Urinary Incontinence

Aka: Urinary Incontinence, Incontinence

1. See Also
   1. Low Pressure Urethra (Type 3)
   2. Overflow Incontinence
   3. Urge Incontinence
   4. Stress Incontinence
   5. Functional Incontinence
   6. Medication Causes of Incontinence
   7. Three Incontinence Questions
   8. Enuresis
2. Definitions
   1. Urinary Incontinence
      1. Involuntary urine loss
   2. Transient Urinary Incontinence
      1. Incontinence lasting <6 months and resolves if underlying cause reversed
3. Epidemiology
   1. 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
   2. High Incidence in female athletes
      1. Female Varsity Athletes: 32%
      2. Female Basketball players: 68%
4. Physiology
   1. 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
   2. Incontinence is not a normal part of aging
      1. Age predisposes to Incontinence
      2. Age does not cause Incontinence
5. Pathophysiology
   1. Disorders of Urinary Storage
      1. Detrussor Hyperactivity
         1. Urge Incontinence
      2. Sphincter incompetence
         1. Urge Incontinence
         2. Stress Incontinence
   2. Disorders of Urine Emptying
      1. Detrussor hypoactivity
         1. Overflow Incontinence
      2. Urethral Sphincter obstruction
         1. Overflow Incontinence
6. Risk Factors
   1. Increasing age
   2. Multiple prior vaginal deliveries
   3. Obesity
   4. Hysterectomy
   5. Comorbid medical conditions (e.g. Diabetes Mellitus, Congestive Heart Failure, Dementia)
   6. Diuretics
   7. High impact Exercise
7. Types: Common
   1. 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
   2. 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
   3. 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)
8. Types: Less Common
   1. 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
   2. 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
   3. Low Pressure Urethra (Type 3)
      1. Urethral tone loss (<60 cm H20)
      2. Causes: Trauma, surgery
9. Differential Diagnosis: (Mneumonic: "DIAPPERS") - Causes transient acute Incontinence
   1. Delirium
   2. Infection or Inflammation
      1. Recurrent Urinary Tract Infection
      2. Infectious Vaginitis
      3. Interstitial Cystitis
      4. Carcinoma-in-situ of the Bladder
   3. Atrophic Urethritis or Atrophic Vaginitis
   4. 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
   5. Psychological causes
   6. Excessive Urine Output (e.g. Diabetes Mellitus)
   7. Restricted Mobility (i.e. difficult ambulation)
   8. Stool Impaction
10. History
    1. Voiding Diary (3 day journal)
       1. https://www.niddk.nih.gov/health-information/health-topics/urologic-disease/daily-bladder-diary/Documents/diary_508.pdf
       2. Frequency of Incontinence episodes
       3. Measured volumes of voids
       4. Estimated volumes of Incontinence
    2. Volume overload (CHF, Chronic Kidney Disease, Cirrhosis)
       1. Urge Incontinence
    3. Decreased mobility (e.g. Arthritis)
       1. Urge Incontinence
       2. Functional Incontinence
    4. Cerebrovascular Accident, Dementia or other diminished mental status
       1. Urge Incontinence
       2. Functional Incontinence
    5. Spinal Stenosis
       1. Overflow Incontinence
11. Symptoms: Triggers
    1. Provocation with cough, valsalva, or bearing down
       1. Suggests Stress Incontinence
    2. Spontaneous loss of urine
       1. Detrussor Instability
       2. Urge Incontinence
12. Symptoms: Urine Volume
    1. Small volume leakage with activity (5-10 ml/episode)
       1. Stress Incontinence
    2. Spontaneous uncontrolled large volume Bladder emptying
       1. Urge Incontinence
13. Symptoms: Timing
    1. Predictable episodes (e.g.cough, sneezing, Exercise)
       1. Stress Incontinence
    2. Immediately follows urge to void
       1. Urge Incontinence
    3. Nocturia
       1. Urge Incontinence
    4. Urinary Frequency
       1. Urge Incontinence
14. Exam: General
    1. Cognitive and Functional Assessment
       1. See Mental State Exam
       2. See Activities of Daily Living
    2. Fecal Impaction
       1. Overflow Incontinence
    3. Decreased anal sphincter tone
       1. Overflow Incontinence
15. Exam: Female Genitourinary Exam
    1. Vulvar or Vaginal Atrophy (Menopause)
       1. Stress Incontinence
       2. Urge Incontinence
    2. Pelvic Organ Prolapse
       1. Stress Incontinence
       2. Overflow Incontinence (if obstruction)
    3. Perform Pelvic exam, lifting anterior vaginal wall
       1. Changes Bladder neck position
       2. Retest with cough or valsalva
16. Exam: Male Genitourinary Exam
    1. Benign Prostatic Hyperplasia
       1. Overflow Incontinence
17. Labs
    1. Urinalysis
       1. Evaluate for Urinary Tract Infection, Hematuria, Proteinuria and urinary Glucose
    2. Renal Function tests
       1. Indicated in cases of suspected urinary obstruction
18. Diagnosis
    1. See Provoked Full Bladder Stress Test
    2. See Cough Stress Test
    3. Urodynamic Testing (Cystometrography)
       1. Indicated for Incontinence not due to stress or urge
    4. 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
19. Evaluation
    1. 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
    2. Rule-out Overflow Incontinence
       1. Check post-void residual if indicated by history
    3. Consider neurologic or post-surgical cause
       1. See Low Pressure Urethra
    4. Distinguish Urge Incontinence from Stress Incontinence
       1. If secondary cause is unlikely
20. Management: General
    1. Management is per specific Incontinence cause
       1. Urge Incontinence
       2. Stress Incontinence
       3. Overflow Incontinence
       4. Functional Incontinence
       5. Low Pressure Urethra (Type 3)
    2. Make toilets more accessible
       1. Higher toilets
       2. Well lit floors
       3. Change bedroom to be close to bathroom
       4. Consider bedside commode
    3. Wear clothes that are removed easily
    4. Use moderation in fluid intake (but avoid aggressive fluid restriction)
    5. Lose weight (if obese)
    6. Smoking Cessation
    7. Avoid Diuretics
       1. Avoid Alcohol
       2. Avoid Caffeine
       3. Avoid carbonated beverages
21. Management: Urology Referral Indications
    1. Incontinence secondary to Recurrent Urinary Tract Infections (or other relapsing condition)
    2. Incontinence with Muscle Weakness or other new-onset neurologic symptoms
    3. Severe Benign Prostatic Hyperplasia
    4. Severe Pelvic Organ Prolapse (beyond introitus)
    5. Incontinence with associated Pelvic Pain
    6. Incontinence with persistently positive urinary sediment
       1. Hematuria
       2. Proteinuria
    7. Postvoid residual Urine Volume >200 ml
    8. Prior pelvic surgery or pelvic radiation
    9. Idiopathic Urinary Incontinence diagnosis
22. Complications
    1. Increased anxiety and depressed mood
    2. Increased Urinary Tract Infections
    3. Increased Skin Infections
    4. Increased fall risk
    5. Increased Caregiver Burden
    6. Increased overall mortality among older institutionalized adults
       1. Damian (2017) J Adv Nurs 73(3): 688-99 [PubMed]
23. Resources
    1. Help for Incontinent People
       1. Phone: (864) 579-7900
    2. AUA Step By Step Incontinence Treatment
       1. http://www.drylife.org/drylife.html
    3. Bladder Control in Women
       1. http://www.niddk.nih.gov/health/urolog/uibcw/
24. References
    1. Frank (2010) Can Fam Physician 56(11): 1115-20 [PubMed]
    2. Gibbs (2007) Am J Med 120(3): 211-20 [PubMed]
    3. Goode (2010) JAMA 303(21): 2172-81 [PubMed]
    4. Hersh (2013) Am Fam Physician 87(9): 634-40 [PubMed]
    5. Holroyd-Leduc (2008) JAMA 299(12): 1446-56 [PubMed]
    6. Hu (2019) Am Fam Physician 100(6): 339-48 [PubMed]
    7. Khadelwal (2013) Am Fam Physician 87(8): 543-50 [PubMed]