Urinary Incontinence

UCLA Multicampus Program of Geriatrics and Gerontology

Definition
INCONTINENCE: Involuntary loss of urine or stool in sufficent amount or frequency to constitute a social and/or health problem. A heterogeneous condition that ranges in severity from dribbling small amounts of urine to continuous urinary incontinence with concomatant fecal incontinence

How Common is Incontinence?

Prevalence increases with age (but it is not a part of normal aging) 25-30% of community dwelling older women 10-15% of community dwelling older men 50% of nursing home residents; often associated with dementia, fecal incontinence, inability to walk and transfer independently

Urinary Incontinence is Often

Under-Diagnoses and Under-Treated

Only 32% of primary care physicians routinely ask about incontinence 50-75% of patients never describe symptoms to physicians 80% of urinary incontinence can be cured or improved

Why is Incontinence Important?

Social stigmata - leads to restricted activities and depression Medical complications - skin breakdown, increased urinary tract infections Institutionalization - UI is the second leading cause of nursing home placement

Anatomy of Micturition
Detrusor muscle External and Internal sphincter Normal capacity 300-600cc First urge to void 150-300cc CNS control
Pons - facilitates Cerebral cortex - inhibits

Harmonal effects - estrogen

Peripheral Nerves in Micturition

Parasympathetic (cholinergic) - Bladder contraction Sympathetic - Bladder Relaxation Sympathetic - Bladder Relaxation ( adrenergic) Sympathetic - Bladder neck and urethral contraction ( adrenergic) Somatic (Pudendal nerve) - contraction pelvic floor musculature

Peripheral Nerves in Micturition

Taking the History

Duration, severity, symptoms, previous treatment, medications, GU surgery 3 Ps
Position of leakage (supine, sitting, standing) Protection (pads per day, wetness of pads) Problem (quality of life)

Bladder record or diary

1

Potentially Reversible Causes

D I A P P E R S - Delirium - Infection - Atrophic vaginitis or urethritis - Pharmaceuticals - Psychological disorders - Endocrine disorders - Restricted mobility - Stool impaction

Medications That May Cause Incontinence

Diuretics Anticholinergics - antihistamines, antipsychotics, antidepressants Seditives/hypnotics Alcohol Narcotics -adrenergic agonists/antagnists Calcium channel blockers

Categories of Incontinence
Urge incontinence Stress incontinence Overflow incontinence Functional incontinence

Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder

Most common cause of UI >75 years of age Abrupt desire to void cannot be suppressed Usually idiopathic Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinsons Disease, dementia

Stress Incontinence
Most common type in women < 75 years old Occurs with increase in abdomenal pressure; cough, sneeze, etc. Hypermotility of bladder neck and urethra; associated
with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases)

Intrinsic sphinctor problems; due to pelvic/incontinence

surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)

Overflow Incontinence
Over distention of bladder Bladder outlet obstruction; stricture, BPH, cystocele,
fecal impaction

Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, MS, spinal injury,
medications

Functional Incontinence
Does not involve lower urinary tract Result of psychological, cognitive or physical impairment

Physical Examination
Mental status Mobility Fluid overload Abdominal exam Neurologic exam Pelvic Rectal

Diagnostic Tests
Stress test (diagnostic for stress incontinence; specificity >90%) Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture Simple (bedside) Cystometrics

Bladder Pressure-Volume Relationship

Interpretation of Post-Void Residual

PVR < 50cc PVR > 150cc PVR > 200cc PVR > 400cc - Adequate bladder emptying - Avoid bladder relaxing drugs - Refer to Urology - Overflow UI likely

Treatment Options
Reduce amount and timing of fluid intake Avoid bladder stimulants (caffeine) Use diuretics judiciously (not before bed) Reduce physical barriers to toilet (use bedside commode)

Treatment Options
Bladder training
Patient education Scheduled voiding Positive reinforcement

Pelvic floor exercises (Kegel Exercises) Biofeedback Caregiver interventions

Scheduled toileting Habit training Prompted voiding

Pharmacological Interventions
Urge Incontinence
Oxybutynin (Ditropan) Propantheline (Pro-Banthine) Imipramine (Tofranil)

Stress Incontinence
Phenylpropanolamine (Ornade) Pseudo-Ephedrine (Sudafed) Estrogen (orally, transdermally or transvaginally)

Surgical Interventions
Surgery is reported to cure 4 out of 5 cases, but success rate drops to 50% after 10 years.

Urethral Hypermotility
Marshall-Marchetti-Kantz procedure Needle neck suspension

Intrinsic sphincter deficiency

Sling procedure

Other Interventions
Pessaries Periurethral bulking agents (periurethral injection of collagen, fat or silicone) Diapers or pads Chronic catheterization
Periurethral or suprapubic Indwelling or intermittant

Pessaries

Indwelling Catheter