Treatment and management interventions
Each older adult’s life experience is unique, as is each person’s experience with UI. Effective treatment requires a multifaceted approach that focuses on the level of patient understanding and the impact of UI on QOL and function.
Lifestyle interventions. Behavior modification, lifestyle changes, and environmental interventions are first-line treatments for UI, with the goals of improving QOL, maintaining function and enhancing self-esteem. A specific UI diagnosis is not necessary before beginning treatment with noninvasive interventions that are simple, inexpensive, and measurable.
All behavioral interventions require active participation and motivation on the part of the person living with UI. Interventions should be individualized and mutually agreed upon with the older adult.
Risk factors that can be modified — such as weight, smoking, alcohol consumption, physical activity, ingestion of bladder irritants and fluid intake — as well as normalizing bowel patterns should be addressed with appropriate patients.
Education is a crucial component in the management of UI and should be accomplished with all patients regardless of UI diagnosis. Education dispels myths, helps with compliance issues, and empowers the older woman in optimal care of her health.
Pelvic-floor muscle exercises (PFMEs), or Kegel exercises, provide the foundation for an effective UI management program. While many women will report they are familiar with PFMEs, patients often explain that they practice while urinating on the toilet and starting/stopping the urine stream. This method actually disrupts voiding patterns, weakens pelvic muscles, and can lead to retention and UTIs. Women can use this method initially to identify the specific muscle group involved, but they should not engage in this method routinely.
The correct method to perform the exercises must be explained; written instructions should be given as well. Having the patient do several exercises while in the office will confirm that she is executing them correctly.
An effective approach to teaching PFMEs is to ask the patient to imagine trying to hold back the passage of flatus by squeezing the muscles in the pelvic region. If the patient is comfortable doing so, another method is to have her insert a finger into the vagina and squeeze the surrounding muscles. Relaxing the muscle helps the patient recognize the sensation she should feel when accurately performing PFMEs independently.
Patients should pull up the muscle as if they were trying to touch their chin. Exercises should be done following urination and can be accomplished in any position. Patients should be told not to lift their buttocks, tighten the abdomen or thigh muscles, move their legs, strain down or hold their breath.
In the beginning, the activity should be held for a slow count of 5 or 10, depending on the functional status and frailty of the patient. The patient should then relax for twice as long, or a count of 10 (20 if initially held for 10), to be sure the muscle has returned to baseline and there are no fasciculations. PFMEs should be carried out in a series of three to five repetitions at least three times a day. Patients should be instructed to do the exercises every day. To begin, the older adult should associate performing PFMEs while engaged in a daily activity, such as eating, grooming or taking medication, which helps promote adherence to the treatment regimen.
Inform the patient that a change in severity of urine leakage may take four to 12 weeks to achieve. PFMEs have been reported to provide an 81% reduction in urine leakage episodes.30 Emphasize the need for persistence with the exercises, which should become part of the woman’s daily routine. Positive benefits gained from performing PFMEs will be lost if the exercises are stopped, as the muscles will atrophy.31
A variety of devices are available to help patients with SUI, but numerous studies report poor adherence.32 Keep in mind the patient’s manual dexterity, visual acuity, and willingness to actually touch herself and insert the devices. Decisions on whether to utilize any of these devices should be individualized and mutually determined.
There are a plethora of absorbent products on the market. Know what is available and what is appropriate for each patient. While decreasing urine leakage is the expected outcome, it may still be necessary for the older adult to wear some type of disposable product to engage in social activities and decrease the possibility of urine odor, thus maintaining or improving QOL.
The type of pads or protective garments recommended should be individualized based on UI diagnosis, volume of incontinence and cost.33 The use of such products should not foster dependence or take away from other desirable treatment.34 Older adults should be discouraged from using plastic-lined, tight-fitting products at night because of the potential for skin breakdown and infection related to the warm and moist environment created by the use of various products and urine.
Pharmacotherapy. Medications are a major cause of UI and urinary retention in the elderly. Many frequently prescribed medications can cause urinary symptoms, including frequency and urge. Keep in mind that if a patient is receiving a sedative, hypnotic or analgesic, “any drug that dulls the brain, dulls the bladder, because your brain tells you when you have to void.”35 Pharmacotherapy may be useful to augment behavioral and lifestyle treatment and management interventions.
Most traditional anticholinergic therapies are limited in their effectiveness. For the treatment of SUI, anticholinergics are inappropriate and ineffective.36 Medications for UUI should not be used until other treatment interventions and modalities have failed over a sufficient period of time.
Drugs can be particularly helpful for women who have prominent urge symptoms, no cardiac problems or cognitive deficits, and can tolerate and address the side effects of dry mouth, blurry vision or constipation. If possible, halt or decrease dosages of current medications that may be contributing to UI before adding a drug to treat it.37 The well-known mantra for geriatric pharmacology, “start low and go slow,” should be invoked when prescribing drug therapy for UI.
At times, the patient is so distraught about UI that she is unable to engage in behavioral interventions at the outset of the treatment process. Appropriate drug therapy may help her gain some control over her symptoms and become more motivated to work on behavioral or lifestyle interventions. Behavioral therapies, lifestyle changes and environmental enhancement are the interventions of choice.
Referral. For most patients, UI can be handled effectively in the office setting. Interventions described in this article can be appropriately implemented and monitored by knowledgeable office-based clinicians. Circumstances for which referral should be considered include:
- Failure to respond to treatment over time
- Worsening symptoms
- Appearance of new symptoms
- Microscopic hematuria in the absence of infection
- Anatomical abnormalities or severe prolapse
- History of prior urologic corrective surgery followed by urine leakage
- Inability to determine a diagnosis after working with the patient for a reasonable length of time
- Positive neurologic findings in the absence of a current diagnosis
- A PVR (if completed) >200 mL on two occasions.
- Maintaining positive relationships with providers in the community who have expertise in UI is imperative
Continence surgery is indicated whenever conservative treatment fails or the patient wants definitive treatment.27 Surgery is the final management option for individuals with UI. Palliative measures can be used for those patients whose UI is not curable.38
Perhaps the single most important action that clinicians can take is to ask every older woman about UI and then to follow with the basic approaches to evaluation and management. Age-appropriate, evidence-based UI guidelines need to be part of the office practice.
UI should be approached from an interdisciplinary perspective in which a variety of health-care team members are able to gather information from the patient and provide individualized education in a holistic manner. Evidence exists that older adults demonstrate significant improvement in UI symptoms when education, counseling, support and encouragement in behavior management and lifestyle interventions are provided.
Continued UI research is warranted, especially research that includes older adults who reside in the community. Information obtained from voiding diaries is used extensively, yet reliability and validity of any specific instrument have not been tested with older adults. Hopelessness and spiritual distress, as precursors to health decline, and impact on QOL need to be studied more extensively in older adults with UI.
Research should aim at developing better outcome measures to assess the effectiveness of basic interventions for UI. UI is an aging problem and the people of the world are aging, thus making UI a global health concern that will not be going away soon.
Linda J. Keilman, DNP, GNP-BC, is an assistant professor and a gerontologic nurse practitioner at Michigan State University College of Nursing in East Lansing. The author has no relationships to disclose regarding the content of this article.
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