//fpnotebook.com/
Urinary Incontinence
Aka: Urinary Incontinence, Incontinence
- See Also
- Low Pressure Urethra (Type 3)
- Overflow Incontinence
- Urge Incontinence
- Stress Incontinence
- Functional Incontinence
- Medication Causes of Incontinence
- Three Incontinence Questions
- Enuresis
- Definitions
- Urinary Incontinence
- Involuntary urine loss
- Transient Urinary Incontinence
- Incontinence lasting <6 months and resolves if underlying cause reversed
- Epidemiology
- Increased prevelance with age
- Age 44 year women: 17%
- Age 75 year women: 27%
- Overall Prevalence in adult women >50% in some studies
- High Incidence in female athletes
- Female Varsity Athletes: 32%
- Female Basketball players: 68%
- Physiology
- Physiology of urination and Bladder control
- Detrussor Muscle (Bladder) control
- Parasympathetic innervation
- Beta adrenergic control
- Internal Urethral sphincter
- Alpha adrenergic control
- External Urethral sphincter
- Somatic or voluntary control
- Incontinence is not a normal part of aging
- Age predisposes to Incontinence
- Age does not cause Incontinence
- Pathophysiology
- Disorders of Urinary Storage
- Detrussor Hyperactivity
- Urge Incontinence
- Sphincter incompetence
- Urge Incontinence
- Stress Incontinence
- Disorders of Urine Emptying
- Detrussor hypoactivity
- Overflow Incontinence
- Urethral Sphincter obstruction
- Overflow Incontinence
- Risk Factors
- Increasing age
- Multiple prior vaginal deliveries
- Obesity
- Hysterectomy
- Comorbid medical conditions (e.g. Diabetes Mellitus, Congestive Heart Failure, Dementia)
- Diuretics
- High impact Exercise
- Types: Common
- Urge Incontinence (Overly sensitive Bladder)
- Loss of large Bladder volumes (contrast with Stress Incontinence) typically in older patients (esp. post CVA)
- Associated with strong sense of urinary urgency; Urinary Frequency and Nocturia may be present
- Caused be detrussor overactivity and more commonly associated with CNS or spinal cord disorders
- Example Causes: CVA, Cystitis, Bladder Cancer, Bladder stones
- Stress Incontinence (Loss of pelvic support at Urethra)
- Loss of small Bladder volumes (contrast with urge) that occurs with coughing, sneezing, lifting
- Urethral Hypermobility and Urethral sphincter dysfunction
- Most common cause of Urinary Incontinence in younger women
- Mixed Urinary Incontinence
- Combined Stress Incontinence and Urge Incontinence
- Occurs in one third of adults with Urinary Incontinence (most common Urinary Incontinence cause)
- Types: Less Common
- Overflow Incontinence (Urinary Retention)
- Bladder overdistention with Urinary Retention
- Presents with dribbling or continuous urine leakage
- Post-void residual >200 cc of urine
- Bladder outlet obstruction is less common in women (consider evaluation for tumor mass)
- Example Causes: Diabetic Neuropathy, BPH, or pelvic mass
- Functional Incontinence
- Normal Bladder with decreased access to toilet (physical or cognitive Impairment)
- Typically occurs in debilitated patients (e.g. severe Arthritis) or Dementia
- Low Pressure Urethra (Type 3)
- Urethral tone loss (<60 cm H20)
- Causes: Trauma, surgery
- Differential Diagnosis: (Mnemonic: "DIAPPERS") - Causes transient acute Incontinence
- Delirium
- Infection or Inflammation
- Recurrent Urinary Tract Infection
- Infectious Vaginitis
- Interstitial Cystitis
- Carcinoma-in-situ of the Bladder
- Atrophic Urethritis or Atrophic Vaginitis
- Pharmaceuticals
- See Medication Causes of Urinary Incontinence
- Diuretics
- Sedative-Hypnotic Medications
- Antipsychotic Medications
- Antidepressants
- Analgesics including Narcotics
- Muscle relaxants
- Sympathetic blockers
- Psychological causes
- Excessive Urine Output (e.g. Diabetes Mellitus)
- Restricted Mobility (i.e. difficult ambulation)
- Stool Impaction
- History
- Voiding Diary (3 day journal)
- https://www.niddk.nih.gov/health-information/health-topics/urologic-disease/daily-bladder-diary/Documents/diary_508.pdf
- Frequency of Incontinence episodes
- Measured volumes of voids
- Estimated volumes of Incontinence
- Volume overload (CHF, Chronic Kidney Disease, Cirrhosis)
- Urge Incontinence
- Decreased mobility (e.g. Arthritis)
- Urge Incontinence
- Functional Incontinence
- Cerebrovascular Accident, Dementia or other diminished mental status
- Urge Incontinence
- Functional Incontinence
- Spinal Stenosis
- Overflow Incontinence
- Symptoms: Triggers
- Provocation with cough, valsalva, or bearing down
- Suggests Stress Incontinence
- Spontaneous loss of urine
- Detrussor Instability
- Urge Incontinence
- Symptoms: Urine Volume
- Small volume leakage with activity (5-10 ml/episode)
- Stress Incontinence
- Spontaneous uncontrolled large volume Bladder emptying
- Urge Incontinence
- Symptoms: Timing
- Predictable episodes (e.g.cough, sneezing, Exercise)
- Stress Incontinence
- Immediately follows urge to void
- Urge Incontinence
- Nocturia
- Urge Incontinence
- Urinary Frequency
- Urge Incontinence
- Exam: General
- Cognitive and Functional Assessment
- See Mental State Exam
- See Activities of Daily Living
- Fecal Impaction
- Overflow Incontinence
- Decreased anal sphincter tone
- Overflow Incontinence
- Exam: Female Genitourinary Exam
- Vulvar or Vaginal Atrophy (Menopause)
- Stress Incontinence
- Urge Incontinence
- Pelvic Organ Prolapse
- Stress Incontinence
- Overflow Incontinence (if obstruction)
- Perform Pelvic exam, lifting anterior vaginal wall
- Changes Bladder neck position
- Retest with cough or valsalva
- Exam: Male Genitourinary Exam
- Benign Prostatic Hyperplasia
- Overflow Incontinence
- Labs
- Urinalysis
- Evaluate for Urinary Tract Infection, Hematuria, Proteinuria and urinary Glucose
- Renal Function tests
- Indicated in cases of suspected urinary obstruction
- Diagnosis
- See Provoked Full Bladder Stress Test
- See Cough Stress Test
- Urodynamic Testing (Cystometrography)
- Indicated for Incontinence not due to stress or urge
- Post-void residual (Bedside Ultrasound performed after patient attempts to completely void)
- Urine PVR <50 ml
- Stress Incontinence
- Urge Incontinence
- Mixed Incontinence
- Urine PVR >200 ml
- Overflow Incontinence
- Variable
- Functional Incontinence
- Evaluation
- Rule-out reversible cause
- Medication adverse effects
- Atrophic Vaginitis
- Benign Prostatic Hyperplasia (BPH)
- Polyuria
- Medication
- Diabetes Mellitus
- Fecal Impaction
- Urinary Tract Infection
- Functional Incontinence
- Limited mobility
- Altered Level of Consciousness
- Rule-out Overflow Incontinence
- Check post-void residual if indicated by history
- Consider neurologic or post-surgical cause
- See Low Pressure Urethra
- Distinguish Urge Incontinence from Stress Incontinence
- If secondary cause is unlikely
- Management: General
- Management is per specific Incontinence cause
- Urge Incontinence
- Stress Incontinence
- Overflow Incontinence
- Functional Incontinence
- Low Pressure Urethra (Type 3)
- Make toilets more accessible
- Higher toilets
- Well lit floors
- Change bedroom to be close to bathroom
- 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
- Avoid Alcohol
- Avoid Caffeine
- Avoid carbonated beverages
- Management: Urology Referral Indications
- 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
- Hematuria
- Proteinuria
- Postvoid residual Urine Volume >200 ml
- Prior pelvic surgery or pelvic radiation
- Idiopathic Urinary Incontinence diagnosis
- Complications
- 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
- Damian (2017) J Adv Nurs 73(3): 688-99 [PubMed]
- Resources
- Help for Incontinent People
- Phone: (864) 579-7900
- AUA Step By Step Incontinence Treatment
- http://www.drylife.org/drylife.html
- Bladder Control in Women
- http://www.niddk.nih.gov/health/urolog/uibcw/
- References
- Frank (2010) Can Fam Physician 56(11): 1115-20 [PubMed]
- Gibbs (2007) Am J Med 120(3): 211-20 [PubMed]
- Goode (2010) JAMA 303(21): 2172-81 [PubMed]
- Hersh (2013) Am Fam Physician 87(9): 634-40 [PubMed]
- Holroyd-Leduc (2008) JAMA 299(12): 1446-56 [PubMed]
- Hu (2019) Am Fam Physician 100(6): 339-48 [PubMed]
- Khadelwal (2013) Am Fam Physician 87(8): 543-50 [PubMed]