Background: Effective urinary incontinence (UI) management in patients with serious illness has been associated with an improved sense of dignity (1), along with a reduced risk of agitation, dermatitis, and caregiver burden (2-4). This Fast Fact examines management options for UI in palliative care settings.

General UI Management Principals: 

• 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, 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 (seeFast 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 like scheduled voiding, and bladder training have been shown to reduce UI frequency and severity (9,10).

Individualized UI Management Principals Based Upon UI Sub-Types:

• 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 (SNRI) has shown improvement in global quality of life, with >50% reduction in stress incontinence episodes (relative risk [RR] 1.24; 95% CI 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 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 via 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).

Protective Pads/ Undergarments: Data suggests that patients prefer using pads and undergarments over catheters at EOL, especially when they are alert and aware (18). Correctly sized, genital-specific pads improve patient satisfaction with UI care (19). Their long-term use, however, can lead to local dermatitis and dignity concerns however for some patients (20).

Urinary catheters, condom catheters and other urine collection devices:  

• 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 (UTIs). Data suggests 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 via 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 reference #23).  Data shows 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. 

Conclusion:  An individualized UI management plan should be implemented based on patient symptoms, type of UI, prognosis, and goals of care. Although catheterization is not preferred, it can be a viable option in dying patients with limited mobility.

References:

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15. Li J, Yang L, Pu C, et al. The role of duloxetine in stress urinary incontinence: a systematic review and meta-analysis. Int Urol Nephrol 2013; 45:679.
16. Richter HE, Burgio KL, Brubaker L, Nygaard IE, Ye W, Weidner A, et al. Pelvic Floor Disorders Network. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol. 2010 Mar;115(3):609-617. 
17. Lukacz ES. Treatment of urinary incontinence in females. In: UpToDate, Brubaker L, Schmader K (Ed), UpToDate, Waltham, MA. (Accessed on March 26, 2021.
18. Farrington N, Fader M, Richardson A, Prieto J, Bush H. Indwelling urinary catheter use at the end of life: a retrospective audit. Br J Nurs. 2014 May 8-21;23(9):S4, S6-10.
19. Chughtai B, Thomas D, Russell D, Phongtankuel V, Bowles K, Prigerson H. Prevalence and Risk Factors for Fecal Incontinence in Home Hospice. Am J Hosp Palliat Care. 2019 Jan;36(1):33-37.
20. Centers for Disease Control and Prevention (CDC) – Infection Control. Guideline for preventing catheter associated urinary tract infections. November 5, 2015. Accessed February 21, 2021. https://www.cdc.gov/infectioncontrol/guidelines/cauti/evidence-review.html
21. Feneley RC, Hopley IB, Wells PN. Urinary catheters: history, current status, adverse events and research agenda [published correction appears in J Med Eng Technol. 2016;40(2):59]. J Med Eng Technol. 2015;39(8):459-470. 
22. Gray M, Skinner C, Kaler W. External Collection Devices as an Alternative to the Indwelling Urinary Catheter: Evidence-Based Review and Expert Clinical Panel Deliberations. J Wound Ostomy Continence Nurs. 2016 May-Jun;43(3):301-7.
23. Zavodnick J, Harley C, Zabriskie K, Brahmbhatt Y. Effect of a Female External Urinary Catheter on Incidence of Catheter-Associated Urinary Tract Infection. Cureus. 2020;12(10):e11113.

Authors’ Affiliations: Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; University of Pittsburgh Medical Center; Pittsburgh PA 
Conflicts of Interest: none to report

Version History:  First electronically published August 2021; originally edited by Sean Marks MD