympathetic pelvic nerve fibers that, unless inhibited by higher centers, lead to a parasympathetic motor response and bladder contraction. In micturition, the detrusor muscle contracts, thus drawing the bladder downward, and the external sphincter, under voluntary control, relaxes. Micturition is inhibited by sympathetic nervous system stimulation. All are coordinated by higher centers to initiate or inhibit bladder emptying. Therefore, problems can arise at one or more levels: the physical structure of the bladder, the enervation of the bladder and urethra, and the cognitive function of the patient. Each may result in or may be a factor in urinary incontinence. Other factors may be involved in producing urinary incontinence. Estrogens may be associated with increased prevalence of urinary incontinence. Benzodiazepines and selective serotonin reuptake inhibitors are also associated with an increase in the frequency of urinary incontinence. Another factor in urinary incontinence needs to be mentioned here: urinary incontinence may result from failure by the care provider to manage reversible causes, such as urinary tract infections.
TYPES OF URINARY INCONTINENCE Overactive Bladder Syndrome Overactive bladder (OAB) is characterized by urgency, a sudden compelling desire to pass urine that is difficult to defer. It is usually accompanied by frequency and nocturia, and it may occur with urge urinary incontinence. The exact cause of OAB is not entirely known, but it is both myogenic and neurogenic. OAB affects about 16% of the adult population, and the prevalence increases with age. OAB can have a negative impact on health, ability to function, and quality of life. Elderly patients with urge urinary incontinence are also more likely to be admitted to nursing homes (8). Patients, families, and physicians may treat OAB as a normal consequence of aging, an attitude that results in underdiagnosis and undertreatment of this condition. In the typical population requiring palliative care, namely elderly patients, preexisting OAB can lead to urinary incontinence. As palliative care patients become weaker or have significant pain, it is more difficult for them to reach the washroom in time, and the result is urgency urinary incontinence.
Other Forms of Urgency Incontinence Inflammation of the bladder, tumors at or near the internal urethral orifice, urinary infections, inflammation secondary to radiation, and some neurological disorders may also result in an urgency type of urinary incontinence.
Stress Incontinence Stress urinary incontinence consists of involuntary urethral loss of urine associated with increased intra-abdominal pressure from coughing, sneezing, jumping, laughing, or, in severe cases, even walking. It is associated with faulty urethral support that results in abnormal sphincter function and an inability to resist increased
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bladder pressure. It is more common in women, but it can be present in men, especially those who have had prostate or bladder neck surgery. In female patients, parity, pelvic surgery, obesity, menopause, and smoking are also cofactors in the development of stress urinary incontinence. In palliative care, preexisting stress urinary incontinence may be made worse by symptoms such as poorly controlled coughing or nausea. New stress urinary incontinence may be caused by surgery to the bladder neck, radiation-induced inflammation and fibrosis, tumors external to the bladder that cause increased intravesical pressure, and spinal cord damage.
Overflow Incontinence The continuous urinary leakage seen with overflow urinary incontinence is mostly the result of overflow with chronic urinary retention secondary to urethral stricture or blockage. The bladder remains palpable and percussible, considerable residual urine is present, and the condition is nonpainful. Benign or malignant prostatic disease, spinal nerve damage, and urethral obstruction from tumors are common causes of this problem in palliative care.
Incontinence Secondary to Neurological Dysfunction Spinal cord damage from any cause, sacral tumors, pelvic surgery, and pelvic tumors that invade the nerve supply to the bladder may result in partial or total urinary incontinence.
Incontinence Associated with Cognitive Failure Patients who suffer from significant dementia or delirium are almost always incontinent.
ASSESSMENT An initial evaluation should include the following: 1. A good history. Ask about the following: urinary frequency; the presence of the sensation of urgency; leakage; the influence of activities that increase intra-abdominal pressure; a pattern of urinary incontinence (occasional, continual); neurogenic symptoms such as paresthesia, dysesthesia, anesthesia, motor weakness, or lack of sensation of bladder fullness; pain; and the presence of hematuria or dysuria. 2. A review of the patient’s disease process and treatments. 3. A review of previous imaging to look for sources of neurogenic urinary incontinence and pelvic masses. New imaging may be required, depending on the stage of the patient’s illness and whether this will change management. 4. Patient, caregiver, or care provider monitoring for at least 2 days. Ask for a voiding diary, which should record urinary frequency, urgency, volume of urine, relation to other symptoms (if any), and the presence of pain on urination. 5. A targeted physical examination. Ask for the following: an abdominal examination to exclude a distended bladder; a neurological assessment of the perineum and
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lower extremities; a pelvic examination in women, if warranted; a genital and prostate examination in men, if warranted; and a rectal examination to assess for pelvic masses and anal sphincter tone. This may include a bulbocavernosus reflex. Both are tests of nerve function to the area. 6. Urinalysis. Reagent strip testing of urine is a sensitive and inexpensive screening method that can be supplemented with urine microscopy and culture. 7. Depending on the patient’s illness stage, further investigations such as residual urine determination, urodynamic studies, and cystoscopy may be indicated if they can help with the management of urinary incontinence. Consultation with a urologist can be very helpful.
MANAGEMENT The management of urinary incontinence starts with evaluation for and treatment of reversible causes. Infections should be treated after urine has been obtained for a culture. Some change may need to be made once the organism’s sensitivity to antibiotics is determined. Prostatic obstruction may require surgical intervention, again depending on the stage of the illness. Urethral stricture may require dilation. Obviously, spinal cord compression must be dealt with in the usual fashion. For most palliative care patients, however, the conditions leading to urinary incontinence are not reversible, and a palliative approach must be taken. One of the most important steps in managing patients with nonreversible urinary incontinence is to educate the patient (when possible) and the family about the cause of the urinary incontinence and the various aspects of the treatment. Patients may need counseling to deal with their grief over this particular issue because it is often equated with the need for institutional care. The benefits of appropriate treatment need to be emphasized.
Behavioral Therapy Behavioral therapy includes techniques such as bladder training, timed or prompted voiding, pelvic muscle exercises, and biofeedback. Behavioral therapy may improve bladder control by changing the incontinent patient’s voiding habits and teaching skills for preventing urine loss (9). However, because of the multitude of issues facing palliative care patients, these techniques may be applicable only in the early palliative stages.
Pharmacologic Therapy OVERACTIVE BLADDER First-line therapy of OAB involves the use of anticholinergic drugs aimed at decreasing the urgency from detrusor muscle contractions. Commonly used agents include oral oxybutynin hydrochloride, tolterodine tartrate, and flavoxate hydrochloride. Controlled-release oxybutynin and transdermal oxybutynin are clearly effective in reducing episodes of urinary incontinence and are superior to placebo. Tolterodine, at a dose of at least 2 mg, is similarly effective in reducing episodes of
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urinary incontinence. Direct comparisons between oxybutynin and tolterodine show little treatment effect difference between the two drugs (10). Newer drugs have been marketed for the treatment of OAB. Trospium chloride has efficacy equivalent to twice-daily immediate-release oxybutynin and a lower incidence of dry mouth. Both darifenacin and solifenacin have proven efficacy and are available in once-daily formulations. Whether these agents have a distinct advantage over other anticholinergic drugs has yet to be determined, although they are marketed as having fewer side effects. Tricyclic antidepressant agents, often used as adjuvants for neuropathic pain, may be used for their anticholinergic effects. Pharmacologic treatment is problematic, however. Many patients do not improve much and may experience only a small reduction in episodes of urinary incontinence, and many experience no improvement. Complete continence is rarely achieved. Although this may be important for some patients, if urinary incontinence continues despite treatment, it produces a continued burden and frustration with quality of life. Because the benefits are unpredictable and have not been studied well in the palliative care patient (in whom OAB may be related to tumors and treatments), patients should be offered a brief trial of these anticholinergic agents. The most difficult part of taking these drugs may be the significant, adverse effects associated with their anticholinergic properties. Dry mouth is frequent, often occurring in the majority of patients. Palliative care patients frequently already have dry mouth because of oral candidiasis, chemotherapy and radiation treatments, and other medications, particularly opioids. The addition of further xerostomia from these agents may be intolerable to these patients. Constipation, already a very common problem in palliative care patients, may also be increased. These drugs should be used cautiously in patients with gastric or intestinal hypomotility because they enhance those problems. Anticholinergic drugs should also be avoided in patients with significantly impaired renal or hepatic function. Patients with cardiac arrhythmias cannot take these drugs. Major side effects, such as ventricular arrhythmias or sudden death, are not associated with anticholinergic drugs. Few central nervous system effects are observed in clinical trials of the specific agents, but these drugs may be associated with sedation, hallucinations, and confusion, particularly in elderly patients. Again, palliative care patient populations have not been studied.
STRESS INCONTINENCE a-Adrenergic and b-adrenergic agonists, such as phenylpropanolamine hydrochloride, midodrine, and pseudoephedrine, increase the internal sphincter tone and bladder outflow resistance. b-Adrenergic agonists may also have some effect. a-Adrenergic receptors are widespread in the cardiovascular system, however, which is the mechanism for systemic cardiovascular side effects such as arrhythmia and hypertension. A meta-analysis of the effects of the adrenergic agonist drugs phenylpropanolamine and midodrine suggests that an adrenergic agonist drug is more effective than placebo in reducing the number of pad changes and episodes of urinary incontinence and in improving subjective symptoms (11). Patients who use adrenergic agonists usually experience minor side effects that rarely result in discontinuation of treatment. These include dizziness, palpitations, excitability,
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and sleep disturbance. Rare but serious side effects, such as cardiac arrhythmias and hypertension, may occur. OVERFLOW INCONTINENCE For the overflow urinary incontinence that results from benign prostatic hypertrophy, the relief of outflow obstruction using a-blocker therapy is based on the hypothesis that clinical, prostatic hypertrophy is caused partly by a1-adrenergic– mediated contraction of prostatic, smooth muscle that results in bladder outlet obstruction. Treatment options for symptomatic patients include a-adrenergic antagonists such as alfuzosin, doxazosin, tamsulosin, and terazosin. The data suggest that these agents are equally effective. Data are insufficient to support a recommendation for the use of prazosin hydrochloride. Adverse effects of these drugs include nasal congestion, hypotension, fatigue, ejaculatory problems, cardiac arrhythmias, headaches, and edema (12). The 5-a-reductase inhibitors finasteride and dutasteride are effective for patients who have demonstrable prostatic enlargement, but these are long-term treatments. Patients who have symptomatic prostatic enlargement but no symptoms can be offered a 5-a-reductase inhibitor to retard progression of the disease, but response is limited. The benefit of these drugs in palliative care patients is not clear.
Use of Diapers Diaper or pad technology has advanced rapidly. Diapers are now more absorbent, suppress odors better, and are more fitted, thus reducing the possibility of leakage. The cost may be significant, but it is offset by reduction in care provider time, the need to launder bedding, the ability to keep someone at home, and the reduced stress of family caregivers. Diapers need to be changed frequently. Family members who are caring for the patient at home should be educated about how to apply the diapers so minimal lifting is required. Patients can be dressed and still wear a diaper. Diapers may be problematic in the patient with severe incident pain, however, so urinary catheters should be considered in these patients. Incontinence pads are probably overused and are not very effective in absorbing large quantities of urine.
Skin Care Urinary incontinence that is not adequately treated can lead to skin problems. Skin maceration and irritation can be minimized by frequent diaper changes, the treatment of skin candidiasis and intertrigo, and the use of barrier creams that usually contain silicone or zinc oxide to protect the skin. Skin that is irritated is much more likely to develop wounds, and wound prevention strategies must be employed.
Urinary Urethral Catheters Urinary catheters are often seen as a last resort for patients with urinary incontinence. The major problem with catheters relates to the development of infections
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with long-term use. Although urinary catheters are used with relative frequency in palliative care settings, few reviews have been done. A urinary catheter should be considered for incontinent patients if behavioral changes, nursing care, special clothes, special bed clothes, and medication changes are unsuccessful. Indications for the use of a urinary catheter in palliative care patients include the following (13): 1. Management or prevention of decubitus ulcers and other skin wounds 2. Painful, physical movements that preclude frequent changes of clothes and bed linen 3. A decision by the patient and family that dryness and comfort outweigh the risks of catheterization 4. Overflow urinary incontinence associated with obstruction 5. Urine retention that is not surgically correctable 6. Continuous bladder irrigation in patients with hemorrhage from bladder tumors 7. An explicit request from the patient or family (primarily for patients at the end of life) External, condom catheters have been used for a long time in men. They are poorly accepted by patients, are often difficult to apply and maintain in place, and are uncomfortable. They are associated with skin irritation and ulceration, urinary infections, and (rarely) penile gangrene from inappropriate fitting and neglect. Unless they are preferred by patients, it is probably best to avoid the use of these devices in palliative care. Indwelling urinary catheters can be made of material such as rubber or silicone and may be impregnated with antibacterial chemicals. Complications of indwelling catheters include bladder and urethral infections, pyelonephritis, septicemia, bladder spasm, and hemorrhage from the bladder. It has not been determined whether palliative care patients are more susceptible to these problems because of their cachexia and reduced immune function. Most patients with catheters and asymptomatic bacteriuria should not receive antimicrobial therapy (14). The rationale for this recommendation includes the following: 1. The risk of complications from asymptomatic bacteriuria is low. 2. Treatment does not prevent bacteriuria from recurring. 3. Treatment may lead to the presence of antimicrobial-resistant bacteria that are more challenging to treat. Most experts recommend against using antimicrobial agents to eradicate bacteriuria in asymptomatic patients unless the patient has an abnormal urinary tract or will soon undergo genitourinary tract manipulation or instrumentation. The introduction of the closed-drainage indwelling catheter system is an extremely important advance in the prevention of urinary catheter-related infections. The use of a presealed, urinary catheter junction (as delivered in most catheter sets these days) is important. Aseptic insertion techniques and careful maintenance of the catheter and drainage bag are essential. The collection bag should remain below the level of the bladder to prevent reflux of urine into the bladder, and the drainage tube should be checked for kinking. The drainage bag should be emptied at least
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twice daily. Finally, glove use and proper hand hygiene practices are important in preventing the acquisition of pathogens. Several different types of urethral catheters with anti-infective properties have been developed and evaluated. One such anti-infective catheter uses silver, an effective antibacterial substance, in the form of silver alloy. Results of one meta-analysis indicate that silver alloy catheters are likely to prevent bacteriuria (15), but the effect of these catheters on the more important clinical outcomes (e.g., bacteremia) remains to be determined. Although silver alloy catheters are more expensive, they seem economically efficient when they are used in patients who receive indwelling catheterization for 2 to 10 days (16). Catheters impregnated with antibiotics are now being evaluated, although they may be problematic because of the induction of antibiotic-resistant organisms. Intermittent catheterization is a common method of urinary collection in patients with overflow urinary incontinence, especially from spinal cord damage. Inserting and removing a sterile or clean urinary catheter several times daily may reduce the risk of bacteriuria (compared with an indwelling catheter), and the technique can be taught to patients and family members. Suprapubic catheters may be required in patients with urethral obstruction from tumors.
Other Behavioral Techniques It may be possible to prevent urgency urinary incontinence by prompting the patient to void frequently and to suppress the urge initially by tightening the voluntary sphincter. In institutions, the patient must be brought to toileting facilities before the urge becomes too great. If the patient is bed bound, ready access to urine bottles for men or to slipper-type bedpans for women may avoid embarrassing urinary incontinence. Reduced cognitive abilities may, however, make these interventions ineffective.
PEARLS
Urinary incontinence has important negative effects on quality of life. Careful assessment to determine the type of urinary incontinence may lead to specific but limited pharmacologic treatment. Indwelling urinary catheters can be used effectively in palliative care patients when indicated.
PITFALLS
Ignoring urinary incontinence will increase patients’ suffering and will decrease quality of life. Unless managed properly with aseptic technique, indwelling catheters can become a source of infection.
SUMMARY Urinary incontinence is a relatively frequent occurrence in palliative care patients, and it is a sensitive issue for patients and family. Management requires
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careful assessment, education and counseling, and a variety of medications. It often requires instrumentation such as catheters, especially in the last few days of life.
References 1. Kutner JS, Kassner CT, Nowels DE: Symptom burden at the end of life: Hospice providers perceptions. J Pain Symptom Manage 2001;21:473–480. 2. Solano JP, Gomes B, Higginson IJ: A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006;31:58–69. 3. Diokno AC: The epidemiology of urinary incontinence. J Gerontol Med Sci 2001;56:3–4. 4. Temml C, Haidinger G, Schmidbauer J, et al: Urinary incontinence in both sexes: Prevalence rates and impact on quality of life and sexual life. Neurourol Urodynam 2000;19:259–271. 5. Barber MD, Visco AG, Wyman JF, et al: Continence Program for Women Research Group: Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002;99:281–289. 6. Wilson MG: Urinary incontinence: A treatise on gender, sexuality, and culture. Clin Geriatr Med 2004;20:565–570. 7. Madersbacher H, Madersbacher S. Men’s bladder health: Part I. Urinary incontinence in the elderly. J Mens Health Gender 2005;2:31–37. 8. Thom DH, Haan MN, Van Den Eeden SK: Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing 1997;26:367–374. 9. Lavelle JP, Karam M, Chu FM, et al: Management of incontinence for family practice physicians. Am J Med 2006;119(Suppl 3A):37–40. 10. Thomas DR: Pharmacologic management of urinary incontinence. Clin Geriatr Med 2004; 20:511–523. 11. Alhasso A, Glazener CM, Pickard R, N’Dow J: Adrenergic drugs for urinary incontinence in adults. Cochrane Database Syst Rev 2003;2CD001842. 12. American Urological Association Practice Guidelines Committee: AUA Guideline on Management of Benign Prostatic Hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170:530–547. 13. Fainsinger R, Bruera E: Urinary catheters in palliative care. J Pain Symptom Manage 1991;6:449–451. 14. Saint S, Chenoweth CE: Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003;17:411–432. 15. Saint S, Elmore JG, Sullivan SD, et al: The efficacy of silver alloy coated urinary catheters in preventing urinary tract infection: A meta-analysis. Am J Med 1998;105:236–241. 16. Plowman R, Graves N, Esquivel J, Roberts JA: An economic model to assess the cost and benefits of the routine use of silver alloy coated urinary catheters to reduce the risk of urinary tract infections in catheterized patients. J Hosp Infect 2001;48:33–42.