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Tailor-made incontinence care: match type of incontinence to resident assessment for optimal treatment. Second of two parts. (Incontinence).

THE FIRST STEP IN TREATING URINARY incontinence is to determine what type of incontinence the resident has. This can be accomplished through a detailed assessment such as the one outlined in part one of this series. (See "Urinary incontinence in elderly women," August 2002 CLTG, page 18.) Once the incontinence is classified, the physician should discuss goals of treatment with the resident, her family, and caregiver. In some cases, complete dryness may not be possible and improvement of symptoms may be a more tangible goal.

Another important issue is what type of treatment the resident is willing or able to endure. Some residents are too fragile to undergo surgical treatments, while others lack the cognitive function to participate in more conservative modes of therapy. This article reviews the available treatments and postoperative care for women age 65 and older.

Stress urinary incontinence (SUE) Noninvasive treatments

* Pelvic floor exercises (PEE) and biofeedback. PFEs are commonly referred to as Kegel exercises. These exercises are periodic, voluntary contractions of the pelvic floor muscles that are designed to increase muscle tone.' This non-surgical approach to the treatment of SUI is associated with very low morbidity and reasonable success rates. Subjective improvements of up to 84 percent have been reported among motivated residents.

Biofeedback involves monitoring of the PFEs by vaginal, perineal, or rectal probes and relaying this information back to the resident via a computer screen or printout. This technique provides resident reinforcement and guidance as to proper muscle utilization and duration and amplitude of the contraction. Biofeedback training of PFEs is usually done weekly in a physician's office and is discontinued once the resident can identify and contract the proper pelvic muscles. Residents are then instructed to perform PFEs several times per day. Motivation is critical to durable success and maintenance programs are essential. Unfortunately, recurrence of SUI is inevitable if the PFEs are discontinued.

* Medical Therapy. In postmenopausal women, local hormonal treatment of the vaginal mucosa--in the form of tablets or intravaginal estrogen cream--has been shown to improve symptoms of SUI. These agents improve the quality of the vaginal tissues and the ability of the urethra to form a tight seal, which help prevent urine leakage. There is no interaction with oral hormonal intake, and it is often recommended in preparation for vaginal surgery.

* Uretbral or vaginal devices. There are several devices designed to control SUI by occluding the urethra or supporting the bladder neck. Ninety percent of women report significant improvement with intraurethral devices. But the risks of these devices, such as blood in the urine and urinary tract infection, prevent their widespread use. Additionally, many elderly residents cannot remove these devices independently and require the aid of a caregiver when they need to urinate.

Invasive treatments

* Endoscopic. Minimally invasive surgical procedures that are designed to improve bladder outlet resistance have included endoscopic injection of bullring agents into the urethra or bladder neck. The currently preferred agent is glutaraldehyde-cross-linked collagen. This agent is injected while the resident is under local anesthesia in a physician's office. Although rates of initial improvement vary depending upon the severity of SUI, they can be as high as 70 percent to 90 percent. Complete and lasting cures are infrequent and favorable early results tend to decline over time, so repeat injections are often necessary.

Approximately 3 percent of residents have an allergy to collagen and thus are not candidates for this mode of therapy. For these residents, fat injection has been used, but it has proved to be less durable than collagen. Carbon-coated beads are another FDA-approved injectable agent that recently became available for the treatment of SUI. Mid- and long-term results are not yet available.

* Surgical. Surgery for SUI is designed to restore support to the bladder neck and to improve bladder outlet resistance without causing bladder outlet obstruction. It may be performed vaginally or abdominally, but vaginal procedures generally allow shorter convalescence and are less painful. Often, they are the best choice for elderly residents.

A bladder neck suspension (BNS) stabilizes the proximal urethra and bladder neck. Sutures are placed at the level of the bladder neck and attached to ligaments within the pelvis, the pubic bone, or the tendinous insertion of the rectus muscle. Success rates range from 60 percent to 85 percent after four to seven years of follow-up.

A pubovaginal sling (PVS) increases the urethra's resistance to the intra-abdominal pressure that causes urine leakage. This is accomplished by placing a hammock on the under-surface of the urethra to provide urethral closure upon increase in intra-abdominal pressure. Materials used for the hammock include the resident's own tissues (vaginal wall, rectus fascia, and fascia lata); donor tissues (cadaveric fascia); and synthetics (Marlex mesh, Prolene mesh, Gortex, etc.). The success rate for PVS is approximately 85 percent at 4 years of follow-up. (2)

Urge urinary incontinence (UUI)

Noninvasive treatments

* Behavior modification. Often, especially after the treating physician reviews the resident's voiding diary, it may be apparent that social habits contribute to the resident's UUI. The physician may suggest that the resident limit fluid intake, or, if a diuretic is prescribed, reduce the amount or alter the time at which it is taken. Also, the resident may be prompted to urinate at specified time intervals (every two to three hours) instead of only when the urge arises. These simple behavior adjustments may make a significant difference in the resident's quality of life.

PFEs and biofeedback are effective treatments for UUI. Contraction of the pelvic floor muscles may inhibit the involuntary bladder contractions responsible for UUI. These exercises are done in the same manner as for SUI. Again, resident motivation is the best indicator of success and recurrence will occur if PFEs are discontinued.

* Medical Therapy Medical therapy aims to reduce unstable bladder contractions during filling and to increase bladder capacity. To accomplish this, anticholinergics (oxybutinin chloride or tolterodine) may be prescribed. These medications are usually taken one to three times per day and are usually effective after several weeks of therapy. If the resident is known to have an overactive bladder and a weak bladder contraction, these medications may cause urinary retention. Anticholinergics have been known to cause dry mouth and constipation, which can be quite bothersome.

* Surgical treatment. Historically, UUI has not been successfully treated with surgery. These procedures include bladder denervation, insertion of sacral nerve stimulators, and bladder augmentation. Bladder augmentation is indicated when the resident has a very small bladder capacity and high voiding pressures. This procedure is rarely performed in the elderly due to its complexity and associated morbidity. Thus, the elderly are usually managed with bladder drainage in the form of urethral or suprapubic catheters.

* Catheters. This mode of treatment is most convenient for residents and caregivers, but it is associated with significant complications. Chronic catheterization can predispose the resident to urinary tract infections, bladder stones, and bladder cancer. As a result, intermittent catheterization is preferred over chronic catheterization in most instances. A chronic indwelling catheter should be changed every four to six weeks.

All of the surgical procedures described can be done under general or regional anesthesia, and require a one or two night hospital stay. Longer procedures and longer hospitalization are required when additional procedures--such as hysterectomy or correction of pelvic organ prolapse--are necessary. Most residents are discharged with a urethral catheter and suprapubic tube. Once the catheter is removed, the suprapubic tube serves as a means to check the post void residual urine volume. As with all anti-incontinence procedures, there is a risk of postoperative urinary retention. This is usually transient and secondary to tissue swelling. Independent voiding is usually achieved within five to seven days. There is a 5 percent and 8 percent risk of long-term (greater than four weeks) urinary retention with the BNS and PVS procedures, respectively. (2)

The options available to treat and manage urinary incontinence in elderly women are many. The decision on which one would best serve your resident's needs should be discussed with the resident, her family, her physician, and her caregiver and based on a thorough assessment.

References

(1.) Bo K, Talseth T, et al. Single-blind, randomized control trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. Br Med J 1999;318:487-493.

(2.) Leach GE, Dmochowski RR, Appell RA, et al. Report on the surgical management of female stress urinary incontinence clinical practice guidelines. Baltimore: American Urological Association, 1997.

Tracey Small Wilson, MD, is a fellow in female urology, urodynamics, and pelvic reconstruction; and Phillipe F. Zimmern, MD, is professor of urology and director of Bladder Incontinence Center; both at University of Texas Southwestern Medical Center, Dallas.
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Author:Zimmern, Philippe E.
Publication:Contemporary Long Term Care
Date:Sep 1, 2002
Words:1440
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