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ABSTRACT: In response to the growing population of older patients with incontinence, pharmaceutical companies are developing new drugs to treat the condition. Before prescribing medications for incontinence, however, physicians should determine the nature and cause of the patient's incontinence. The evaluation should rule out reversible conditions, conditions requiring special evaluation, and overflow bladder. The best treatment for urge incontinence is behavior therapy in the form of pelvic floor muscle exercises. Medications, used as an adjunct to behavior therapy, can provide additional benefit. Many therapies are available for patients with stress incontinence, including pelvic floor muscle exercise, surgery, intravaginal support devices, pessaries, peri-urethral injections, magnetic chairs, and intraurethral inserts. No medication has been approved for the treatment of stress incontinence, although medications are under development.
Anticholinergic Drugs for Overactive Bladder - Cochrane for Clinicians
ABSTRACT: Understanding the distinctions between the management of clinical problems in nursing homes compared with the community setting helps improve the overall care of nursing home residents. Liberalizing diets helps avoid unintentional weight loss in nursing home residents, although the use of feeding tubes usually does not improve nutrition or decrease aspiration risk. Medical assessment, treatment of comorbidities, and appropriate use of rehabilitation therapies minimize the frequency of falls. Toileting programs may be used to treat incontinence and retention in cooperative patients. Adverse effects and drug interactions should be considered when initiating pharmacologic treatment of overactive bladder. Urinary tract infection and pneumonia are the most common bacterial infections in nursing home residents. Signs and symptoms of infection include fever or hypothermia, and functional decline. Virus identification is recommended for influenza-like illnesses. Nonpharmacologic behavioral management strategies are the preferred treatment for dementia-related problem behaviors. The Beers criteria, which outline potentially inappropriate medication use in older persons, provide guidance for medication use in the nursing home.
ABSTRACT: In most cases, the evaluation of urinary incontinence requires only a history, a physical examination, urinalysis and measurement of postvoid residual urine volume. The initial purposes of the evaluation are to identify conditions requiring referral or specialized work-up and to detect and treat reversible causes that may be present. If the patient does not appear to require referral and a reversible cause is not identified, the next step is to categorize the patient's symptoms as typical of either urge or stress incontinence and treat the patient accordingly. If treatment fails or a presumptive diagnosis of urge or stress incontinence cannot be reached, the final step would be to perform more sophisticated tests or refer the patient for testing to define the cause and determine the best treatment.
Health Screening in Older Women - Article
ABSTRACT: Health screening is an important aspect of health promotion and disease prevention in women over 65 years of age. Screening efforts should address conditions that cause significant morbidity and mortality in this age group. In addition to screening for cardiovascular disease, cerebrovascular disease and cancer, primary care physicians should identify risk factors unique to an aging population. These factors include hearing and vision loss, dysmobility or functional impairment, osteoporosis, cognitive and affective disorders, urinary incontinence and domestic violence. Although screening for many conditions cannot be proved to merit an "A" recommendation (indicating conclusive proof of benefit), special attention to these factors can decrease morbidity and improve quality of life in aging women.
ABSTRACT: Because the prevalence of urinary incontinence increases with age, a working knowledge of the diagnosis and treatment of the various types of urinary incontinence is fundamental to the care of women. As the population of the United States ages, primary care physicians can expect to see an increasing number of patients with urinary incontinence. By obtaining a careful medical history and performing a comprehensive physical examination, the primary care physician can initiate successful treatment for the majority of patients without the need for invasive testing. This article offers a comprehensive approach to the evaluation and management of urinary incontinence in women.
The Geriatric Assessment - Article
ABSTRACT: The geriatric assessment is a multidimensional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. It is usually initiated when the physician identifies a potential problem. Specific elements of physical health that are evaluated include nutrition, vision, hearing, fecal and urinary continence, and balance. The geriatric assessment aids in the diagnosis of medical conditions; development of treatment and follow-up plans; coordination of management of care; and evaluation of long-term care needs and optimal placement. The geriatric assessment differs from a standard medical evaluation by including nonmedical domains; by emphasizing functional capacity and quality of life; and, often, by incorporating a multidisciplinary team. It usually yields a more complete and relevant list of medical problems, functional problems, and psychosocial issues. Well-validated tools and survey instruments for evaluating activities of daily living, hearing, fecal and urinary continence, balance, and cognition are an important part of the geriatric assessment. Because of the demands of a busy clinical practice, most geriatric assessments tend to be less comprehensive and more problem-directed. When multiple concerns are presented, the use of a “rolling” assessment over several visits should be considered.
Hormone Therapy for Postmenopausal Women with Urinary Incontinence - FPIN's Clinical Inquiries
ABSTRACT: Most cases of urinary incontinence in women fall under one of three major subtypes: urge, stress, or mixed. A stepped-care approach that advances from least invasive (behavioral modification) to more invasive (surgery) interventions is recommended. Bladder retraining and pelvic floor muscle exercises are first-line treatments for persons without cognitive impairment who present with urge incontinence. Neuromodulation devices, such as posterior tibial nerve stimulators, are an option for urge incontinence that does not respond to behavioral therapy. Pharmacologic therapy with anticholinergic medications is another option for treating urge incontinence if behavioral therapy is unsuccessful; however, because of adverse effects, these agents are not recommended in older adults. Other medication options for urge incontinence include mirabegron and onabotulinumtoxinA. Sacral nerve stimulators, which are surgically implanted, have also been shown to improve symptoms of urge incontinence. Pelvic floor muscle exercises are considered first-line treatment for stress incontinence. Noninvasive electrical and magnetic stimulation devices are also available. Alternatives for treating stress incontinence include vaginal inserts, such as pessaries, and urethral plugs. Limited or conflicting evidence exists for the use of medications for stress incontinence; no medications are approved by the U.S. Food and Drug Administration for this condition. Minimally invasive procedures, including radiofrequency denaturation of the urethra and injection of periurethral bulking agents, can be used if stress incontinence does not respond to less invasive treatments. Surgical interventions, such as sling and urethropexy procedures, should be reserved for stress incontinence that has not responded to other treatments.