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Key Features

Essentials of Diagnosis

  • Involuntary loss of urine

  • Stress incontinence: leakage of urine upon coughing, sneezing, or standing

  • Urge incontinence: urgency and inability to delay urination

  • Overflow incontinence: variable presentation

General Considerations

Transient causes (the mnemonic "DIAPPERS")

  • Delirium (a common cause in hospitalized patients)

  • Infection (symptomatic urinary tract infection)

  • Atrophic urethritis and vaginitis

  • Pharmaceuticals

    • Potent diuretics

    • Anticholinergics

    • Psychotropics

    • Opioid analgesics

    • α-Blockers (in women)

    • α-Agonists (in men)

    • Calcium channel blockers

  • Psychological factors (severe depression with psychomotor retardation)

  • Excess urinary output caused by

    • Diuretics

    • Excess fluid intake

    • Metabolic abnormalities (eg, hyperglycemia, hypercalcemia, diabetes insipidus)

    • Peripheral edema and its associated nocturia

  • Restricted mobility (see Immobility in Elderly)

  • Stool impaction

Established causes

  • Detrusor overactivity (urge incontinence)

    • Uninhibited bladder contractions that cause leakage

    • Most common cause of established geriatric incontinence, accounting for two-thirds of cases; usually idiopathic

    • Detrusor hyperactivity with incomplete contractions (DHIC) is a subtype of urge incontinence that can present with urgency with incomplete bladder emptying

  • Urethral incompetence (stress incontinence)

  • Urethral obstruction

    • Common in older men but rare in older women

    • May be due to prostatic enlargement, urethral stricture, bladder neck contracture, or prostatic cancer in men

    • Cystoceles or other anatomic problems can be causes in women

  • Detrusor underactivity (overflow incontinence)

    • Least common cause of incontinence

    • May be idiopathic or due to sacral lower motor nerve dysfunction

Clinical Findings

Symptoms and Signs

  • Atrophic urethritis and vaginitis

    • Vaginal mucosal friability

    • Erosions

    • Telangiectasia

    • Petechiae

    • Erythema

  • Detrusor overactivity (urge incontinence)

    • Complaint of urinary leakage after the onset of an intense urge to urinate that cannot be forestalled

    • A standing full bladder stress test (asking the patient to cough while standing) may result in a few second delay in release of urine

  • Urethral incompetence (stress incontinence)

    • Urinary loss occurs with laughing, coughing, or lifting heavy objects

    • Most commonly seen in women but can be seen following prostatectomy in men

    • A standing full bladder stress test (asking the patient to cough while standing) should result in immediate release of urine

  • Urethral obstruction

    • Common symptoms include dribbling, urge incontinence, and overflow incontinence

    • Detrusor overactivity (which coexists in two-thirds of cases) may cause symptoms of urgency

  • Detrusor underactivity (overflow incontinence)

    • Urinary frequency, nocturia, and frequent leakage of small amounts

    • An elevated postvoid residual (generally over 450 mL) distinguishes detrusor underactivity from detrusor overactivity and stress incontinence, but only urodynamic testing differentiates it from urethral obstruction in men

Diagnosis

Laboratory Tests

  • Review medications

  • Check urinalysis, urine culture for infection

  • Consider tests for hyperglycemia, hypercalcemia, diabetes insipidus

Imaging Studies

  • Ultrasonography can determine postvoid residual

  • In older men for whom surgery is planned, urodynamic confirmation of obstruction is strongly advised

Diagnostic Procedures

  • To test for stress incontinence...

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