39: Urinary Incontinence

Older women and men are more likely to experience urinary incontinence (UI) than younger adults; however, this is not an inevitable condition of aging. Approximately, 15% to 30% of healthy older adults experience some urinary leakage. The prevalence is nearly 50% in frail community dwellers and between 50% and 75% in institutionalized older adults. UI occurs more frequently in women than in men in most age groups, but the prevalence of UI increases with age in both men and women.

UI too often goes unreported because of patient embarrassment or reluctance to discuss the condition. Less than 20% of incontinent adults are assessed for this condition by primary care providers. Underevaluation may be a result of time constraints, underappreciation of the prevalence, or uncertainty about the disease management.

Leading risk factors for incontinence in older adults include increasing age, female gender, cognitive impairment, genitourinary surgery, obesity, and impaired mobility.

The financial impact of incontinence in caregiver time, medication costs, and continence supplies is substantial. An estimated $12 billion is spent annually on incontinence in the United States. This is comparable to the health care costs of other chronic diseases such as osteoporosis and breast cancer.

UI has long been classified as a geriatric syndrome: a symptom complex found more frequently in older adults which is often multifactorial in etiology and which requires a multidimensional approach to risk factor modification and treatment. To understand how to prevent, diagnose and treat the condition accurately, it is important to understand the normal physiology of voiding and how normal voiding can be disrupted.

To maintain continence, a person must have intact cognitive, neurologic, muscular, and urologic systems. Consciousness, motivation, comprehension, and attention are needed to properly recognize the need to void and sequence the necessary steps to pass urine in an appropriate time and location. Diseases such as dementia, depression, stroke, and delirium can disrupt the cognitive function needed to exert control over voiding. Muscular dexterity is needed to manipulate clothing and toileting supplies, and to physically reach a toilet or urinal. Arthritis and muscular conditions, which impair ambulation and joint functioning, can result in incontinence episodes.

Neurologically, micturition is a coordinated balance between the spinal cord sympathetic and parasympathetic systems (Figure 39–1) and cerebral signaling. The pontine micturition center coordinates the cognitive inhibition/disinhibition to void and the spinal cord response to urinary tract stimulation. Innervation to the detrusor muscle and distal urethra/pelvic floor comes from the sacral 2–4 nerve roots and the innervations to the proximal urethra comes from the thoracic 11–lumbar 2 nerve roots. The sympathetic system allows urinary storage by contracting the urethral sphincter and relaxing the detrusor muscle. The parasympathetic system allows voiding by contracting the detrusor and relaxing the urethral sphincter. Diseases, such as spinal cord injury and multiple sclerosis, can impede the neurologic balance between the bladder wall and sphincter. The genitourinary organs and tissues can be diseased or damaged to a degree that impairs controlled urination. Prostatic enlargement, bladder prolapse, urethral structuring, bladder stones, and estrogen-deficient tissue atrophy can cause enough anatomic abnormality that incontinence develops.

Because UI has many different etiologies, triggers, and risk factors, the timing, frequency and severity of symptoms can be quite variable. Prevention thus focuses on reducing the impact of chronic disease on incontinence-related risk, as well as preventing the development of incontinence itself. It may not be possible to completely prevent UI, but measures to reduce the impact and frequency of the condition may be reasonable goals. Like most geriatric syndromes, prevention of symptoms or events often requires a multifactorial approach, which is designed to eliminate the factors that lead to incontinent episodes.

There are few studies that target primary prevention of UI. Most treatment trials target secondary prevention by attempting to reduce the number of episodes in those who already have some degree of UI. In one primary prevention study of poststroke patients, a multidimensional approach that included dedicated rehabilitation and a continence care team was found to reduce the development of UI. Another study of continent older women who were taught pelvic floor exercises showed a reduction in the later development of incontinence. A small trial of weight loss reduced the development of UI in some obese patients, but increased exercise lead to increased incontinence in others. Diabetes is associated with higher rates of UI. In 1 trial of obese women with prediabetes, a healthy lifestyle that included healthy diet, reduced weight, increased activity levels, and smoking cessation was associated with a lower subsequent development of stress, but not urge, incontinence symptoms. These findings were seen in the younger population, but not in the subgroup of older adults.

Symptoms & Signs

UI is generally classified into 4 different types based on the pathophysiologic cause of the leakage. Many people experience more than 1 type, or “mixed” incontinence. Leakage may be transient (reversible), episodic, or persistent in nature, based on the risk factors contributing to the condition.

Functional incontinence

• Definition: Loss of urine in the setting of a normal structural and functional urinary system

• Signs/symptoms: Impaired awareness/concern, altered cognition, large-volume leakage

• Potential causes: Dementia, delirium, depression, immobility, impaired manual dexterity, excessive urine output

Stress incontinence

• Definition: Loss of urine when abrupt increase in intraabdominal pressure exceeds urethral sphincter closing pressure

• Signs/symptoms: Often small volumes, associated with activities such as cough, laugh, sneeze, standing, bending

• Potential causes: Genitourinary (GU) atrophy or prolapse, urethral sphincter trauma, pelvic floor weakness

Urge incontinence—

Also known as overactive bladder (OAB), detrusor hyperactivity, and detrusor instability.

• Definition: Loss of urine caused by uninhibited detrusor activity at inappropriately low urinary volumes

• Signs/symptoms: Small- or large-volume leakage, abrupt onset, urgency, frequency

• Potential causes: Bladder irritants, stones, infection or foreign body, detrusor noncompliance (scarring, fibrosis, and aging)

Overflow incontinence

• Definition: Loss of urine in the setting of excessive bladder volume as a result of impaired bladder wall contraction or urinary sphincter relaxation

• Signs/symptoms: Dribbling, weak urinary stream, intermittency, hesitancy, frequency, nocturia, high postvoid urinary volume

• Potential causes: Benign prostatic hyperplasia (BPH), prostate cancer, urethral stricture, GU organ prolapse, anticholinergic medication, neuropathy, spinal cord injury

In men, UI may be associated with other symptoms, which are referred to as lower urinary track symptoms (LUTS). These symptoms include incomplete emptying, frequency, hesitancy, urgency, weak stream, straining, and nocturia. Men with UI should also be asked about erectile dysfunction as previous surgery, cancer treatment, or infections can affect both continence and erectile dysfunction. Both men and women may also have pelvic pain in conjunction with UI. This should prompt a more extensive evaluation for malignant, infectious, or non-GU causes of the symptoms.

Clinical Evaluation

The evaluation of UI should include a thorough history of the condition, including duration, frequency, severity, and burden of symptoms. Several tools can be used to evaluate the severity or impact of UI. Some older adults are able to document symptoms using a voiding diary. A 48-hour log of bladder symptoms should include the timing, circumstances, severity, volume, triggers, and frequency of each incontinent episode. The diary should also include timing, volume and frequency of nonincontinent voids. Environmental factors, medication dosing, comorbid illnesses and associated physical symptoms such as pain should also be noted.

The International Prostate Symptom Score (IPSS), which uses the American Urological Association Symptom Score Index (AUA-SI), plus a quality-of-life question, can stratify symptom severity in men with UI associated with LUTS (Table 39–1). Each question is weighted 0 (low) to 5 (high). The IPSS is helpful to the clinician in gauging the impact of symptoms on the patient and for judging the effectiveness of a symptom-targeted treatment.

The Overactive Bladder Validated 8 Question Awareness Tool (OAB-V8) can be used in both men and women to identify symptoms associated with overactive bladder (see Table 39–1). Each question is weighted 0 (low) to 5 (high) and a score of 8 or more suggests overactive bladder.

Physical Evaluation

A targeted physical examination should be performed to exclude potential causes of urinary system dysfunction. A cardiovascular exam should document evidence of congestive heart failure or excessive peripheral edema. The abdominal exam should assess for a palpable bladder, pain, or masses. A digital rectal exam is needed to evaluate for an enlarged or tender prostate that would suggest BPH or infection. Rectal or prostate masses would suggest carcinoma, and fecal impaction should be removed as a possible cause of disrupted urinary flow. Rectal tone, perineal sensation, and peripheral motor and sensory exam should be performed to identify spinal cord or neuropathic conditions. The penis should be examined for phimosis, drainage or lesions. An external GU exam in women should identify any organ prolapse or excessive GU tissue atrophy. A bimanual examination should assess for uterine or pelvic masses that may be compromising urinary flow.

Laboratory Testing

The evaluation of UI should include a basic laboratory evaluation to exclude metabolic, infectious, and malignant conditions that would affect urinary flow and function: serum electrolytes, glucose, creatinine, calcium, and urinalysis for blood, white cells, protein and culture if indicated. With supporting evidence, a more extensive evaluation for endocrine, neurologic, or malignant conditions may require additional laboratory or radiologic testing.

Imaging and Specialized Bladder Testing

It is imperative that bladder overdistention is identified as soon as possible as this may require emergent intervention. The use of an ultrasonic bladder scanner to assess urinary volume after voiding will identify urinary retention. This is performed at the bedside and is available in many hospitals but rarely found in the ambulatory or nursing home setting. Less than 50 mL should be present in the bladder after voiding; more than 200 mL indicates significant bladder dysfunction and requires ongoing evaluation. If unavailable, postvoid urinary catheterization to measure urinary volume will provide necessary information and can relieve urinary obstruction if identified.

Imaging of the kidneys and urinary tract may be helpful in identifying nephrolithiasis, cysts, tumors and obstruction. Renal ultrasound and CT urogram are first-line studies for evaluating the structure and function of the urinary system.

A urinary stress test can be done in women during the external gynecologic examination. The bladder should be full when performing this evaluation. In the lithotomy or standing position, the woman is asked to cough or bear down while observing for evidence of leakage of urine or organ prolapse. Small and immediate leakage of urine suggests stress incontinence; larger volume or delayed leakage suggests detrusor instability.

Urodynamic testing will provide information on bladder storage and voiding pressures but is not routinely indicated unless the initial evaluation and treatment steps are unsuccessful. Urodynamic studies can be helpful in identifying individuals with mixed incontinence and for those considering surgical evaluation for UI. This testing includes measurement of urinary pressure and flow volumes through catheters inserted into the bladder and the rectum or vagina (Figure 39–2). For frail or demented older adults, this testing may not be practical or well tolerated.

Direct observation with cystoscopy may be needed to provide tissue samples, locate and relieve obstruction, and visualize urinary tract structural abnormalities.

UI is often the result of a primary GU organ or tissue dysfunction; however, certain diseases or conditions may secondarily cause UI (Table 39–2). In most cases, secondary causes affect the neurologic innervation, structural integrity of the GU tissues, or volume of urine, and thus overwhelm normal bladder functioning. In these cases, treating the secondary cause may alleviate the condition entirely. Malignancies, infections, and obstructing lesions are of highest concern and should be quickly excluded in new or acute onset of UI.

In rare cases, urinary leakage may occur through a fistula between the urinary and genital tract or urinary and gastrointestinal tract. This is generally found in individuals with past surgeries, pelvic radiation therapy, or malignancies of the pelvis.

UI can have significant physical and psychological effects on older adults. Older adults with UI are more likely to self-report an overall poor health status. Studies demonstrated that depressive symptoms are more prevalent in incontinent seniors and the severity of depressive symptoms correlates positively with the severity of incontinence. Men with LUTS have higher rates of anxiety, depression, and sexual dysfunctioning. Women with UI may also report a negative impact on sexual functioning, especially with mixed-type incontinence.

Depending on the type of incontinence, certain complications may be more common in older adults. A systematic review demonstrated that urinary incontinence is associated with an increase in falls for adults with urge but not stress incontinence. Sleep disruption can occur as a result of nocturia with overflow and urge, especially in the setting of excessive nocturnal diuresis. Overflow incontinence, if caused by severe urinary retention, may result in hydronephrosis and renal dysfunction. Urinary retention is also a risk factor for the development of delirium in older adults.

UI can cause embarrassment and social withdrawal. Older adults may avoid leaving home or curtail social activities because of fear of incontinence. If medications, such as diuretics, exacerbate UI, compliance with medications and control of comorbid diseases may be reduced. Many adults will reduce water intake to avoid a full bladder at inopportune times. This increases the risk for urinary tract infection and for dehydration.

Although not recommended for nonobstructive UI, some older adults request a urinary catheter to manage chronic urinary leakage. The use of indwelling and condom-type catheters is associated with an increased risk of urinary tract infections.

Chronic skin wetness from UI may compromise skin integrity. Dermatitis, candidiasis, cellulitis and skin breakdown may occur when the skin is repeatedly moist.

Treatment for UI can include behavioral, pharmacologic, and device or surgical intervention. With all types of incontinence, it is important to maximize treatment for comorbid conditions that can exacerbate urinary symptoms. Medications that contribute to bladder dysfunction and polyuria should be modified if possible (Table 39–3). In some people, reducing dietary diuretics, such as caffeine and alcohol, and bladder irritants, such as spicy foods or acidic fruits, can reduce urinary symptoms. Cautious avoidance of excess liquid intake at certain times of the day may be useful.

Behavioral Modifications

Behavioral modification utilizes lifestyle and environmental modifications to reduce episodes of UI.

Habit Training

Habit training identifies UI triggers and employs situational bladder emptying to prevent incontinence episodes. Examples include toileting after meals, prior to bedtime, or before vigorous physical exercise if these events are regularly associated with incontinence.

Scheduled (Timed) Voiding

Scheduled voiding utilizes regularly timed attempts to void, regardless of urge or sensation to urinate. This approach minimizes large bladder volumes that may result in incontinent episodes. The interval between voids can be increased or decreased based on success in staying dry. This is especially useful in cognitively impaired or nursing home populations where caregivers can plan interval toileting, for example, every 2 hours, to reduce incontinence episodes.

This technique can also be used for bladder retraining in cognitively intact individuals with urge type incontinence. Scheduled voids are first performed at an interval that allows for maximal dryness. The interval is then increased by 30–60 minutes every few days to “train” the bladder to accommodate an increasing volume of urine. With success, time between voiding can reach 3–4 hours without urgency symptoms or leakage.

Prompted Voiding

Prompted voiding employs frequent inquiry about the need to pass urine and assistance to the toilet when the response is “yes.” This is generally used by caregivers of cognitively impaired adults with functional or urge incontinence.

Pelvic Muscle Training

Pelvic muscle training (a.k.a. Kegel exercises) strengthens the urinary sphincter and pelvic floor by exercising the pelvic floor muscles which are under voluntary control. This is most useful in women with stress-type incontinence. The pelvic muscles are contracted for 8–10 repetitions of 6–8 seconds each. To ensure the proper muscles are being used, instruct women to “hold back” the urine flow while voiding on the toilet. Hold these muscles contracted for progressively longer times, up to 10 seconds if possible. Three sets of these contractions should be performed 3–4 times daily to augment the closing pressure of the pelvic floor–urethral sphincter mechanism. Some women have difficulty localizing the pelvic floor muscles, which are used for continence control. Specially trained gynecologic physical therapists can assist women in isolating and appropriately exercising these muscles. Techniques, such as biofeedback, electrical stimulation, and the insertion of weighted vaginal cones, can be used to improve pelvic floor strength.

Pharmacotherapy

Pharmacotherapy can be effective for all forms of UI, but medication must be carefully selected to target the underlying etiology of the incontinence (Table 39–4). In many cases, medications modulate bladder wall and sphincter function through antimuscarinic or anticholinergic effects on sympathetic or parasympathetic pathways. Because many older adults have mixed type of incontinence, medications must be used cautiously, as improvement in one type of incontinence (eg, urge type) may worsen another form (eg, overflow type).

A meta-analysis has shown that topical estrogen can improve incontinence in women with both stress- and urge-type symptoms. Topical estrogen is usually supplied through vaginal suppositories and creams. For some women, however, ring devices impregnated with estrogen that are placed in the vagina for up to 3 months can be more practical than daily estrogen administration. Systemic (oral) estrogen is not beneficial for control of UI, and, in fact, may worsen urinary symptoms.

Anticholinergics—

The mainstay of pharmacotherapy for urge incontinence is the use of medications with anticholinergic effects through inhibition of muscarinic postganglionic cholinergic sites on the bladder wall. This reduces bladder wall contraction and thus increases bladder capacity. Numerous medications are now available in this category. These medications may be available in sustained-release oral and transdermal formulations, which are generally better tolerated; however, efficacy is not superior to the immediate-release formulations. Given the heterogeneity in studies and variety of clinical outcomes measured, it is difficult to say with certainty, even with meta-analysis data, that any one medication is truly superior to another. The anticholinergic side effects of these medications can be troublesome to older adults and include dry eyes and mouth, constipation, headache, dizziness, orthostatic blood pressure changes, and confusion.

α1-Adrenergic blockers—

The prostate, bladder neck, and urethral tissue contract under the stimulation of α-adrenergic receptors. Alpha blockade allows relaxation of these tissues to improve urine flow and is used most frequently in men with bladder outlet obstruction caused by BPH. The literature clearly demonstrates the benefit of α blockers in reducing urinary retention in this population. A number of α blockers are available. Most of these medications are “nonselective” for urinary tract tissue and also block the α receptors on the vascular system, causing vasodilation and hypotension. Tamsulosin and silodosin are “selective” α_1A blockers, with minimal binding to nonurinary tissues and thus less potential to cause hypotension. These medications are considered preferential for older men because of their more favorable side-effect profile.

Because α blockade allows for urethral relaxation, these medications have potential for use in non-BPH overflow incontinence from neurogenic bladder, urethral obstruction, or urethral noncompliance. Studies show benefit in urinary symptoms and flow rates with use of α-blocker in these conditions. Alpha blockers have also been shown to improve the success in removing an indwelling urinary catheter after placement for urinary retention. Studies suggest that as little as 48 hours of α-blockade treatment may be needed prior to successful catheter removal. There is growing interest in using α blockers for women with bladder outlet obstruction. Recent studies demonstrate improvement in urinary flow and urinary symptoms in women with bladder outlet obstruction or neurogenic bladder, but not with overactive bladder.

5α-Reductase inhibitors—

5α-Reductase inhibitors (5αRI) block the conversion of testosterone to the active metabolite, dihydrotestosterone, reduce prostate tissue volume and thus reduce bladder outflow obstruction. Both finasteride and dutasteride have been well studied and demonstrate improvement in overflow incontinence and LUTS in men with BPH (see Chapter 40, “Benign Prostatic Hyperplasia & Prostate Cancer,” for more on treatment of benign prostatic hypertrophy).

Other bladder agents—

Bethanechol is a muscarinic agonist at smooth muscle cholinergic receptors. Although it generally is used to stimulate gastric motility it has the pharmacologic potential to increase detrusor tone and improve bladder emptying in the setting of neurogenic bladder. There is no evidence that bethanechol is clinically efficacious for managing urinary symptoms and the side effects of dizziness, hypotension, nausea, and abdominal cramping make this medication a poor choice for older adults.

Tricyclic antidepressants—

Because of the anticholinergic properties, tricyclic antidepressants (TCAs) may improve symptoms of detrusor hyperactivity. A few studies have been done to demonstrate efficacy of this class of medication for UI, but most have looked at imipramine. Side effects of TCAs limit use in many older adults.

Desmopressin—

Nocturia occurs in many older adults as a result of increased nocturnal mobilization of peripheral edema and increased levels of atrial natriuretic peptide. This can lead to nocturnal UI. Studies indicate desmopressin can effectively reduce nocturia and bothersome urinary symptoms; however, significant hyponatremia developed in some older subjects. Routine use of desmopressin for nocturnal UI is not recommended in older adults.

Devices and Surgery

Incontinence pads, adult diapers, and incontinence garments are regularly used to manage incontinence episodes. An estimated 4.4 billion dollars are spent annually in United States nursing homes alone for incontinence products, laundry service and continence care.

Urinary collection devices for management of transient or chronic urinary retention include intermittent or indwelling catheters. For the cognitively intact and motivated person (or caregiver), intermittent catheterization is preferable as it is less likely to result in urinary tract infection when compared to other forms of urinary catheterization. External (condom-type) catheters are not appropriate for management of urinary retention but may be desirable for men who want to avoid urinary leakage from other types of UI. These devices also increase the risk of urinary tract infection, and can cause skin irritation or infection, so should be used cautiously.

Pessaries—

Women with GU organ prolapse can experience overflow urinary incontinence from obstruction or worsening of stress urinary incontinence. Those who do not desire, or are not appropriate surgical candidates, can benefit from placement of a pessary. Pessaries are plastic or silicone devices that are inserted into the vagina to physically prevent the prolapse of surrounding tissues into the vaginal canal. These devices come in a variety of sizes and shapes including ring, cube, and Gellhorn types. Some devices must be removed regularly and require dexterity and motivation for use. Other types can remain in place for several weeks and can be changed for cleaning and inspection by medical providers.

Urethral devices—

Temporary urethral blockade may be attained by using internal urethral plugs or external adhesive seals or patches (foam pads). Plugs function like a balloon and must be inserted into the urethra and inflated when continence is desired. These devices are generally used for stress type incontinence. Permanently placed balloon devices can be implanted with adjustable inflation/deflation mechanisms to control continence. These are generally used in men with postprostatectomy destruction of the urethral sphincter. Complete continence is achieved in approximately 30% of men, and complication rates average between 20% and 30%.

Urethral bulking procedures involved the injection of collagen around the bladder neck, external to the urethral sphincter, to increase the urethral impedance to urinary flow. This may be done in women with stress or urge incontinence or in men after prostate surgery. Unfortunately improvement in symptoms is often modest, with low cure rates and deterioration in benefit over time.

An artificial urethral sphincter can be surgically implanted for control of stress-type incontinence. This is usually performed in men after prostate surgery and has been shown to have significant benefit on control of UI. Unfortunately, up to 25% of devices must be revised or replaced within 5 years of implantation because of erosion or mechanical failure of the device.

Surgical suspension options—

Five major types of surgical suspension procedures are used for management of UI in women and are generally performed for stress-type incontinence: anterior repair, suburethral sling, colposuspension, long-needle suspension, and tension-free vaginal tape (TVT). Anterior repair (colporrhaphy) utilizes sutures or support material to elevate the urethra and/or bladder neck and reconstruct the pubocervical fascia. Cure rates and effectiveness deteriorate substantially with time and this procedure is losing favor for treatment of UI. Needle-suspension procedures are more minimally invasive means of supporting the bladder neck by placing sutures through a transcutaneous approach. This procedure has significantly less success and higher complications than other techniques and is generally not being recommended for the routine treatment of UI. Open colposuspension (also referred to as Burch procedure) uses sutures to elevate the periurethral fascia toward the Cooper ligament. A systematic review of more than 4000 women demonstrated a cure rate of 80% with this procedure, and 60% remained continent at 5 years. Open colposuspension has largely been replaced by the less-invasive suburethral sling or TVT procedures. The sling procedure uses a band of either synthetic or autologous fascial material. The band is guided under the bladder neck and both ends are anchored into the pelvic tissue to approximate normal bladder position. TVT uses a similar suspension technique, but at the midurethra and without anchoring of the material. The evidence suggests that TVT is equally effective as traditional fascial sling operations. TVT is more effective than open colposuspension.

The outcome of treatment for UI is affected by many factors, including the type of UI, severity of symptoms, and underlying comorbidity. In general, with the appropriate treatment significant reduction in symptom burden can be achieved. If an inciting trigger for incontinence can be identified and alleviated, clinical cure may be possible. Surgical interventions for UI are very favorable, but are generally indicated for stress-type incontinence alone. Behavioral interventions can be helpful when applied to the correct type of incontinence but require a motivated and sustained effort on the part of the patient or caregiver. Complete dryness may not be possible but reducing the number and severity of episodes can have substantial benefit on quality of life and caregiver burden. Pharmacologic treatments also can substantially reduce symptom burden are generally not expected to provide a complete clinical cure for all urinary symptoms.