Urinary Incontinence

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Contents 1 More Specific Terms 2 Introduction 3 Classification 4 Etiology 5 Epidemiology 6 History 7 Clinical-manifestations 8 Laboratory 9 Diagnostic-procedures 10 Radiology 11 Complications 12 Management 13 More General Terms 14 Additional Terms 15 References

More Specific Terms

• enuresis
• functional incontinence
• involuntary detrusor contraction
• mixed urinary incontinence
• overflow incontinence
• stress urinary incontinence
• transient (reversible) urinary incontinence
• urge incontinence
• voiding or bladder diary (incontinence chart)

Introduction

• Involuntary loss of urine sufficient to be a problem. There are several types of UI, but all are characterized by an inability to restrain or control urinary voiding (see mixed urinary incontinence, nocturnal enuresis, overflow incontinence, stress incontinence, transient urinary incontinence, urge incontinence).

Classification

• transient (reversible) urinary incontinence
• stress incontinence
• urge incontinence
• overflow incontinence
• mixed urinary incontinence
• functional ( idiopathic) incontinence

Etiology

• reversible factors ( DRIP) D: delirium, dementia, depression R: restricted mobility, retention I: infection, inflammation ( atrophic vaginitis), impactation P: pharmaceuticals, polyuria ( glycosuria, CHF)
• reversible factors (DIAPPERS) D: delirium I: infection A: atrophic vaginitis P: pharmaceuticals P: psychologic factors ( depression or behavioral disturbance) E: excess urine output (excess fluid intake, diuretics, edema) R: restricted mobility S: stool impactation
• see see more specific type

• urge incontinence
• stress urinary incontinence
• overflow incontinence
• mixed urinary incontinence
• transient urinary incontinence
• functional incontinence

• see pharmaceutical causes of urinary incontinence

Epidemiology

• 15-30% of elderly in the community

• 25-30% of women > 60 years

• more common in whites than blacks [6,8]

• 10-15% of men > 60 years

• 50% of nursing home patients

• strong association with dementia

• incidence increases with age

• NOT part of normal aging
• NOT associated with menopause [4,13] or HRT [13]
• common in nulliparous as well as parous women

• underdiagnosed & under-reported (63% report to physicans) [8]
• common reason for nursing home placement

History

• malignancies, neuroendocrine disorder, pelvic surgery or irradiation, parity, frequency, dysuria, hematuria, fever, polydipsia, weight gain, change in bowel habits, fecal incontinence, sexual function, sensory or motor symptoms

Clinical-manifestations

• loss of perineal sensation
• loss of bulbocavernosus reflex
• palpable bladder
• urine loss with Valsalva maneuver
• enlarged prostate
• decreased rectal sphincter tone
• impactation
• signs of estrogen deprivation

Laboratory

• urinalysis with reflex urine culture
• serum chemistries

• urea nitrogen
• creatinine
• electrolytes
• glucose

• urine cytology (if hematuria)

Diagnostic-procedures

• postvoid residual ( PVR)
• urodynamic testing (failure of initial therapy)

Radiology

• pelvic or abdominal ultrasound
• intravenous pyelography ( IVP)
• computed tomography ( CT) of pelvis

Complications

• urinary tract infections
• skin breakdown
• falls
• psychologic distress [6]
  
• disease interaction(s) of venous stasis with urinary incontinence
• disease interaction(s) of obstructive sleep apnea (OSA) with urinary incontinence
• disease interaction(s) of lumbar spinal stenosis with urinary incontinence
• disease interaction(s) of spinal cord injury with urinary incontinence
• disease interaction(s) of Parkinson's disease with urinary incontinence
• disease interaction(s) of normal pressure hydrocephalus (NPH) with urinary incontinence
• disease interaction(s) of multiple sclerosis with urinary incontinence
• disease interaction(s) of dementia with urinary incontinence
• disease interaction(s) of stroke with urinary incontinence
• disease interaction(s) of diabetes mellitus with urinary incontinence
• disease interaction(s) of heart failure with urinary incontinence

Management

• general

• treat reversible causes
• try the least invasive intervention 1st
• weight reduction & fluid restriction can improve urinary incontinence in selected women [9,14]
• voiding diary if etiology is unclear
• limit caffeine intake
• treat constipation
• enhance mobility
• bedside commode if mobility impaired
• catheterization

• indications

• urinary obstruction
• acontractile bladder

• avoid chronic catheterization if possible

• see specific type of urinary incontinence
• stable symptoms

• no benefit of treating bacteruria even with pyuria

• indications for urology referral

• unclear diagnosis after simple bedside tests
• recurrent symptomatic urinary tract infection
• hematuria
• previous lower urinary tract surgical procedures
• trauma
• irradiation
• prostate abnormality with symptomatic obstruction
• marked pelvic prolapse
• inability to pass urethral catheter
• significant urinary retention (> 200 mL PVR*)
• abnormal renal function with symptoms of retention
• lack of response to treatment

• devices

• pessary (see pessary)
• occlusive devices (see occlusive devices ...)
• absorbent products (diapers, pads)

• most common non-pharmaceutical intervention [6]

• periurethral bulking injection (see periurthethral ...)
• pelvic muscle exercises ( stress & urge incontinence)
• prevention (see prevention of fecal & urinary incontinence)
  
• * PVR = post-void residual

More General Terms

• incontinence
• urologic disease

Additional Terms

• office evaluation of urinary incontinence
• pharmaceutical causes of urinary incontinence
• pharmaceuticals used to treat urinary incontinence
• prevention of fecal & urinary incontinence

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 528-30
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
3. UCLA Specialty Women's clinic, 2001
4. Journal Watch 21(21):168, 2001 Sherburn et al Is incontinence associated with menopause? Obstet Gynecol 98:628, 2001 PMID: [1]
5. Journal Watch 22(18):142, 2002 Buschsbaum GM et al Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol 100:226, 2002 PMID: [2]
6. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
7. Journal Watch 23(20):159, 2003 Grodstein T et al Association of age, race, and obstetric history with urinary symptoms among women in the Nurses' Health Study. Am J Obstet Gynecol 189(Aug):248 2003 PMID: [3]
8. Journal Watch 24(18):146, 2004 Jackson RA, Vittinghoff E, Kanaya AM, Miles TP, Resnick HE, Kritchevsky SB, Simonsick EM, Brown JS; Health, Aging, and Body Composition Study. Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study. Obstet Gynecol. 2004 Aug;104(2):301-7. PMID: [4]
9. Journal Watch 25(17):134, 2005 Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. Weight loss: a novel and effective treatment for urinary incontinence. J Urol. 2005 Jul;174(1):190-5. PMID: [5]
   - Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in women. J Urol. 2005 Jul;174(1):187-9. PMID: [6]
10. Landefeld CS et al, National Institutes of Health state-of-the-science statement: Prevention of fecal and urinary incontinence in adults. Ann Intern Med 2008, 148:449 PMID: [7]
11. Shamliyan TA et al, Systematic review: Randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008, 148:459 PMID: [8]
12. Minassian VA et al, Urinary incontinence in women: Variation in prevalence estimates and risk factors. Obstet Gynecol 2008, 111:324 PMID: [9]
13. Waetjen LE, Feng WY, Ye J, Johnson WO, Greendale GA et al; Study of Women's Health Across the Nation (SWAN). Factors associated with worsening and improving urinary incontinence across the menopausal transition. Obstet Gynecol. 2008 Mar;111(3):667-77. PMID: [10]
14. Subak LL et al, Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women N Engl J Med 360:481-490 January 29, 2009 Number 5 [11] PMID: [12]
15. Landefeld CS et al National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med. 2008 Mar 18;148(6):449-58. Epub 2008 Feb 11. PMID: [13] (also see National Guideline Clearinghouse)
16. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
17. Urinary Incontinence: NIH Institute and Center Resource [14] 187) National Guideline Clearinghouse Urinary incontinence American Medical Directors Association (AMDA). ngc-guideline: [15]
    - Management of urinary incontinence in primary care. A national clinical guideline. (Scottish Intercollegiate Guidelines Network) ngc-guideline: [16]
    - Nursing management of patients with urinary incontinence. (Singapore Ministry of Health) ngc-guideline: [17]
    - Urinary incontinence in women. American College of Obstetricians and Gynecologists ngc-guideline: [18]
    - Urinary incontinence (UI) in older adults admitted to acute care. In: Evidence-based geriatric nursing protocols for best practice. Hartford Institute for Geriatric Nursing ngc-guideline: [19]
    - Prevention of fecal and urinary incontinence in adults. National Institutes of Health state-of-the-science conference statement: ngc-guideline: [20]
    - (1) Incontinence in women. In: Guidelines on urinary incontinence. European Association of Urology ngc-guideline: [21] (2) 2010 addendum to 2009 urinary incontinence guidelines.
    - (1) Pharmacotherapy. In: Guidelines on urinary incontinence. (2) 2010 addendum to 2009 urinary incontinence guidelines. European Association of Urology ngc-guideline: [22]
    - Incontinence in men. In: Guidelines on urinary incontinence. European Association of Urology ngc-guideline: [23]
    - Urinary incontinence in frail/older men and women. In: Guidelines on urinary incontinence. European Association of Urology ngc-guideline: [24]
    - Guidelines for the evaluation and treatment of recurrent urinary incontinence following pelvic floor surgery. Society of Obstetricians and Gynaecologists of Canada ngc-guideline: [25]
18. Evaluation and Management of Urinary Incontinence: recommendations from the Brigham and Women's Hospital, Finnish Medical Society, The John A. Hartford Foundation Institute for Geriatric Nursing, Scottish Intercollegiate Guidelines Network, and the Singapore Ministry of Health. [26]

urinary incontinence (UI)