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)

• Excess urinary output caused by

  • Diuretics

  • Excess fluid intake

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

  • Peripheral edema

• 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 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 (diabetes mellitus), hypercalcemia, hyponatremia (diabetes insipidus)

Imaging Studies

• Ultrasonography can determine postvoid residual

• In older men for whom ...