Urinary Incontinence

Urinary Incontinence
1. Involuntary urine loss
Transient Urinary Incontinence
1. Incontinence lasting <6 months and resolves if underlying cause reversed

Increased prevelance with age
1. Age 44 year women: 17%
2. Age 75 year women: 27%
3. Overall Prevalence in adult women >50% in some studies
High Incidence in female athletes
1. Female Varsity Athletes: 32%
2. Female Basketball players: 68%

Physiology of urination and Bladder control
1. Detrussor Muscle (Bladder) control
  1. Parasympathetic innervation
  2. Beta adrenergic control
2. Internal Urethral sphincter
  1. Alpha adrenergic control
3. External Urethral sphincter
  1. Somatic or voluntary control
Incontinence is not a normal part of aging
1. Age predisposes to Incontinence
2. Age does not cause Incontinence

Disorders of Urinary Storage
1. Detrussor Hyperactivity
  1. Urge Incontinence
2. Sphincter incompetence
  1. Urge Incontinence
  2. Stress Incontinence
Disorders of Urine Emptying
1. Detrussor hypoactivity
  1. Overflow Incontinence
2. Urethral Sphincter obstruction
  1. Overflow Incontinence

Increasing age
Multiple prior vaginal deliveries
Obesity
Hysterectomy
Comorbid medical conditions (e.g. Diabetes Mellitus, Congestive Heart Failure, Dementia)
Diuretics
High impact Exercise

Urge Incontinence (Overly sensitive Bladder)
1. Loss of large Bladder volumes (contrast with Stress Incontinence) typically in older patients (esp. post CVA)
2. Associated with strong sense of urinary urgency; Urinary Frequency and Nocturia may be present
3. Caused be detrussor overactivity and more commonly associated with CNS or spinal cord disorders
4. Example Causes: CVA, Cystitis, Bladder Cancer, Bladder stones
Stress Incontinence (Loss of pelvic support at Urethra)
1. Loss of small Bladder volumes (contrast with urge) that occurs with coughing, sneezing, lifting
2. Urethral Hypermobility and Urethral sphincter dysfunction
3. Most common cause of Urinary Incontinence in younger women
Mixed Urinary Incontinence
1. Combined Stress Incontinence and Urge Incontinence
2. Occurs in one third of adults with Urinary Incontinence (most common Urinary Incontinence cause)

Overflow Incontinence (Urinary Retention)
1. Bladder overdistention with Urinary Retention
2. Presents with dribbling or continuous urine leakage
3. Post-void residual >200 cc of urine
4. Bladder outlet obstruction is less common in women (consider evaluation for tumor mass)
5. Example Causes: Diabetic Neuropathy, BPH, or pelvic mass
Functional Incontinence
1. Normal Bladder with decreased access to toilet (physical or Cognitive Impairment)
2. Typically occurs in debilitated patients (e.g. severe Arthritis) or Dementia
Low Pressure Urethra (Type 3)
1. Urethral tone loss (<60 cm H20)
2. Causes: Trauma, surgery

Delirium
Infection or Inflammation
1. Recurrent Urinary Tract Infection
2. Infectious Vaginitis
3. Interstitial Cystitis
4. Carcinoma-in-situ of the Bladder
Atrophic Urethritis or Atrophic Vaginitis
Pharmaceuticals
1. See Medication Causes of Urinary Incontinence
2. Diuretics
3. Sedative-Hypnotic Medications
4. Antipsychotic Medications
5. Antidepressants
6. Analgesics including Narcotics
7. Muscle relaxants
8. Sympathetic blockers
Psychological causes
Excessive Urine Output (e.g. Diabetes Mellitus)
Restricted Mobility (i.e. difficult ambulation)
Stool Impaction

Provocation with cough, valsalva, or bearing down
1. Suggests Stress Incontinence
Spontaneous loss of urine
1. Detrussor Instability
2. Urge Incontinence

Vulvar or Vaginal Atrophy (Menopause)
1. Stress Incontinence
2. Urge Incontinence
Pelvic Organ Prolapse
1. Stress Incontinence
2. Overflow Incontinence (if obstruction)
Perform Pelvic exam, lifting anterior vaginal wall
1. Changes Bladder neck position
2. Retest with cough or valsalva

Urinalysis
1. Evaluate for Urinary Tract Infection, Hematuria, Proteinuria and urinary Glucose
Renal Function tests
1. Indicated in cases of suspected urinary obstruction

See Provoked Full Bladder Stress Test
See Cough Stress Test
Urodynamic Testing (Cystometrography)
1. Indicated for Incontinence not due to stress or urge
Post-void residual (Bedside Ultrasound performed after patient attempts to completely void)
1. Urine PVR <50 ml
  1. Stress Incontinence
  2. Urge Incontinence
  3. Mixed Incontinence
2. Urine PVR >200 ml
  1. Overflow Incontinence
3. Variable
  1. Functional Incontinence

Rule-out reversible cause
1. Medication adverse effects
2. Atrophic Vaginitis
3. Benign Prostatic Hyperplasia (BPH)
4. Polyuria
  1. Medication
  2. Diabetes Mellitus
5. Fecal Impaction
6. Urinary Tract Infection
7. Functional Incontinence
  1. Limited mobility
  2. Altered Level of Consciousness
Rule-out Overflow Incontinence
1. Check post-void residual if indicated by history
Consider neurologic or post-surgical cause
1. See Low Pressure Urethra
Distinguish Urge Incontinence from Stress Incontinence
1. If secondary cause is unlikely

Management is per specific Incontinence cause
Make toilets more accessible
1. Higher toilets
2. Well lit floors
3. Change bedroom to be close to bathroom
4. Consider bedside commode
Wear clothes that are removed easily
Use moderation in fluid intake (but avoid aggressive fluid restriction)
Lose weight (if obese)
Smoking Cessation
Avoid Diuretics
1. Avoid Alcohol
2. Avoid Caffeine
3. Avoid carbonated beverages

Incontinence secondary to Recurrent Urinary Tract Infections (or other relapsing condition)
Incontinence with Muscle Weakness or other new-onset neurologic symptoms
Severe Benign Prostatic Hyperplasia
Severe Pelvic Organ Prolapse (beyond introitus)
Incontinence with associated Pelvic Pain
Incontinence with persistently positive urinary sediment
1. Hematuria
2. Proteinuria
Postvoid residual Urine Volume >200 ml
Prior pelvic surgery or pelvic radiation
Idiopathic Urinary Incontinence diagnosis

Increased anxiety and depressed mood
Increased Urinary Tract Infections
Increased Skin Infections
Increased Fall Risk
Increased Caregiver Burden
Increased overall mortality among older institutionalized adults
1. Damian (2017) J Adv Nurs 73(3): 688-99 [PubMed]