07. Incontinence

Definition

Involuntary loss of urine severe enough to have social or hygienic consequences.

It is NOT an inevitable part of aging, although physiologic changes of aging (BPH, decreased estrogen) increase risk.

Relevance

Individuals with urinary incontinence have higher utilization of healthcare and worse quality of life. UI is also significantly associated with a patient’s ability to complete ADLs. Treatment of incontinence can decrease risk of falls.

Differential Diagnosis

Concern for specific etiologies depends on whether incontinence is acute (in which case ruling out overflow incontinence and neurogenic bladder are paramount) vs chronic.

  • D: delirium
  • I: infection (symptomatic)
  • A: atrophic urethritis/vaginitis
  • P: pharmaceuticals (diuretics, sedatives), psychiatric cause (depression)
  • E: excessive urinary output (hyperglycemia, hypercalcemia, CHF)
  • R: restricted mobility
  • S: stool impaction, sensation (i.e. neurogenic bladder)

Indications for Catheter Use

Incontinence alone is NOT an indication for catheter placement!

Catheters may be Indicated for:

  • Inability to void: outlet obstruction (e.g. BPH), neurogenic bladder with retention, medications
  • Severe cases of gross hematuria or pyuria with concerns for obstruction, monitoring and/or irrigation
  • After anesthesia (short term only)
  • Incontinence AND open wounds needing protection (pressure ulcers)
  •  Severe illness requiring close monitoring of I/O
  •  Palliative care AND patient preference

Bladder catheters should NOT be placed for the following reasons:

  • Routinely on admission
  • Patient request
  • Limited mobility
  • Pain
  • Dementia/delirium

Evaluation

History

  • Ask every patient about incontinence (35% of community-dwelling elderly have incontinence, but only half of incontinent persons have told a physician).
    • During the last 3 months, have you leaked urine, even a small amount?
  • If the patient is incontinent, focus the history by type of incontinence.
    • Stress UI: physical activity, coughing, sneezing, lifting, or exercise.
    • Urge UI (aka detrusor instability): urge, feeling need to empty but could not get to the toilet fast enough.
    • Overflow UI: frequent or constant leakage or dribbling, losing urine without warning.
  • Focused ROS:
    • Endo: polyphagia, polydipsia, polyuria
    • Neuro: weakness, sensation changes, mobility
    • Abd: pain, constipation, stool incontinence
    • GU: hematuria, dysuria
    • Psych
  • Medication review

Exam

  • Abdominal: palpate for bladder.
  • POCUS for bladder size and hydronephrosis (enlargement of calices, cortical thinning) or ask RN to bladder scan.
    • Post-void residual: >200mL indicates inadequate emptying.
  • GU: examine women for vaginal atrophy, mass, uterine prolapse, cystocele, rectocele; examine men for prostate size.
  • Rectal: r/o stool impaction, evaluate for tone, prostate size.
  • Neuro: saddle area sensation, distal strength

Labs

  • UA with micro, urine culture
  • Chemistries: BUN, Cr, glucose, calcium

Radiology

  • MRI L/S spine if concern for neurologic etiology (especially for acute onset incontinence and/or focal neuro exam)
  • Ultrasound kidney if concern for hydronephrosis
  • Voiding cystourethrogram if suspect fistula tract

Management

Acute presentation of urinary incontinence requires neurosurgery evaluation. Consider dexamethasone if possible spinal compression.

Conservative strategies for all types of chronic UI:

1. Fluid restrict at night (no fluids within 2-4 hrs of bedtime).

2. Avoid caffeine and alcohol in evening.

3. Bedside commode or urinal.

4. Time diuretics for the daytime.

5. Timed voids: instruct patient to go on toilet every 3-4 hours regardless of sensation of needing to void.

6. Catheterization / diapers

a. For chronic neurogenic bladder: intermittent catheterization q6hr is preferred to bladder catheter.

b. Consider absorbent pads or frequent diaper changes to help prevent skin breakdown.

7. Medications

a. Vary by type of incontinence, but often have significant side effects in the elderly.

b. Urge incontinence

i. Oxybutynin, tolterodine, trospium (less drug-drug interactions), solifenacin and darifenacin (maybe less drowsiness), imipramine (less prescribed due to new medications with less side effects).

ii. These medications are generally anticholinergic and must be used with caution in the elderly. Use lowest dose possible.

c. Stress incontinence: pseudoephedrine, topical estrogen for atrophy

d. Overflow incontinence: alpha-blocker, finasteride, temporary bethanechol for urinary retention while addressing underlying cause

8. Consults

a. Urology consultation if elevated PVR, hematuria

b. Surgical options may be appropriate after outpatient evaluation

References

http://coe.ucsf.edu/wcc/  (UCSF Women’s Continence Center)

Holroyd-Leduc JM, Tannenbaum C, Thorpe KE. What type of urinary incontinence does this woman have? JAMA. 2008; 299(12): 1446-1456.

Thirugnanasothy S. Managing urinary incontinence in older people. BMJ. 2010; 341.

Tang DH, Colayco D, Piercy J, Patel V, Globe D, and Chancellor MB. Impact of urinary incontinence on health-related quality of life, daily activities, and healthcare resource utilization in patients with neurogenic detrusor overactivity. BMC Neurology 2014; 14: 17.

De Gagne JC, So A, Oh J, Park S, Palmer MH. Sociodemographic and health indicators of older women with urinary incontinence: 2010 National Survey of Residential Care Facilities. J Am Geratr Soc. 2013 Jun; 61 (6): 981-6.

Goepel M, Kirschner-Hermanns R, Welz-Barth A, Klaus-Christian S, and Rubben H. Urinary Incontinence in the Elderly. Dtsch Arztebl Int. 2010 Jul; 107(30): 531–536