Urinary Incontinence

Jeffery Albaugh, R.N., B.S.N.

Urinary incontinence is a common problem that affects over 11 million people of all ages. It is not an inevitable part of the normal aging process. It is a highly treatable condition that requires complete evaluation by a physician.

Incontinence is not a disease in and of itself, but a symptom of other problems and a signal to see a physician.

Urinary incontinence is defined as the involuntary loss of urine. It is estimated that 30 percent of men and women over 60 living at home experience problems with bladder control. Incontinence is often curable, and always manageable. The key is to find the cause and treat it appropriately.

Risk Factors

• Urinary tract infection
• Medications that adversely affect the bladder (e.g., anticholinergics, anti-Parkinsonism, diuretics, narcotics, especially Demerol*)
• Obesity
• History of genitourinary (GU) surgery or abnormality
• Increased urinary volume by osmotic diuretics, e.g., calcium, glucose
• Frailty
• Mobility deficits
• Postmenopausal atrophic vaginitis
• Pelvic prolapse
• Neurological disease, delirium, dementia
• Fecal impaction
• Diabetes mellitus

Evaluation

History

• onset of symptoms (acute or chronic)
  underlying factors:
• diuretics and other medications that may effect the bladder (as above)
• mobility
• mental status changes (delirium, dementia)
• neurological impairment
• disease processes such as diabetes & Parkinson's

Types of Incontinence (It is most often multifactorial.)

• Urge Incontinence-the inability to prevent urinary leakage when feeling a strong urge to urinate. Symptoms include frequent urination, voiding small amounts of urine, strong urge to urinate, inability to get to the bathroom prior to leakage.
• Stress Incontinence-the loss of urine when sneezing, coughing, or doing strenuous activity. It is often related to pelvic floor weakening.
• Overflow Incontinence-occurs when the bladder does not empty properly and at a certain volume begins to overflow causing leakage. Symptoms include a palpably swollen bladder, supra-pubic tenderness, and reduced urine stream.
• Functional Incontinence-the patient is functionally unable to get to the bathroom in time and it is not associated with urinary tract problems. (This is very infrequently the only cause.)
• Iatrogenic Incontinence-the incontinence is an effect of some drug or medical treatment. Symptoms include a change in urination after surgery or starting a new medication.

Voiding diary

A log of intake and output, usually for 3-7 days.

History of genitourinary disease

• infections
• tumors
• calculi
• surgical procedure

Physical Exam

I. Neurological Exam

a. Mental status

b. Inspection of the spinal column

c. Lower extremity motor function assessment

d. Assessment of sensation particularly in the lumbrosacral dermatomes

e. Anal sphincter tone, bulbocavernosus reflex

II. Abdominal Exam-check for masses

III. Pelvic Exam-assess for rectocele, vagicele, bladder prolapse: note urinary leakage with cough.

IV. Prostate Exam-note size, nodules, tenderness; check PSA.

V. Diagnostic studies

a. Urinalysis

b. Urine culture

c. Check of post-void residual volume via catheterization

d. Urodynamics- available through the Center for Bladder Health

VI. Functional, mobility, and environmental assessment.

Treatment

A wide variety of treatments are available once the underlying cause of incontinence has been defined.

• Pharmacologic treatment-a wide variety of medications are now available.
• Bladder training- to change unhealthy habits and promote appropriate voiding patterns (Kegel exercises).
• Pelvic floor exercises-to strengthen the pelvic floor muscles and decrease stress incontinence. These exercises are also utilized to decrease uninhibited bladder contractions.
• Biofeedback- to teach patients how to do appropriate, well isolated pelvic floor contractions
• Electric stimulation- used for both stress and urge incontinence
• Surgical intervention
• Hormone replacement therapy
• Toileting routines, e.g., every 2-3 hour prompting for patients with cognitive impairment

Indications for consultation

Evaluation of incontinence

Urinary retention

Urodynamic evaluation

Bladder training/Biofeedback/Pelvic floor stimulation

Surgical treatment

Specific Management of Urinary Incontinence

A. Urinary tract infection

• Sterilize urine with appropriate antibiotic

B. Stress incontinence

• Kegel exercises to increase pelvic floor strength
• Alpha-adrenergic agonists (e.g., pseudoephedrine, imiprimine)
• Local estrogens
• Surgical bladder neck suspensions
• Periurethral injections

C. Urge Incontinence

• Bladder relaxants, e.g., oxybutynin 5mg bid
• Local estrogens
• Toileting routines

D. Overflow incontinence

• Alpha adrenergic blockers, e.g. prazosin, Terazosin
• Anti-androgens, 5 alpha reductive inhibitors (Finesteride)
• Catheterization routines
• Surgical procedures to relieve obstruction

Indications for Consultation

• Urinary retention
• Urodynamic evaluation
• Bladder training/biofeedback/pelvic floor stimulation
• Surgical treatment