39: Urinary Incontinence

Essentials of Diagnosis

General Principles in Older Adults

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.

Normal Voiding

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 ...