Course Authors

John E. Morley, M.D.

During the last three years, Dr. Morley has received grant/research support from Vivus, Merck & Co., Upjohn, B. Braun McGaw, Bayer Corp and Nestec, Ltd. He has also served on the Speakers' Bureau for LXN, Organon, Ross, Pharmacia & Upjohn, Glaxo Wellcome, Hoechst Marion Roussel, Searle, Merck & Co., Roche, Bristol-Myers Squibb, Novartis, Pratt, B. Braun McGaw, Pfizer and Parke-Davis.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 

Learning Objectives

Upon completion of this Cyberounds^®, you should be able to:

 

Mrs. B is an 82-year-old female who had the desire to urinate. While rushing to the bathroom she was incontinent of a large volume of urine, slipped in her own urine and fell. She was not injured. She reports having frequently had episodes of incontinence over the last few months. Her urinalysis was negative, and she had a postvoid residual of 85 cc. What is the most likely cause of her incontinence?

1. stress incontinence
b) urge incontinence c) overflow incontinence d) reflex incontinence

(Click here for the answer)

Types of Incontinence

Acute onset of incontinence is not rare in older individuals and is usually associated with an underlying disease. The causes of acute incontinence are best remembered by the mnemonic, DRIP:

Drugs, delirium
Retention of urine, Restricted mobility
Impaction, Infection
Polyuria, Prostatism

The treatment of acute incontinence includes frequent toileting and treatment of the underlying cause. Catheterization should be avoided as it increases the likelihood of nosocomial infections.

Chronic Incontinence

The causes of chronic incontinence are:

• Urge incontinence, the most common form of incontinence, is characterized by loss of small or large volumes of urine when the patient has insufficient warning following the first urge to void to allow him or her to reach the toilet.
• Stress incontinence occurs in women who usually have had children and is characterized by loss of small volumes of urine following coughing, sneezing or other maneuvers that increase intra-abdominal pressure. It is due to prolapse of the internal urethral sphincter outside of the abdominal cavity.
• Reflex incontinence occurs in persons with spinal cord damage. There is reflex loss of urine due to failure of inhibitory spinal fibers to inhibit urination.
• Functional incontinence occurs when either a persons physical or mental state deters the person from urinating in the toilet, i.e., the person lacks the physical ability to reach the toilet or lacks an adequate thought process to go to the toilet when having the urge to urinate. Causes include strokes, dementia and depression.
• Overflow incontinence is of two types:
  • Neurogenic - inadequate parasympathetic drive to urine as occurs in persons with autonomic neuropathy.
  • Obstructive - prostate enlargement is the usual cause.

Diagnosis

The diagnosis of chronic incontinence is made by taking a history and by doing bedside urodynamics:

The patient empties their bladder and then, lying on the examination table with a bedpan underneath them, is asked to cough. Loss of urine indicates stress incontinence. The patient is then catheterized. A postvoid residual (PVR) greater than 100 cc indicates overflow incontinence. A 50 cc syringe is then attached to the catheter and the bladder is filled with normal saline. The patient is asked to indicate when the first urge to urinate is felt. If this occurs before 300 cc or if it is accompanied by immediate, vigorous movement of the meniscus in the syringe, the diagnosis is urge incontinence.

When 400 cc of saline has been instituted into the bladder, the catheter is removed and the person is asked to cough again. Loss of urine = stress incontinence. The patient is then asked to void into a container and a calculated PVR is obtained. If greater than 100 cc, then overflow incontinence is diagnosed.

Management of Incontinence

The Table below (Table 1) provides a useful summary of the treatments for various types of incontinence.

Table 1. Managing Incontinence.

Finally, remember that many older persons develop DHIC (detrusor hypercontractibility and impaired contraction). This is a combination of urge and neurogenic incontinence. Treatment depends on needs of patient, e.g., if being wet during the day is unacceptable, then oxybutynin is given in the a.m. and bethanechol in the evening.

Conclusion

Urinary incontinence is a straightforward condition, both to identify the cause and to treat. Treatment can have a major impact on the older person's quality of life. Readers are encouraged to ask questions concerning specific problematic patients in their practice to allow a more complete exposition of this important area.

Cyberounds^® is pleased to provide a Patient Handout which can be printed and distributed.