From the Guidelines
For a 73-year-old female with urge urinary incontinence, I strongly recommend starting with bladder training as the first-line treatment, as suggested by the American College of Physicians guideline 1. This approach involves scheduled voiding every 2-3 hours while awake, gradually increasing intervals as symptoms improve.
- Bladder training can help improve bladder capacity and reduce the frequency of urge incontinence episodes.
- Additionally, pelvic floor exercises (Kegels) can be performed to strengthen urinary control, by contracting the pelvic floor muscles for 5 seconds, 10-15 repetitions, 3 times daily.
- Limiting bladder irritants such as caffeine, alcohol, and artificial sweeteners, and reducing fluid intake in the evening can also help minimize nighttime urgency. If these measures are insufficient after 4-6 weeks, pharmacologic treatment can be considered, with the choice of medication based on tolerability, adverse effect profile, ease of use, and cost of medication, as recommended by the American College of Physicians guideline 1.
- Anticholinergic medications like oxybutynin (starting at 5mg once daily) or tolterodine (2mg twice daily) can be effective, but they carry risks of confusion, dry mouth, and constipation in older adults.
- Beta-3 agonists like mirabegron (25mg daily, increasing to 50mg if needed) may offer fewer cognitive side effects. Regular reassessment every 3 months is important to evaluate efficacy and side effects, and to adjust the treatment plan as needed 1.
From the FDA Drug Label
CLINICAL STUDIES Tolterodine tartrate tablets were evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in four randomized, double-blind, placebo-controlled, 12-week studies. The efficacy endpoints for study 007 (see Table 3) included the change from baseline for: Number of incontinence episodes per week Number of micturitions per 24 hours (averaged over 7 days) Volume of urine voided per micturition (averaged over 2 days)
Management of Urge Incontinence:
- The patient is a 73-year-old female with urge incontinence.
- Tolterodine 2 and Trospium 3 are two medications that have been studied for the treatment of overactive bladder with symptoms of urge urinary incontinence.
- Both medications have been shown to be effective in reducing the number of incontinence episodes, urinary frequency, and increasing void volume.
- However, the mean age of patients in the studies was 60 years, and it is unclear how these medications will perform in a 73-year-old female.
- Conservative Clinical Decision:
- Consider starting with a low dose and gradually increasing as needed and tolerated.
- Monitor the patient closely for adverse effects and efficacy.
- Consider consulting with a specialist if the patient's symptoms do not improve or if adverse effects occur.
From the Research
Management of Urge Incontinence
The management of urge incontinence in a 73-year-old female can be approached through various treatment options.
- Behavioral modification is the first-line treatment, which includes bladder retraining and pelvic floor muscle exercises, as recommended by 4.
- Neuromodulation devices, such as posterior tibial nerve stimulators, can be considered if behavioral therapy is unsuccessful, as stated in 4.
- Pharmacologic therapy with medications like mirabegron and onabotulinumtoxinA can be used to treat urge incontinence, although anticholinergic medications are not recommended for older adults due to adverse effects, as noted in 4.
- Sacral nerve stimulators, which are surgically implanted, have also been shown to improve symptoms of urge incontinence, as mentioned in 4.
Role of Pelvic Floor Muscle Training
Pelvic floor muscle training (PFMT) is a widely recommended conservative treatment for incontinence and overactive bladder, as discussed in 5.
- PFMT can be used to control bladder function and is effective for incontinence, urgency, frequency, and nocturia.
- It can be combined with other treatment modalities and holds potential for prevention of bladder symptoms, as stated in 5.
Irrelevant Study
The study 6 is not relevant to the management of urge incontinence in a 73-year-old female, as it discusses the histidine in the nucleotide-binding site of NADP-linked isocitrate dehydrogenase from pig heart.