Management of Urinary Incontinence in Older Adults in Rehabilitation Care Settings
Purpose of Review
This review focuses on updates in the management of urinary incontinence occurring in older adult populations living with conditions frequently managed by physical medicine and rehabilitation specialists.
Urinary incontinence is common among older adults who live with neurologic diseases, such as stroke, Parkinson’s disease, multiple sclerosis, and traumatic brain injury, and may be cared for in outpatient and acute rehabilitation facilities. While the evidence is growing regarding treatment strategies specific to patients with neurogenic bladder, behavioral treatment approaches may be a viable first option depending on cognitive status and mobility. Drug therapy choices should consider mechanism of action and formulation to minimize the potential for adverse effects. Minimally invasive strategies provided by continence specialists are available for refractory symptoms.
Evidence suggests a multidisciplinary approach incorporating multicomponent treatment strategies can improve common urinary symptoms among older adults in both outpatient and acute inpatient rehabilitation settings of care.
KeywordsUrinary incontinence Acute inpatient rehabilitation Neurogenic bladder Behavioral therapy Drug therapy
Compliance with Ethical Standards
Conflict of Interest
Camille Vaughan reports that her spouse is a full-time employee at Kimberly-Clark Corp outside the submitted work, and grant funding from the US Department of Veterans Affairs, National Institutes of Health, and the Agency for Healthcare Research & Quality. Colleen Fitzgerald reports personal fees from an UptoDate Editor, non-financial support from Board Membership with the International Pelvic Pain Society, personal fees from employment with the Loyola University Chicago Medical Center, personal fees from Expert Testimony, grants from NICHD K23 (finished in 2016), travel and registration expenses as a PAINweek lecturer, and personal fees as an editor outside the submitted work. In addition, Dr. Fitzgerald has a US Patent Application No. 14/213,880 issued. Alayne Markland declares no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 1.• Mallinson T, Fitzgerald CM, Neville CE, Almagor O, Manheim L, Deutsch A, et al. Impact of urinary incontinence on medical rehabilitation inpatients. 2017;36(1):176–83. https://doi.org/10.1002/nau.22908. Summary of studies demonstrating prevalence of incontinence and association with clinical outcomes in common rehabiliation patients.
- 3.Vaughan CP, Markland AD, Smith PP, Burgio KL, Kuchel GA. Report and research agenda of the American Geriatrics Society and National Institute on Aging bedside-to-bench conference on urinary incontinence in older adults: a translational research agenda for a complex geriatric syndrome. J Am Geriatr Soc. 2017;66(4):773–82. https://doi.org/10.1111/jgs.15157.Google Scholar
- 4.Milsom I, Altman D, Cartwright R, Lapitan MCM, Nelson R, Sjostrom S, et al. Epidemiology of urinary incontinence and other lower urinary tract symptoms, pelvic organ prolapse, and anal incontinence. Incontinence 6th edition. Bristol, UK: International Continence Society; 2017.Google Scholar
- 5.Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–78.Google Scholar
- 7.Hall SA, Curto TM, Onyenwenyi A, Lemack GE, Tennstedt SL, Link CL, et al. Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) survey. 2012;31(7):1149–55. https://doi.org/10.1002/nau.22232.
- 8.Ruffion A, Castro-Diaz D, Patel H, Khalaf K, Onyenwenyi A, Globe D, et al. Systematic review of the epidemiology of urinary incontinence and detrusor overactivity among patients with neurogenic overactive bladder. Neuroepidemiology. 2013;41(3–4):146–55. https://doi.org/10.1159/000353274.Google Scholar
- 9.Kushner DS, Johnson-Greene D. Association of urinary incontinence with cognition, transfers and discharge destination in acute stroke inpatient rehabilitation. J Stroke Cerebrovasc Dis. 2018;27(10):2677–82. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.05.028.Google Scholar
- 10.Kovindha A, Wattanapan P, Dejpratham P, Permisirivanich W, Kuptniratsaikul V. Prevalence of incontinence in patients after stroke during rehabilitation: a multi-centre study. J Rehabili Med. 2009;41(6):489–91.Google Scholar
- 13.Balash Y, Peretz C, Leibovich G, Herman T, Hausdorff JM, Giladi N. Falls in outpatients with Parkinson’s disease: frequency, impact and identifying factors. J Neurol. 2005;252:1310–5.Google Scholar
- 16.Tanji H, Anderson KE, Gruber-Baldini AL, Fishman PS, Reich SG, Weiner WJ, et al. Mutuality of the marital relationship in Parkinson’s disease. Mov Disord. 2008;23(13):1843–9.Google Scholar
- 18.Aarsland D, Larsen JP, Tandberg E, Laake K. Predictors of nursing home placement in Parkinson’s disease: a population-based, prospective study. J Am Geriatr Soc. 2000;48(8):938–42.Google Scholar
- 19.Fink H, Kuskowski M, Taylor B, Schousboe J, Orwoll E, Ensrud K, et al. Association of Parkinson’s disease with accelerated bone loss, fractures and mortality in older men: the Osteoporotic Fractures in Men (MrOS) study. Osteoporos Int. 2008;19(9):1277–82. https://doi.org/10.1007/s00198-008-0584-4.Google Scholar
- 21.Zecca C, Riccitelli GC, Disanto G, Singh A, Digesu GA, Panicari L, et al. Urinary incontinence in multiple sclerosis: prevalence, severity and impact on patients’ quality of life. 2016;23(7):1228–34. https://doi.org/10.1111/ene.13010.
- 23.Khalaf KM, Coyne KS, Globe DR, Armstrong EP, Malone DC, Burks J. Lower urinary tract symptom prevalence and management among patients with multiple sclerosis. Int J MS Care. 2015;17(1):14–25.Google Scholar
- 24.Keller JJ, Liu S-P, Lin H-C. Traumatic brain injury increases the risk of female urinary incontinence. 2013;32(4):354–8. https://doi.org/10.1002/nau.22309.
- 26.Davis NJ, Vaughan CP, Johnson TM II, Goode PS, Burgio KL, Redden DT, et al. Caffeine intake and its association with urinary incontinence in United States men: results from National Health and Nutrition Examination Surveys. J Urol. 2013;189(6):2170–4. https://doi.org/10.1016/j.juro.2012.12.061.Google Scholar
- 29.Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infect Dis Clin N Am. 2003;17(2):367–94.Google Scholar
- 31.Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ et al. Diagnosis, evaluation, and follow-up of asymptomatic microhematuria in adults. American Urological Association. 2016. https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-for-currency-2016). Accessed November 30 2018.
- 32.Cifu DX, Stewart DG. Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions. Arch Phys Med Rehabil. 1999;80(5 Suppl 1):S35–9.Google Scholar
- 33.Wikander B, Ekelund P, Milsom I. An evaluation of multidisciplinary intervention governed by functional independence measure (FIMSM) in incontinent stroke patients. Scand J Rehabil Med. 1998;30(1):15–21.Google Scholar
- 37.Thomas LH, French B, Sutton CJ, Forshaw D, Leathley MJ, Burton CR et al. Programme Grants for applied research. Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care. Southampton (UK): NIHR journals library, Southampton SO16 7NS, UK.; 2015.Google Scholar
- 39.Vaughan CP, Burgio KL, Goode PS, Juncos JL, McGwin G Jr, Johnson TM 2nd. Pelvic floor muscle exercise-based behavioral therapy improves urinary symptoms in Parkinson disease (abstract). Mov Disord. 2017;32(9):e18.Google Scholar
- 41.Tornic J, Sartori AM, Gajewski JB, Cox A, Schneider MP, Youssef NA, et al. Catheterization for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: a systematic review. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS). Neurourol Urodyn. 2018;37(8):2315–22. https://doi.org/10.1002/nau.23733.Google Scholar
- 50.Halleberg Nyman M, Forsman H, Wallin L, Ostaszkiewicz J, Hommel A, Eldh AC. Promoting evidence-based urinary incontinence management in acute nursing and rehabilitation care-a process evaluation of an implementation intervention in the orthopaedic context. J Eval Clin Pract. 2018;25:282–9. https://doi.org/10.1111/jep.12879.Google Scholar
- 53.Amarenco G, Sutory M, Zachoval R, Agarwal M, Del Popolo G, Tretter R, et al. Solifenacin is effective and well tolerated in patients with neurogenic detrusor overactivity: results from the double-blind, randomized, active- and placebo-controlled SONIC urodynamic study. Neurourol Urodyn. 2017;36(2):414–21. https://doi.org/10.1002/nau.22945.Google Scholar
- 54.Yamanouchi. Vesicare (solifenacin succinate) tablet prescribing information. Paramus, NJ2004.Google Scholar
- 55.Chapple CR, Nazir J, Hakimi Z, Bowditch S, Fatoye F, Guelfucci F, et al. Persistence and adherence with mirabegron versus antimuscarinic agents in patients with overactive bladder: a retrospective observational study in UK clinical practice. Eur Urol. 2017;72(3):389–99. https://doi.org/10.1016/j.eururo.2017.01.037.Google Scholar
- 56.Kelleher C, Hakimi Z, Zur R, Siddiqui E, Maman K, Aballéa S, et al. Efficacy and tolerability of mirabegron compared with antimuscarinic monotherapy or combination therapies for overactive bladder: a systematic review and network meta-analysis. Eur Urol. 2018;74(3):324–33. https://doi.org/10.1016/j.eururo.2018.03.020.Google Scholar
- 57.Burgio KL, Goode PS, Johnson TM, Hammontree L, Ouslander JG, Markland AD, et al. Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial. J Am Geriatr Soc. 2011;59(12):2209–16. https://doi.org/10.1111/j.1532-5415.2011.03724.x.Google Scholar
- 58.Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial. JAMA. 2006;296(19):2319–28.Google Scholar
- 60.Maund E, Guski LS, Gøtzsche PC. Considering benefits and harms of duloxetine for treatment of stress urinary incontinence: a meta-analysis of clinical study reports. Can Med Assoc J. 2017;189(5):E194–203.Google Scholar
- 61.Canbaz Kabay S, Kabay S, Mestan E, Cetiner M, Ayas S, Sevim M, et al. Long term sustained therapeutic effects of percutaneous posterior tibial nerve stimulation treatment of neurogenic overactive bladder in multiple sclerosis patients: 12-months results. 2017;36(1):104–10. https://doi.org/10.1002/nau.22868.
- 62.Kabay S, Canbaz Kabay S, Cetiner M, Mestan E, Sevim M, Ayas S, et al. The clinical and urodynamic results of percutaneous posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with Parkinson’s disease. Urology. 2016;87:76–81. https://doi.org/10.1016/j.urology.2015.09.026.Google Scholar
- 64.• Visco AG, Brubaker L, Richter HE, Nygaard I, MFR P, Menefee SA, et al. Anticholinergic therapy vs. onabotulinumtoxinA for urgency urinary incontinence. N Engl J Med. 2012;367(19):1803–13. https://doi.org/10.1056/NEJMoa1208872. While not performed in a neurogenic bladder population, this comparative effectiveness trial in 249 women demonstrates the relative benefits and risks of onabotulinumtoxinA compared with anticholinergic drug therapy. The group receiving onabotulinumtoxinA was less likely to have dry mouth and had higher rates of transient urinary retention and urinary tract infections. Reductions in incontinence episodes were similar between the two groups. Google Scholar
- 65.• Amundsen CL, Richter HE, Menefee SA, et al. Onabotulinumtoxina vs sacral neuromodulation on refractory urgency urinary incontinence in women: a randomized clinical trial. JAMA. 2016;316(13):1366–74. https://doi.org/10.1001/jama.2016.14617. While not performed in a neurogenic bladder population, this comparative effectiveness study in 364 women with a mean age of 63 years showed the two treatments had clinically similar impact to reduce urgency urinary incontinence. OnabotulinumtoxinA was associted with higher risk of urinary tract infections and transient need for self-catheterization. Neuromodulation device revisions and removals occurred in 3% of participants. Google Scholar
- 66.Knüpfer SC, Schneider SA, Averhoff MM, Naumann CM, Deuschl G, Jünemann K-P, et al. Preserved micturition after intradetrusor onabotulinumtoxinA injection for treatment of neurogenic bladder dysfunction in Parkinson’s disease. BMC Urol. 2016;16(1):55. https://doi.org/10.1186/s12894-016-0174-2.Google Scholar
- 68.Kennelly M, Dmochowski R, Schulte-Baukloh H, Ethans K, Del Popolo G, Moore C, et al. Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: final results of a long-term extension study. Neurourol Urodyn. 2017;36(2):368–75. https://doi.org/10.1002/nau.22934.Google Scholar