Urinary Incontinence Revisited: George Kuchel & Alison Huang

Eric 00:09

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And, Alex, who do we have with us today?

Alex 00:16

Today we’re delighted to welcome George Kuchel, who is a geriatrician and chief of geriatrics and director of the UConn center on Aging at the University of Connecticut. George, welcome to the GeriPal podcast.

George 00:28

Hi, guys. Nice to be on.

Alex 00:30

And we’re delighted to welcome Alison Huang, who’s a primary care doc and researcher and professor of medicine, urology, and epi-biostats at UCSF in the division of General Internal Medicine. Alison and I go way back. Welcome to GeriPal.

Alison 00:44

Thank you. Delighted to be here.

Alex 00:46

A little known fact, we go way, way back. Alison and I were in med school together. She invited me over to her apartment to watch Buffy the vampire Slayer. I accepted, went there, and met my future wife, Cindy Hsu.

Eric 01:00

No way. Really?

George 01:02

Yes.

Alex 01:03

Also a med student. Yep.

Eric 01:04

All thanks to Alison.

Alison 01:06

I like to take credit.

George 01:07

That’s real history in the making.

Eric 01:10

Well, before we start on our topic, which is urinary incontinence, we always ask for a song request. Who has a song request for Alex?

Alison 01:18

Well, I think we want to go with Oops, I Did it Again by Britney Spears.

Eric 01:24

Very apt for the title of urinary incontinence. I suggested even flow. That’s a good one.

Alex 01:31

We’ll do that. Save that one for a future podcast. I do like that one. And someone else suggested Under Pressure, but we’d already done it. And of course, we did Let it Go, on our last podcast about urinary incontinence with Scott Bauer and Christine Kistler. All right, here’s a little bit.

(singing)

Alison 02:33

That was great, Alex. Britney Spears has got nothing on you.

George 02:39

Agreed.

Eric 02:42

We’ve got a lot to cover. On today’s podcast, we’re going to be talking about urinary incontinence. And I’m going to start off with you, George. How do you think about this? Is this just a bladder problem, or is this a bigger geriatric syndrome problem?

George 03:01

So I would say that as many clinical issues in older adults, we need to think about them in two ways. Incontinence and avoiding issues can present in an older individual, in some cases, just like they do a younger person. You certainly can have, as Alison knows well, you can have an older lady who has stress incontinence while coughing or playing tennis, just like younger women. And the issues are essentially the same. But then there is incontinence, which is the same term, same word, but actually presents as a geriatric syndrome.

And it’s really a different kettle of fish. The only thing they have in common is that involves is the outcome, which is incontinence, and the billing code, but as a term implies, psychiatric syndromes. And what that means is these are multifactorial conditions that occur later in life, most typically. And so they have multiple etiologies. There’s no single risk factor. There are multiple different risk factors, both predisposing and precipitating, just like we see with delirium, just like we see with frailty and other geometric syndromes. And the other thing they have in common is that geriatric syndromes cross typical boundaries across typical. As your question alluded to, it’s not just a bladder problem, but issues having to do with mobility and fluid balance and ignition are closely, closely related. Yeah. So similar, yet very different.

Eric 04:31

Yeah. Why is it associated with aging? What’s the aging component? Just that these things, like functionality issues, are common in older adults. Cognition issues are common in older adults. Is there something about what’s going on there that we see that age is the most common risk factor for these things?

George 04:50

It is. And both the incidence and prevalence of incontinence, both men, for men and women, goes up dramatically with age and with aging. But the geriatric syndrome is really a condition of late life. And the way of thinking about it is that all of these predisposing risk factors, both the predisposing and the precipitating their likelihood, goes way up with age as the incidence of other geriatric syndromes. Another way of thinking about it, which as a clinician in the past probably has less meaning, but it’s likely to have more meaning moving forward, is that biological aging itself is the most important risk factor for how fast we age. Everybody ages. Chronological age is one measure. Biological aging or physiological aging varies from individual to individual. And there’s now increasing evidence, as I’m sure Scott Bauer discussed when he met with you because he does a lot of work in this space.

Eric 05:53

For those who don’t know, Scott actually joined us for a Jerry pal podcast on lower urinary neurotrax symptoms. Go ahead.

George 06:00

George is on that, particularly in older men. But he’s very interested in the issue of the role of geroscience and gerotherapeutics, role of biological aging in driving, avoiding issues and incontinence with aging. And we can talk about that later in terms of potential clinical implications that may have code.

Eric 06:20

And then, Alison, is the urinary incontinence the right word I should be using here, or is it under the bigger umbrella, lower urinary tract symptoms. How do you think about this from a clinical perspective when you’re seeing individuals in your office?

Alison 06:37

Yes.

George 06:37

Great.

Alison 06:37

I mean, we use the term urine incontinence to refer to unwanted, accidental leakage of urine, right?

Eric 06:43

Yeah.

Alison 06:44

And it’s one of a variety of lower urinary tract symptoms. Some might argue it’s the most bothersome or disruptive or impactful of lower urinary tract symptoms, and especially common in older women and older adults broadly. George is such a leader in the field and knows well all the work that’s being done to look at what kind of age related changes do we see in the lower urinary tract. There’s work describing changes in bladder muscle contractility and bladder capacity and innervation of the lower urinary tract and pelvic floor support. We might argue, though we don’t know that much about, gosh, which of these changes really are important in the symptoms that people have. It’s easy to describe physiologic or tissue specific organ specific changes. Not so easy to really figure out which of these changes associated with aging are really meaningful in patients experience of symptoms, and perhaps hardest of all, to translate our knowledge into treatment and prevention strategies. There, we may do very poorly, where we can describe our beautiful models of all the kind of risk factors and contributors, ranging from organ level, patient level, behavioral, contextual, environmental. And yet acting upon these factors in a way that really changes patients outcomes has been really hard.

Eric 08:05

Yeah. And it’s also hard because oftentimes people don’t even bring this up in clinic. Do you screen for lower urinary tract symptoms, incontinence, and if so, how?

Alison 08:15

I do because, you know, it’s an area of interest for me.

Eric 08:19

Sure thing, if I’m honest.

Alison 08:20

Right. If it weren’t, would I consistently, you know, of course, this is, all of us who are clinicians are under such pressure to address so many issues and short visits. You know, the standard line about urinary incontinence being don’t ask, don’t tell patients, don’t bring it up spontaneously. Clinicians don’t ask about it. It’s under recognized, under diagnosed, under treated, under discussed, understudied as a result. And all these things lead to the fact that even though we believe that more than a third, close to half, perhaps over half of, for example, older women have some degree of chronic or recurrent urine incontinence, less than half are engaged in any kind of treatment that they think is helpful to them.

Alex 09:03

Yeah, I’m glad you mentioned this, like, reluctance to bring it up and reluctance for clinicians to ask. There’s such a stigma around urinary incontinence in our society. I’d be remiss if I didn’t channel Ken Kavinsky, who I think is right now on vacation in Alaska. Lucky you, Ken. But who would say something at this point like, why isn’t it just more socially acceptable to have some leakage? Why can’t we just change the norms around this so that it’s okay and it’s a natural part of aging? Why do we have to make this into a condition, a disease, a syndrome?

George 09:39

Alex, it’s not just a stigma of it. There’s also a lot of what people have called nihilism, this attitude where people don’t bring it up, not only because they’re ashamed of it, but also because they feel that this is something that nothing can be done about. And they may have personal experiences. I’m sure Alison has seen older women who. Who don’t bring it up because. Because they brought it up before and nothing was done about it, or because they had sisters or mothers who had the issue for years and years and nothing was ever done about it. So there’s also a sense of why talk about it when you can’t do anything about it.

Alison 10:18

I think this makes me think of a pilot project that I’m working on now with other incontinence researchers and folks at Elaine Markland, also folks who are interested in sort of improving access to care across diverse populations and patients with limited english proficiency. But we’re sort of engaged in this effort to try and create more resources for, say, Spanish speaking latino older women, Chinese speaking chinese american older women. And a lot of our discussion in sort of going through translated text is struggling with the vocabulary. Sort of. Do we use the formal word for incontinence that not many people know, or do we use this sort of colloquial term that people don’t want to say because it’s considered offensive or, you know, just even our vocabulary, our terms, the concepts, just culturally, socially are hard to discuss.

George 11:12

Right.

Eric 11:13

What’s the colloquial term? Like? Leakage or…

Alison 11:16

Well, sometimes maybe leakage is better to say than in conscious. Maybe more people will understand. But. But if you need, you need to talk about body fluids, you need to talk about me, you need to talk about, you need to talk about, you know, fecal matter. You need to talk about all of this. It’s hard. It’s not easy. I had a patient recently talk about how she was sitting with a group of her older female friends and they were talking in conversation, oh, how they say, like, one in three women have this problem. But, you know, there’s three of us here and none of us have this problem. And she was silently thinking to herself, I have this problem, but I’m certainly not going to say anything now. Perhaps they all had the problem and none of them wanted to say, we are one of the women, I guess.

Eric 11:57

In, let’s say, my clinic. If I was going to ask one question about this just as a screen, is there a way to ask this question that is not both stigmatizing, but people also understand and it gets around some of these issues.

Alison 12:13

George, I don’t know if you have your favorite question.

George 12:17

Yeah, go ahead, Alison.

Alison 12:20

I may tend to start by normalizing it. Some just start with like, you know, many midlife and older women experience some leakage of urine. Do you ever leak urine? Even a small amount?

George 12:31

Exactly. And I think sometimes using kind of more neutral terms, like talking about, avoiding, talking about any issues with the waterworks, you know, and also questions having to do with sleep. You know, I think it’s really important to realize that sleep avoiding sleep and cognition, and they’re all very closely intertwined, you know. And so often these discussions begin with how do you sleep? How many times a night do you wake up? And then also questions about independence. You know, it’s not just about avoiding, but I’ve seen many cases where patients come in and they’re basically homebound, and then you see that, you know, they shouldn’t be homebound. Their mobility isn’t that bad. And then you realize the reason they’re homebound is because, you know, they have urgency or urge incontinence, literally every hour, every half hour, and they just can’t, they can’t get away long enough.

Eric 13:23

Go ahead, Alex.

Alex 13:24

Eric is pushing on the like, the clinical, practical stuff. But before we dive too deep into that, I just want to take one more step back. George, on this podcast, we have talked about your model for frailty probably like three, four, five times. And I don’t know if that’s just because it’s the Golden Gate Bridge, and.

George 13:44

It’S just going to say that there seems to be geographic bias there.

Alex 13:52

And.

George 13:52

Alison has it behind you guys like, putting up, as you like putting up behind you on the zoom, right?

Alex 13:59

And when people think about frailty, and they think about. And just so for our listeners, just to remind them, the idea is that Golden Gate Bridge is a model for frailty. And, George, maybe we could get you to explain why that is. And also, why is it that somebody who was one of their main foci is urinary incontinence was the one to come up with this model of frailty. Is there any relationship between frailty and urinary incontinence?

George 14:23

Well, multiple. First of all, they’re both geriatric syndromes. They’re both multifactorial conditions happen late in life. They have impacts across all organ systems. And ultimately, frailty is a major. Is also a risk, major risk factor for voiding issues and incontinence. And all of these geometric syndromes are interconnected. So if you go further, and this actually goes back to work, that was really important, the work that was done by Mary Tinetti and her colleagues years ago, showing that these geriatric syndromes have shared risk factors. So if you look at incontinence and frailty, there are conditions such as one risk factor they share is declines in mobility. If you’re less mobile, you’re more likely to be frail, more likely to be incontinent, and many others. And that’s what makes these issues so challenging, because at one level, we use the same term to refer to that incredibly multifactorial, complicated, complex condition as we do to stress incontinence, which is also complex in its own way. But the solutions, as we’ll get to in a few minutes, are completely different. There may be some overlap, but the approach and the solutions are completely different, requiring different skill sets. And that’s the challenge.

Eric 15:43

So I’m going to have a link to the analogy on the Golden Gate Bridge, so we don’t have to review that in some. Sorry, Alex, because I do want to get to the practical things, like, let’s say you have that person coming in, into your office complaining of these symptoms, maybe even every hour. Alison, how do you think about it. I’m going to, because George mentioned like stress or urge incontinence. Do you think, do you put into the four buckets stress, urge, mixed and overflow? Or is there something else that’s kind of guiding how you’re thinking about the workup as your screener is positive?

Alison 16:20

So I do think that the common sort of clinical types of incontinence that we think about, I do think that’s useful in guiding initial treatment approaches. We recognize that there could be overlap. We recognize that as adults get older, they are more, uh, increasingly likely to have mixed incontinence, so that no one single clinical or physiologic mechanism may be responsible for symptoms. But, but still, like thinking about older, uh, especially women, more than men who have primarily stress type incontinence, can direct us to think more about treatment strategies that are focused on supporting the pelvic floor that supports the bladder.

George 16:56

Right.

Alison 16:57

We can think about women who have, and men who have primarily urgency associated incontinence, perhaps associated with overactive bladder, and then think about what kind of strategies are going to help decrease unwanted bladder muscle contractions that send people rushing to the bathroom and maybe not getting there in time. We can really recognize that for a lot of people these are mixed, that it’s not one type or that it’s hard for people to distinguish, really tell you what kind of leakage they’re having, leakage that occurs in the middle of the night, leakage that occurs after they stand up after having used the bathroom, of these kinds, and overflow incontinence, which does tend to be a little less common in older women, I’d say, than older men, partly because there aren’t the same issues related to the prostate. Certain surgical risk factors could play more of a role there with some older adults and others. I think you’re right. Initial approaches, really thinking about, is this somebody where we should be focusing on the pelvic floor? Is this somebody where we should be focusing on bladder muscle? Over activity or oversensitivity, perhaps sometimes? Or is this somebody who just the bladder is not emptying? Yeah.

Eric 18:08

And George, from your perspective, you hear a lot about urge incontinence for women. And for men, you hear a lot about overflow incontinence. BPH, enlarged prostate is urgency, or I guess for that matter, is stress incontinence. Do we see them commonly in men?

George 18:28

So stress incontinence per se is less common in men for a number of reasons. Urge symptoms are common in both genders. Stress incontinence is much more common in women. But as Alison said, typically in terms of these classes, bins, if you will, these simple bins, they kind of fall apart with aging because more and more older adults have combinations of these. And it turns out, actually, it was a classical study published by Neil Resnick in New England Journal of Medicine many years ago, which was a nursing home study of more than 100 incontinent nursing home residents, study of urodynamics. And it showed that actually the most common condition that you see in that population, socio incontinence, is actually a condition that’s associated. And it’s kind of paradoxical, both the bladder being both overactive and underactive at the same time. It was back then it was called DHIC, the truth of hyperactivity and per contractility. But that combination is actually quite common, and it’s quite challenging to diagnose and manage, at least in the traditional sense.

Eric 19:32

So you got a bladder that both can’t squeeze very well and is squeezing all the time.

George 19:37

Exactly, exactly. Contractions occur when they shouldn’t, and when they do, they’re not particularly effective.

Eric 19:44

I want to hold on to that. We’re in a parking lot that, because I want to talk about how we treat these different conditions. But before we get into that, how do you think about the further workup once you’re getting down this, this line, let’s say, for, like, urgency or stress?

George 20:00

Well, to me, the first part of the workup is the history. The history is really the most important. And getting a sense of which bucket is which of these diagnostic buckets falls in. It’s important to some extent, but even more important is when it’s like traditional history taking. And when does the personally, what worsens it, what provokes it, what makes it better, and what impact does it have on their life? That can be incredibly informative. Now, again, in the context of a busy clinical visit, you may not have the time to really go through it in detail. So one thing that we found, well, not just us, but it’s very commonly used in the diagnosis and management of incontinence and frail older adults as incontinence, as a geriatric syndrome, is a 48 hours voiding record. And what we actually do, and there are many versions of this, you can actually create it yourself. It’s very simple. What we do is we actually mail this to our patients before they come in as part of, well, more and more people. We’re doing this also through the inpatient portal because we were trying to get as much information in there as possible. To cut down the amount of information you have to collect during the visit. But a simple 40 hours voting record, which is just two sheets of paper just basically asking the patient or the caregiver or both to fill in, you know, when did they void? When did they have leakage? What time? An estimate of the volume, you know, rough estimate and also what provoked it. And that can be incredibly powerful. I mean, I can informative. I remember as a geriatric fellow many years ago, we actually diagnosed a patient who had polyuria who ultimately, you know, turned out of diabetes insipidus because when you looked at how much they were avoiding, they were just avoiding way too much. And of course, much more common cause of polyuria is drinking too much coke, you know, too much Coca Cola or whatever, you know, but that kind of information can be incredibly informative, both from a diagnostic point of view, but as we get to in a minute, from a management point of view as well.

Eric 22:10

Alison, anything else from your perspective, maybe.

Alison 22:13

Just adding to that. I mean, I think keeping a diary, right. It’s, it’s a useful diagnostic tool, but I think Josh is alluding to. We think of it really as a kind of a management tool as well. That avoiding diary could be a kind of therapeutic intervention only almost. It’s a core compartment of much sort of behavioral treatment programs for urine incontinence. Because as people realize when they’re voiding, when they’re leaking what the stimuli and the precipitators are, they can start to change their behavior.

George 22:42

Exactly. And it’s also empowerment. And I’ll just tell you one quick story. It hasn’t happened often, but it’s happened a couple of times in my career where we mail this voiding record voiding sheet, 40 hours voting sheet to a patient. And this is particularly true with people who are more educated and more attuned to their health and they come to the clinic and the problem is no longer is resolved. Okay. And as Alison was alluding to, simply by paying more attention to this and recording all this detail, they kind of figured it out and they, and then they basically treat themselves. And we’ll get to that in a minute. In terms of how you can, how you can manage these issues. Well, it’s behavioral approaches, but it’s also fluid management. And we’ll talk about all that in a minute.

Eric 23:27

And George, would you be willing to share your 48 hours diary?

George 23:31

Sure. There are many in the public domain. I can email them.

Eric 23:34

Great. Wonderful. We’ll include a link to that on our show notes before we get into interventions and treatments. Urgency. Commonly, people get a UA and for other types of incontinence, too. Where does a UA and a culture fit into all of this, given that, you know, rates of asymptomatic bacteria are also high in this population?

George 23:57

That’s amazing. That’s a wonderful question you’re bringing up.

Alison 24:00

I think, a challenging issue here. You’re right. Clinical guidelines for evaluation of overactive bladders. Certainly most forms of urine incontinence do recommend performing urinalysis. And yet you could say if you’re trying to evaluate an older patient who’s had chronic, intermittent, uh, urinary symptoms for years, you know, how likely it is that a acute UTI is, is really the, what’s responsible there. And you certainly could argue that, you know, we’re systematically performing urinalyses in all of these patients because we can and because the guidelines say, are we increasingly just picking up, you know, for example, the 20% of older women who have some degree of asymptomatic bacteria? Are we just starting ourselves down the road towards more antibiotic over treatment for bacteria and resistant infections and resistant urinary tract infections down the line? It’s a really challenging area. It’s one, honestly, where I feel like we need a lot more research.

Eric 25:00

What do you do in clinical practice, Alison?

Alison 25:03

I think we actually really need to take the time to ask patients more about the nature of their symptoms. There are some folks that could benefit from your analysis. There are some folks where acute onset.

Eric 25:17

Urgency seems very reasonable.

Alison 25:19

Yeah, it’s very reasonable. Intermittent chronic symptoms over time, not so much so reasonable. So I have to say, I don’t systematically perform urinalyses. And all older patients who are presenting with these symptoms, which in some ways might be in contrast to guidelines.

Eric 25:35

How do you think about it, George?

George 25:37

No, I completely agree. I was going to say the same thing. Right now we need more research. I mean, this is really unclear, but I agree, if somebody has recent change in symptoms, that’s probably reasonable to do it, but otherwise, probably not necessary.

Eric 25:51

Okay.

Alison 25:52

Eric, you’re sort of bringing up the fact that there are multiple urinary syndromes that we see often in older adults, and they can overlap, but they can also be distinct. And recurrent urinary tract infections is considered sort of a urologic syndrome in older adults also, and where kind of overactive bladder and urgency incontinence might end and recurrent urinary tract infections begin, and other syndromes like genital urinary syndrome of menopause in older women for example, I think we need a lot more work to be able to tease apart the overlap and the distinctions between these.

Eric 26:30

Okay, we’re going to move to treatments because this comes up an issue with, like, stress and urgency. Like sometimes it’s important to know exactly which bucket these fall into. But there are some non pharmacological treatments that may work for multiple. Is that like Kegel exercises come up a lot?

Alison 26:49

So you’re right. I mean, I think we often think that first line treatment for more than one type of urinary incontinence involves behavioral treatment, behavioral changes, and George has already mentioned a few of these, whether it’s sort of timed urination, changes in fluid intake, suppressing unwanted sort of bladder urges to urinate when they first come on in order to train the bladder to get used to accommodating greater urine volume. So in some ways, we have the best evidence base for these kinds of behavioral approaches for more than one form of urinary continence in older adults, provided that we can teach people to use them and they can practice them effectively and consistently.

Eric 27:35

Is there a good way to do that? Aside from referring somebody to, what do you call somebody who does?

Alison 27:43

I think you’re again bringing up the challenges. So I think that when older adults have access to clinicians who have training on educating and counseling patients, neurogynecologists. Yes. Right. And sometimes, you know, to pelvic floor physical therapists, to nurses or practice assistants who have training and teaching these techniques and guiding patients and practices them, then great. I think what’s challenging is that many older adults don’t have access to clinicians who can provide that kind of training and support. And clinicians feel strapped. You know, they don’t have enough time to teach. They revert towards the things they know best and are perhaps most lucrative for their practices. Right. I’m an internal medicine physician. What do we do? We prescribe medicines. Right, right. And what do you. Urologist and urnet clusters are surgeons or surgical specialists. You know, procedures are what they do. And so I think a great many older adults don’t have access to education and support that they need.

Eric 28:48

Yeah.

Alex 28:48

So there’s a systemic problem that needs to be addressed around the way our system reimburses for medications more than for physical therapy, for example. And the way that maybe patients may expect, have come to expect that if they go to their doctor, they’ll get a prescription.

Alison 29:08

Yes. I mean, you could just argue that any kind of syndrome or condition that affects as many of half of older women in the community, as at least a third of older men in the community, really requires more creative approaches to delivering treatment. Our traditional kind of one on one, intense clinician visit model of delivering care is just simply not adequate to address the needs of the vast majority of older adults who have these symptoms.

Eric 29:36

And Alison, in your own clinic, do you have like a go to kind of strategy? How you think about non pharmacological therapy for, let’s say, urge incontinence or stress?

Alison 29:49

I think we should start with the behavioral because sometimes there really are even low hanging fruits, obvious behavioral practices, triggers that patients can recognize. So some of that is being ready with high quality, patient friendly information to provide, to handout, sometimes often with ladder diaries. Avoiding diaries is really helpful. I think there are going to be patients who are going to have trouble practicing. So I mean, now I think there are videos online that can help people understand and maintain their practice. As I mentioned, I’m doing other work that sort of, you know, looking into smartphone tools or to sort of support people in making these changes. Because really when it comes to behavioral, we’re talking about self management. Like treatment is self treatment. It’s just that older adults need to be able to have the support and information to do it effectively and to maintain those changes over time. Then there’s some folks who can’t or don’t want to engage in behavioral practices, or they don’t get the benefit from the behavioral practices. And we think about, are you somebody who could benefit from a medication or a procedure?

Eric 31:02

The thoughts from a non pharmacological perspective, George, when you’re thinking about these different buckets or these mixes of incontinence, I.

George 31:10

Think the way I think about it is, first of all, looking at fluid intake. And as I said, there are simple issues that can be addressed, such as somebody who drinks large amounts of caffeinated beverages and such certain times of the day, especially before they go to sleep, times when people take their diuretics can be important medications. There’s a lot of medications that actually make voiding much worse, that really have problems. And in terms of behavioral interventions, the combination of two things that really work well, it’s been shown in the literature over and over again, is, one, improving mobility. The moment you improve mobility, you improve avoiding issues, very, very logical for many reasons. The other that really helps is distraction exercises. What I often tell people is that when they feel, particularly when they feel the sense of urgency, the normal natural reaction is to think of I need to get to the bathroom, and thinking of ways of getting to the bathroom as quickly as possible. In fact, there’s a lot of literature, including very good behavioral literature, showing the distraction in terms of thinking about anything else. I tell people, for example, to think about, okay, if you’re. If you walk from your house to the bank, okay, think about all the. All the streets that you’re gonna have to cross. Okay, think about the names of, you know, all the vegetables you can think of that begin with the letter a or b, you know, anything that will distract them. Okay?

Eric 32:36

Yeah.

George 32:37

And think about anything other than avoiding it will help. And there’s extensive literature to support that, including people who are cognitively impaired. Actually, one of our colleagues, Joe Ostlander, who works with Alex and I on Jags, he and Jack Schnelly, published a study many years ago done in the VA. So all men, obviously, that simply, you know, some very. Some mobility exercise, getting people to void, helping them go to the bathroom, and some distraction exercises, improved voiding issues and incontinence dramatically. Now, there’s data that they never published, but I’ve seen them present, which has to do with how our healthcare system functions, is the moment the research study ended, there was decay in terms of all the improvements. So it works.

The problem is, it’s a lot easier to write, to pull out the, you know, to prescribe something, to prescribe a med than to prescribe something that involves behavioral intervention. But if you have a caregiver, if you have a caregiver who is involved and dedicated, having them walk the person to the bathroom on a regular basis, you know, what we call prompted or timed voiding on a schedule. And again, the schedule can be adapted, should be adapted to the voiding record. Okay. Because every person is different in many cases, if you think about it physiologically, and again, I don’t get in all the details, but if you think about bladder filling and bladder physiology, simply keeping bladder volumes under a critical threshold in an individual may be enough to keep them from developing urgency in the first place. Okay. And you can figure that out by talking to them in many ways.

Eric 34:17

Well, let’s talk about the pharmacological treatments, because that plays an interesting role here. So for urgency incontinence, I always think about the beta three agonists. So you got your begron, and then you have antimuscarinic agents, your ditter prans of the world. Are there any other classes I’m forgetting about?

Alison 34:37

Those are the two main classes. Latter, antispasmodic efficacy.

Eric 34:43

Same one’s better than the other. What do you think?

Alison 34:46

You know, it’s, again, you bring up great questions because there are few head to head trials comparing the efficacy of different types of bladder antispasmodic medications. Most of the trials that have been conducted are conducted by the manufacturers of those medications. And perhaps more than you would expect by chance, the findings tend to be favorable for the medication, the more expensive sponsor. I think right now you’re probably aware there’s a lot of concern about potential adverse effects of anti muscarinic.

Eric 35:23

Yeah, they’re in the beerus criteria, right?

Alison 35:26

They’ve been in the beers criteria for a while. I think there’s growing concern. Workshops, symposia, at society meetings. Right. About the concern about these medications. Most of it is based on retrospective analyses of data. So we don’t necessarily have the highest quality evidence to really look at what are the potential adverse effects on, for example, cognition in older adults of taking these medications over time? I think we need higher quality data. Honestly, we could really use better randomized trial data looking prospectively on what are the implications in the short term, in the longer term, of different classes of bladder antispasmetic medications, rather than what we usually have, which is relatively short. Studies, again, conducted by the manufacturers of the medications, sometimes in populations that in the end aren’t as representative of the older adults in the community who are going to take them and really try to understand this.

Eric 36:23

There’s what we want and then there’s what we have. So when push comes to shove, you got a 76 year old with mild dementia coming into your clinic with urgency, incontinence. You’ve tried non pharmacological therapies, George, and you’re thinking about pharmacological prescription. What do you do? Which do you choose?

George 36:45

So I have done it both ways. I have prescribed Marin Bagran on occasion, and I also have a lot of experience prescribing the antispasmodics. And let’s put it this way, there are differences between them, and the pharmaceutical companies certainly play upon them in terms of being more selective for certain muscular receptors. There are some potential differences in ability to cross the blood brain barrier, although none of these have been studied in people with dementia, where we know the blood brain barrier is disrupted. My approach to this has been to use these drugs as a really last ditch measure when the condition is really impacting, has a real impact on the person’s quality of life. Okay.

And what I try to do is use the lowest dose possible, as rarely as possible at times of day when the symptoms are worse. Okay. And what I’m getting at is again, the bladder diary tells you a lot. When are the symptoms worse and most bothersome? Okay. And to give you an example, for a person who has regular urgency, urgent continence, it may be the two or 3 hours when they need to get to the market and just make it to the grocery store. That may be a small dose of short acting any one of the cholinergics. Again, lowest dose possible. I think there’s some place also for the. I’ve also used on occasion some of the transdermal, which have the advantage of being much smoother and that I use in people who have symptoms around the clock. They also don’t have the hepatic metabolite issue, the hepatic metabolism. But to me it’s a last ditch measure.

Eric 38:24

George, what about those people with BPH? Yeah, but they also have urge symptoms. You know, their pvrs aren’t high. Is this something where you really want to avoid the antimuscarinics? Is there a role for generally?

George 38:39

Generally I avoid them. I think this is the place. So I think for people, and I think you’re referring to men. I tend to focus much more on agents that target the prostate as much as possible.

Eric 38:56

Your alpha blockers or finasterides?

George 38:59

Finasteride. Partly because they do help quite. They can be helpful and also because they’re relatively well tolerated. And also it’s been shown that with BPH, again, the most bothersome symptoms. Okay. It’s not flow rate, it’s not retention. It’s frequency and precipitancy. And that’s what you want to focus. That’s what keeps people up at night. That’s what you focus on. I tend to stay away from antispasmodics in men with BPH issues that could be related to the BPH, in part because I think there’s issue of retention in them.

And also our colleagues in urology are not particularly happy when you prescribe an anti spasmodic one of these patients and they have to come in middle of the night, you know, because they’re in ed with four liters of urine. The other group you have to be very careful is that group I talked about earlier, the people that Neil Reznik described many years ago. Combination of overactive bladder, underactive bladder. There’s some evidence that antispasmodics can actually induce retention in them. So again, you have to be very careful there.

Eric 40:07

Okay, last one. Each of you get one pro tip for our listeners about how you think about your management. Could be workup of urinary incontinence. Alison, what would your pro tip be?

Alison 40:20

I think maybe a pro tip is that we, it’s important to be honest about the evidence and the limitations of the evidence. George was just talking about bladder medications. I think we need to acknowledge that regardless of the type of medications, the evidence we have suggests that benefits are modest in terms of improving symptoms, that we have reason to think there are side effects, and that there are also some potential side effects that we simply don’t know about yet. We have to acknowledge when there’s uncertainty in the evidence and make that part of our shared decision making about what kind of treatment approaches to try.

Eric 40:55

Great, George. Pro tip.

George 40:58

Well, I’m going to go a different direction here, and I completely agree with what Alison said, but I want to give a shout out to the need for people to do high quality research in this area. There’s just very little research being done. And I’ll just share a story that a son of a patient of mine asked me, which illustrates how little we know. And the question was this. And he said, Doctor Kushal, I understand this. My mother is on a medication to block the cholinergic system, anticholinergic to help her with her continence, and she’s on another medication to boost her cholinergic system to help her with their dementia. And it doesn’t make any sense to me. And my answer was, well, it doesn’t make any sense, and I’ll take it a step further. So I pulled this out, and I have a question for you. What do you think is the longest published textbook of medicine in the english language? Ooh.

Eric 41:51

Oslers BMJ.

George 41:54

I hate to disappoint you, but it’s actually published by a drug company. It’s called the Merck manual. And first edition was in 18 in 1899. Okay. And the reason I brought that up, 1899, we’re talking about a century. You know, we’re talking about a long time ago, 120 odd years ago. If you go in there and you look up, you don’t find Alzheimer’s disease because it didn’t exhaust, hadn’t discovered Alzheimer’s disease yet. But if you look at treatment of Alzheimer’s disease, there’s an extract of a plant called physostigma. What do you think that is?

Eric 42:29

Belladonna?

George 42:30

Well, that’s. No, physostigma is an acetylcholinesis inhibitor. Okay. It’s the same principle as donepezil.

Eric 42:38

Yeah.

George 42:39

And if you look at irritative bladder, what’s the treatment atropine okay. So in 120 years, we’re still prescribing this. We have a lot of work to do. The last thing I’m going to say is that ultimately mobility, behavior, and I think long term it’s going to be prevention of things like microvascular disease, heart disease. That’s really going to make an impact on this. A lot of, and I’m sure Scott Bauer talked about that.

Eric 43:05

Well, I want to thank you both for coming on, but before we end, I think we got a little bit more Britney Spears, right? Alex?

Alex 43:12

(singing)

Eric 43:54

Alison and George, thank you for joining us on this GeriPal podcast.

George 43:57

Thank you.

Alison 43:58

Thank you so much for having us.

Eric 44:00

And to all of our listeners, thank you for your continued support.