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KEY CONCEPTS

KEY CONCEPTS

  • imageIn evaluating urinary incontinence (UI), drug-induced or drug-aggravated etiologies must be ruled out.

  • imageAccurate diagnosis and classification of UI type are critical to the selection of appropriate pharmacotherapy.

  • imageGoals of treatment for UI are reduction of symptoms, minimization of adverse effects, and improvement in quality of life.

  • imageNonpharmacologic, nonsurgical treatment is the first-line treatment for several types of UI, and should be continued even when drug therapy is initiated.

  • imageAntimuscarinic agents are second-line treatments for urgency incontinence. Choice of agent should be based on patient characteristics (eg, age, comorbidities, concurrent medications, and ability to adhere to the prescribed regimen).

  • imageβ3-Adrenergic agonists (mirabegron, vibegron) can be considered in patients who failed to achieve optimal efficacy or cannot tolerate adverse effects of antimuscarinic agents.

  • imageDuloxetine (approved in Europe only), α-adrenergic receptor agonists, and topical (vaginal) estrogens (alone or together) are the drugs of choice for urethral underactivity (stress urinary incontinence).

  • imageAssessment of patient outcomes should include efficacy, adverse effects, adherence, and quality of life.

  • imageManagement of UI should target individualized goals and treatment preferences, which may change over time. If therapeutic goals are not achieved with a given agent at optimal dosage for an adequate duration of trial, consider switching to an alternative agent and/or surgery.

PATIENT CARE PROCESS

Patient Care Process for Urinary Incontinence

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Collect

  • Patient characteristics (eg, age, sex, pregnancy status, drug allergy profile)

  • Patient medical and genitourinary surgical history including coexisting conditions that may influence UI

  • Obstetric and menstrual history in women

  • Past conservative, medical, and surgical treatment of UI

  • Social history (tobacco/ethanol use; caffeine and fluid intake; environmental issues; exercise; availability of family caregiver, if relevant)

  • Current medications (see Table 105-1) including over-the-counter (OTC), herbal products, and dietary supplements

  • Objective data

    • Lab tests: urinalysis ± urine culture; if infected, treat and reassess if appropriate

    • Cough stress test to demonstrate stress UI (if appropriate)

    • Postvoid residual urine by bladder ultrasound or catheterization (if suspected urinary retention/overflow incontinence)

Assess

  • Urinary symptoms including bladder diary (see Table 105-2)

  • Presence of bowel symptoms or vaginal prolapse symptoms (in women); estrogen status in women

  • Quality of life, treatment preferences, and goals

  • Mental status, body mass index, physical dexterity, and mobility

  • Abdominal, rectal, prostate (in men), neurological, and pelvic examination (in women)

Plan*

  • Nonpharmacological interventions based on UI severity and subtype (see Table 105-3)

  • Drug therapy regimen for urgency UI, if indicated (see Table 105-5)

  • Monitoring parameters (see Tables 105-6 and 105-7); frequency and timing of follow-up

  • Patient education (eg, purpose of treatment, dietary and lifestyle modification, drug-specific information)

  • Self-monitoring for resolution of UI symptoms and drug adverse events (if indicated)

  • Referrals to other providers when appropriate (eg, urologist, urogynecologist, continence nurse practitioner, physical therapist)

Implement*

  • Provide patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up (eg, adherence assessment, treatment response)

Follow-up: Monitor and Evaluate...

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