Urinary Incontinence in Palliative Care Settings: Part 2: Management #426

Respect, attention, and communication: Research on patient preferences for UI care showed that respect for personhood, establishing a trusting relationship, empathy, and appropriate touch were important aspects.^1,3 Timeliness of care (e.g., providing a bell or nurse call button if appropriate) and maintaining privacy (e.g., closing doors/curtains and concealing incontinence products), and maintaining a calm environment were other valued attributes. Clinicians should remind themselves to check in with the caregiver too, as caregiver support has been shown to be effective in reducing caregiver burden for those who provide UI care (see Fast Fact #419). ³

Identify and correct underlying symptomatic causes: Based on goals of care, symptomatic urinary infections in alert and ambulatory patients can often be effectively treated with a short course of oral antibiotics. Similarly, limiting fluid intake, modifying the diuretic regimen, and removing impacted stool can promptly improve UI symptoms.^5–7

Exercise and behavioral strategies: In alert and mobile patients, a short trial of physical therapy may improve functional status and delay UI care needs.^5–8 Similarly, behavioral strategies such as scheduled voiding, and bladder training have been shown to reduce UI frequency and severity.^9,10

Urge incontinence: Anticholinergic medications such as oxybutynin and tolterodine have been shown to reduce urge incontinence by decreasing bladder and detrusor muscle tone.^11,12 These medications can be associated with significant side effects in older patients, including confusion, dry mouth, and constipation, hence their use should be limited to severe or intractable symptoms.^11,12 Mirabegron (a beta 3 agonist) has been associated reduced urge incontinence episodes, but headaches and flu-like symptoms are common. ¹¹ Vaginal estrogens reduce urge incontinence issues when atrophic vaginitis ¹³ is present.

Stress incontinence: Duloxetine seratonin and norepinephrine uptake inhibitors (SNRI) has shown improvement in global quality of life, with >50% reduction in stress incontinence episodes (relative risk 1.24; 95% confidence interval 1.14–1.36).^14,15 Vaginal pessaries can provide adequate control of stress incontinence but usually require consultation to a gynecology specialist and can be uncomfortable for many women. ¹⁶

Overflow incontinence (OI): Clinicians should review the patient's medication, ideally with a clinical pharmacist to see if any medications may be causing urinary retention. Opioids, anticholinergic medications, antidepressants, and benzodiazepines are common culprits. If benign prostatic hyperplasia (BPH) is a contributing factor, the addition of 5-α reductase inhibitors (e.g., finasteride) and α-antagonists (e.g., terazosin) can reduce OI by improving urine flow. For patients with an extended prognosis (e.g., several months or longer) who wish to avoid long-term catheterization, surgical treatment through a sacral nerve stimulator can be considered. Unfortunately, device malfunction is relatively common after a few years. For women, vaginal pessaries may have a role in OI as well. ¹⁷

Bedside urine collection containers (commonly referred to as bedside urinals) can reduce the need for catheterization and decrease the incidence of falls in cognitively intact patients. ²¹

Urinary catheterization: Immobile patients for whom UI pad changes cause pain and distress should be considered for urinary catheterization since doing so can improve skin care, reduce caregiver burden, and improved the sense of care quality from caregivers.^20,21 Conversely, catheterization is invasive, uncomfortable, and increases the risk for urinary tract infections. Data suggest that 50% male and 75% female patients under hospice care have catheters placed, and most died with it in place. ¹⁸ Unsurprisingly, higher functional status was associated with lower catheterization rates. ¹⁹ Ultimately, these trade-offs must be individualized.

Sheath/condom catheters: These catheters have a soft sheath that fits over the penis and attaches to penile skin through adhesive tape (which can cause penile skin tears over time) so that urine can flow into a collecting bag. ²² External catheter options are available for patients with female genitalia as well (see Ref. ²³ ). Data show no difference in infection rates between a condom catheter at night versus no catheter. ²⁰ In general, they are ineffective for patients with urinary retention from obstructive issues such as BPH.