Urinary incontinence

Urinary incontinence (UI), the complaint of involuntary leakage of urine,¹ is one of the major geriatric syndromes. UI may be accompanied by other lower urinary tract symptoms (Table 23-1).

TABLE 23-1

Lower Urinary Tract Symptoms (LUTS)

Symptom	Description
Urinary incontinence	Involuntary leakage of urine.
Urgency	Compelling, often sudden need to void that is difficult to defer.
Urgency incontinence	Leakage preceded by/associated with urgency. Common precipitants include running water, hand washing, going out in the cold, even the sight of the garage or trying to unlock the door when returning home. The need to “rush to the toilet” and length of time one can forestall an urgency episode are less useful symptoms because they reflect cognition, mobility, toilet availability, and sphincter control as well as bladder function.
Stress incontinence	Leakage with effort, exertion, sneezing, or coughing. Leakage may be provoked by minimal or no activity when there is severe sphincter damage. Leakage coincident with cough, laugh, sneeze, or physical activity suggests failure of sphincter mechanisms. Leakage that occurs seconds after the activity, especially if difficult to stop, suggests a cough-induced uninhibited detrusor contraction.
Mixed incontinence	Presence of both urgency and stress UI symptoms. Patients vary in the predominance, severity, and/or bother of urge versus stress leakage.
Overactive bladder	Symptom syndrome (not a specific pathologic condition) consisting of urgency, frequency, and nocturia, with or without urge incontinence.
Frequency	Complaint of needing to void too often during the day, as defined by the patient.
Nocturia	Complaint of waking at night one or more times to void. If these voids are associated with UI, the term nocturnal enuresis may be used.
Slow (weak) stream	Perception of reduced urine flow, usually compared to previous performance.
Hesitancy	Difficulty in initiating voiding, resulting in a delay in the onset of voiding after the individual feels ready to pass urine.
Straining	Muscular effort either to initiate, maintain, or improve the urinary stream.
Intermittent stream	Sensation that the bladder is not empty after voiding.
Postvoid dribbling	Small amounts/drops of urine after voiding has stopped. More common in men.

UI, urinary incontinence.

Prevalence and impact

UI becomes more common with advanced age in both men and women, but is not a normal part of aging. Among women, the prevalence of UI is 15% to 30% in the community,² 50% among the homebound, and 70% in nursing home residents.³

In men, the prevalence is about one third that of women until age 85, when the ratio becomes 1:1. The prevalence of moderate to severe UI (at least weekly or monthly leakage of more than just drops) is 23% among women aged 60 to 79 years and 32% in those 80 and older.³ Among nursing home residents, prevalence rates range from 43% to 77% (median 58%).³ UI severity (i.e., frequency and volume of leakage) also increases with age.⁴ In a significant number of affected individuals, UI severity will increase if not treated. One third of middle-aged and younger-old women (aged 54 to 79 years) with baseline UI once monthly progressed to leaking at least once a week over 2 years.⁵ Little is known specifically about the incidence and severity of UI over time in older men. The most common type of UI in older persons is urgency UI⁶; however, the prevalence of stress UI in men is rising with increased surgical treatment of prostate cancer. The evidence is inconsistent whether race and ethnicity are associated with UI prevalence in older women,⁷^,⁸ and there are no data on their impact in older men.

UI becomes more common with advanced age in both men and women, but is not a normal part of aging.

UI decreases health-related quality of life, with a negative impact on self-esteem, self-perception of aging, activities, and sexuality.⁹ In older persons, the impact appears greatest in the area of coping with embarrassment with subsequent activity interference, rather than directly precluding activities.¹⁰ Among frail nursing home residents, UI adversely impacts social interactions, an important aspect of quality of life in this setting.¹¹

Persons with UI are at risk for urinary tract infections, skin breakdown, falls, and fractures. Associated caregiver burden can lead to depression and is associated with nursing home placement. Approximately 6% to 10% of nursing home admissions in the United States are attributable to UI.¹² Economic costs are significant for the individual and the health care system (nearly $20 billion in 2000),¹³ and have nearly doubled for older persons in the last decade.¹⁴ Unfortunately, the majority of the expenses (56%) are consequence costs (e.g., from nursing home admissions and loss of productivity). Treatment and diagnosis account for approximately one third of costs. Out-of-pocket expenses, predominantly for protective undergarments, have been estimated to run from $750 to $900 yearly, or almost 1% of the median annual household income.¹⁵^,¹⁶

Optimal management of UI is hampered by the fact that at least half of persons with UI never mention it to their care providers, and in turn physicians often do not ask patients about it or fail to offer specific treatment.

CASE 1 Anna Roberts (Part 1)

Anna Roberts, a 78-year-old woman, returns to see you for follow-up of congestive heart failure. She has gained 4 lbs, has increased pedal edema, and complains of being fatigued and is not sleeping well. You review the status of her hypertension, hyperlipidemia, diabetes, and recent laboratory work. Her medications include lisinopril, amlodipine, furosemide, aspirin, atorvastatin, metformin, glipizide, and calcium with vitamin D. When asked about the weight gain, the patient admits to occasionally skipping doses of furosemide when she is going out for the day for fear of wetting herself.

1. What factors increase the risk for incontinence in Ms. Roberts?

2. What other information is needed to evaluate her symptoms?

UI in older persons is multifactorial, resulting from interactions between lower urinary tract abnormalities, neurologic control of voiding, multimorbidity, and functional impairment.

Risk factors and pathophysiology

Risk factors for UI in older persons reflect the multifactorial nature of the problem. UI shares common risk factors with other geriatric syndromes (e.g., falls and functional dependence), including lower and upper extremity weakness, sensory and affective impairment,¹⁷ and radiologic evidence of white matter signal abnormalities suggesting common etiologic pathways.¹⁸ Along with age and functional impairment, the main risk factors for UI are female gender, obesity (women) diabetes, stroke, depression, fecal incontinence, and hysterectomy.19–23 Nursing home residents with UI are more likely than continent residents to have impaired mobility, dementia, delirium, and receive psychoactive medications.⁹ Parity increases the risk of UI in younger women but the impact attenuates with age. Although there is some evidence for a familial predisposition to UI,²⁴ this may not be a significant risk factor in older persons.

UI is common in persons with cognitive impairment, which is associated with a 1.5- to 3.5-fold increase in UI risk,²⁵ especially for bothersome UI.²⁶ At the same time, UI is not inevitable even in frail cognitively impaired persons, because the association between cognitive impairment and UI is at least in part mediated by functional impairment and disability.²⁷

The pathophysiology of UI in older persons is multifactorial, resulting from interactions between lower urinary tract abnormalities, neurologic control of voiding, multimorbidity, and functional impairment. The lower urinary tract has two main functions, storage of urine and effective voiding. Key components of the bladder for continence are its detrusor smooth muscle and epithelial layer (the urothelium). Continence is mediated through the actions of the central and autonomic nervous systems (Figure 23-1).²⁸ Storage occurs through sympathetic stimulation of alpha-adrenergic receptors in the smooth muscle sphincter causing contraction, and beta-adrenergic receptors in the detrusor causing relaxation. Voiding occurs with parasympathetic stimulation of muscarinic receptors in the detrusor. The urothelium has rich and varied receptor signaling systems that conduct information about bladder filling and sensation through the sacral spinal cord to pontine and subcortical areas.²⁹ The prefrontal cortex is an important center for suppressing urgency and forestalling voiding.³⁰ The micturition center in the pons coordinates the cortical inhibitory inputs with the afferent signaling from the detrusor to allow storage of a large volume of urine at a low pressure, and adequate bladder emptying through detrusor contraction and sphincter relaxation.²⁸ Maintenance of urethral closure during storage is augmented by support by fascia and the levator ani.³¹

Figure 23-1 Physiology of micturition. Ach, acetylcholine; M, muscarnic; NE, norepinephrine.

Very importantly, UI in older persons can be precipitated or worsened by factors outside of the lower urinary tract, including the following ¹⁹:

• Mobility

• Environment (access to toilets)

• Medical conditions (Table 23-2)

TABLE 23-2

Medical Conditions Associated with Urinary Incontinence

CNS, central nervous system; DO, detrusor overactivity; UI, Urinary incontinence; UUI, urgency urinary incontinence.

Adapted from DuBeau CE. Urinary incontinence. In:Durso SC, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 8th ed. New York, NY: American Geriatrics Society; 2013, p 246.

• Medications (Table 23-3)

TABLE 23-3

Medications Associated with Urinary Incontinence

Medication	Effect on Continence
Alcohol	Frequency, urgency, sedation, delirium, immobility
α-Adrenergic agonists	Outlet obstruction (men)
α-Adrenergic blockers	Stress leakage (women)
ACE inhibitors	Associated cough worsens stress and possibly urgency leakage in older adults with impaired sphincter function
Anticholinergics	Impaired emptying, retention, delirium, sedation, constipation, fecal impaction
Antipsychotics	Anticholinergic effects plus rigidity and immobility
Calcium channel blockers	Impaired detrusor contractility and retention; dihydropyridine agents can cause pedal edema, leading to nocturnal polyuria
Cholinesterase inhibitors	Urinary incontinence; potential interactions with antimuscarinics
Estrogen	Worsens stress and mixed leakage in women
Gabapentin, pregabalin	Pedal edema causing nocturia and nighttime incontinence
Loop diuretics	Polyuria, frequency, urgency
Narcotic analgesics	Urinary retention, fecal impaction, sedation, delirium
NSAIDs	Pedal edema causing nocturnal polyuria
Sedative hypnotics	Sedation, delirium, immobility
Thiazolidinediones	Pedal edema causing nocturnal polyuria
Tricyclic antidepressants	Anticholinergic effects, sedation

ACE, angiotensin-converting enzyme; NSAIDs, nonsteroidal antiinflammatory drugs; UI, Urinary incontinence.

Adapted from DuBeau CE. Urinary incontinence. In: Durso SC, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 8th ed. New York, NY: American Geriatrics Society; 2013. p 245.

• Mentation

• Manual dexterity

• Motivation

There are three main types of UI:

• Urgency—leakage associated with a compelling, often sudden, need to void

• Stress—leakage associated with coughing, laughing, activity

• Mixed—both urgency and stress leakage

UI associated with impaired bladder emptying (“overflow” incontinence) is uncommon even among frail older persons and men with benign prostate disease.¹⁹ Overactive bladder (OAB) is a syndrome defined by the symptom of urgency, usually with frequency and nocturia, with or without urgency incontinence.¹ Detrusor hyperactivity with impaired contractility (DHIC) is a type of urgency UI seen in frail patients, in which there is a concomitant elevated postvoiding residual volume (PVR).³²

CASE 1 Anna Roberts (Part 2)

On further questioning, Ms. Roberts says that when she takes her “water pill” she “can’t make it to the bathroom on time.” She is wearing adult diapers, which she changes at least once during the day. She reports having to go to the bathroom at least three times during the night, which is affecting her sleep. She has no leakage when she coughs, denies dysuria, but reports more constipation lately. Her diabetic control has been good.

1. What type of incontinence does this patient have?

2. What additional evaluation and testing are needed before recommending therapy?

Differential diagnosis and assessment

Figure 23-2 provides an outline of diagnosis and assessment of UI. Active screening for UI in all older women is strongly recommended, given the high prevalence of UI and known quality gaps in treatment; screening for UI has been incorporated into health care quality process measures such as those from the Assessing Care of the Vulnerable Elderly (ACOVE) project.³³ Suggested screening questions are: “Do you ever leak urine/water when you don’t want to? Do you ever leak urine on the way to the bathroom? Do you ever use pads, tissue, or cloth in your underwear to catch urine?”³⁴^,³⁵ Screening can be done by clinical staff and patient questionnaires.

Figure 23-2 Evaluation and management of patients with UI.
¹ See Table 23-2.
² See Table 23-3.
³Postvoid residual (PVR) test is optional; considered for women with marked pelvic floor prolapse, longstanding diabetes, history of urinary retention or high PVR, recurrent UTIs, medications that impair bladder emptying, chronic constipation, persistent or worsening UI on treatment with bladder antimuscarinics, or prior urodynamic study demonstrating detrusor underactivity and/or bladder outlet obstruction (Grade C). If PVR is elevated (e.g., 200 mL), consider trial of alpha-blocker (men), treat constipation, decrease or eliminate anticholinergic medications and calcium channel blockers, and consider catheter drainage followed by voiding trial if PVR 300 mL.
⁴Detailed evaluation with reassessment could include the following: bladder diary and PVR, if not previously done; revisiting/testing for comorbidity (e.g., sleep apnea if nocturia with nocturnal polyuria is present); trial of alternative medication for urgency incontinence (another antimuscarinic or switch to beta-3 agonist, if not contraindicated); or addition of biofeedback for pelvic muscle exercise training.
LUT, lower urinary tract; LUTS, lower urinary tract symptoms; OAB, overactive bladder; PVR, postvoiding residual; Rx, treatment; UI, urinary incontinence. (Adapted from DuBeau CE, Kuchel GA, Johnson T, et al. Incontinence in the frail elderly. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. 4th ed. Paris: Health Publications; 2009, p. 961-1025.

Acute onset of UI and the presence of suprapubic, lower abdominal, and/or pelvic pain are red flags for underlying neurologic or neoplastic disease, and should prompt quick referral.

Once a patient acknowledges UI, the next step is to characterize and determine the type of UI symptoms (see Table 23-1), including the frequency and volume of leakage. A proxy for the latter can be the frequency of pad changes. Most UI is relatively slow in onset and should not be associated with pelvic pain. Acute onset of UI and the presence of suprapubic, lower abdominal, and/or pelvic pain are red flags for significant underlying neurologic or neoplastic disease, and should prompt quick referral to neurology or urology/gynecology specialists.

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