Urinary Incontinence

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)

• Excessive 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

• Urethral incompetence (stress incontinence)

• Detrusor overactivity (urge incontinence)

  • Uninhibited bladder contractions that cause leakage

  • Most common cause of established incontinence in older adults, accounting for two-thirds of cases

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

• Overflow incontinence

  • 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 is less common but can also cause overflow incontinence

  • May be idiopathic or have an identifiable cause including medications and sacral lower motor nerve dysfunction

  • When it causes incontinence, detrusor underactivity is associated with urinary frequency, nocturia, and frequent leakage of small volumes

Clinical Findings

Symptoms and Signs

• Atrophic urethritis and vaginitis

  • Vaginal mucosal friability

  • Erosions

  • Telangiectasia

  • Petechiae

  • Erythema

• 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

• 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

• Detrusor underactivity (overflow incontinence)

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

  • Although the measurement of postvoid residual volume is not considered standard in the evaluation of urinary incontinence, it should be measured when overflow is suspected

  • No standardized cutoff has been established for postvoid residual volume, but it is generally above 200 mL in overflow incontinence

• Urethral obstruction

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

  • Detrusor overactivity coexists in two-thirds of cases

Diagnosis

Laboratory Tests