Urinary Incontinence Strategies for Frail Elderly Women

Deborah Lekan-Rutledge

Disclosures

Urol Nurs. 2004;24(4) 

In This Article

Pharmacologic Treatment

Drug therapy is most often directed for two types of incontinence: stress and urge. Drug therapy for overflow incontinence for an underactive or atonic bladder is generally not effective and is not recommended (Urinary Incontinence Guideline Panel, 1996). Drug therapy for stress incontinence is limited. Drugs with alpha-adrenergic agonist actions are believed to increase the urethral sphincter smooth muscle tone leading to improved urethral closure and resistance, thus preventing urine leakage with increased intra-abdominal pressure. The most common drug used for this purpose is pseudoephedrine in its short or long-acting form. However, use of pseudoephedrine in the frail elderly is very limited because of adverse side effects including tachycardia, hypertension, dyspnea, dizziness, nervousness, and abdominal cramping. Duloxetine, a combined serotonin and noradrenaline reuptake inhibitor, is currently under review by the Food and Drug Administration as an agent for increasing external urethral sphincter tone and closure pressure in treating stress incontinence (Newman, 2003b).

The evidence to support estrogen therapy as primary treatment for stress incontinence is not conclusive (Fantl et al., 1996). Estrogen is beneficial for treating vaginal atrophy, urethritis, and atrophic vaginitis, all due to estrogen deficiency. These conditions are often associated with irritative symptoms. Although estrogen therapy increases stimulation of urogenital estrogen receptors and may increase urethral resistance, it is uncertain whether it has a clinically significant effect in preventing stress incontinence. Local treatment with estrogen therapy can help alleviate irritative symptoms, improve the frail older woman's urogenital comfort, and help prevent skin rashes and vaginal infection. Examples include topical estrogen creams (Premarin®, Estrace®, Ogen®), vaginal tablets (Vagifem®), or an elastomer ring (similar to a diaphragm but without the inner latex cup) containing a slow-release estrogen (Estring®). Estring has a 90-day duration and may be more acceptable to the frail older woman over creams or tablets. Replacement of the ring must be done by an advanced practice nurse or physician. Local therapy can be used adjunctively with systemic estrogen therapy to improve local estrogenization.

Drug therapy for urge incontinence is also limited. The primary drugs used in practice are two antispasmodic/antimuscarinic agents: oxybutinin hydrochloride (Ditropan® and Ditropan XL®, Oxytrol® transdermal patch), and tolterodine tartrate (Detrol® and Detrol LA®). These drugs increase residual urine volume, volume at which the first sensation of bladder filling is felt, volume at which the normal desire to void occurs, and maximum bladder pressure during voiding, thus decreasing contractility. Both drugs have an affect on the salivary glands leading to marked dry mouth; however, this effect may be less pronounced with tolterodine tartrate. Tolterodine tartrate has limited use in persons with liver or renal dysfunction.

The tricyclic antidepressant imipramine (Tofranil®) is occasionally used in women who have mixed incontinence be cause it has both anticholinergic/antimuscarinic and alpha-adrenergic activity. Dosages for urge incontinence are lower than the therapeutic dose for treating clinical depression. Adverse side effects often limit the use of imipramine in the frail elderly, especially the cardiovascular side effects including postural hypotension, dizziness, bradycardia, and dysrhythmias, as well as weakness and fatigue. When used, administering this drug at bedtime may help reduce nocturia and urge incontinence during the night and its sedating effects may help with sleep and reduce daytime sedation. Some individuals experience insomnia or excessive stimulation from the drug, in which case, daytime administration is recommended. Since all of the aforementioned drugs can cause urinary retention, voiding patterns and urine output should be monitored. Anticholinergics/antimuscarinics are contraindicated in persons already diagnosed with urinary retention or narrow-angle glaucoma.

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