Diagnostic evaluation of urinary incontinence in geriatric patients

Author: Barry D. Weiss
Date: June, 1998

Urinary incontinence, the unintentional leakage of urine at inappropriate times, is a classic syndrome in geriatric medicine. It affects approximately 13 million persons in the United States, most of whom are older adults.[1] This article describes the evaluation of urinary incontinence in geriatric patients, focusing on a diagnostic approach for use by primary care physicians. A more detailed discussion of the diagnosis and management of urinary incontinence can be found in the revised clinical practice guideline recently published by the U.S. Agency for Health Care Policy nd Research (AHCPR).[1]

Prevalence

Studies on the prevalence of incontinence have yielded varying results, largely because each study has used different populations and criteria to define incontinence.[2-6] Overall, however, estimates indicate that about one half of the homebound and institutionalized elderly are incontinent, as are 25 to 30 percent of older patients discharged after hospitalization for acute medical illnesses. Among community-dwelling, ambulatory, non-homebound persons over 60 years of age, approximately 10 to 15 percent of men and 20 to 35 percent of women have incontinent episodes. Continuous or daily incontinence occurs in about 5 percent of community-dwelling older persons (Table 1).[2-6]

Table 1 Prevalence of Any Degree of Urinary Incontinence ApproximatePopulation subgroup prevalence (%)Nursing home residents 50 (age over 65 years)Homebound elderly persons 50 (age over 65 years)Hospitalized elderly persons 25 to 30 (age over 65 years)Community-dwelling older 25 to 35 women (age over 60 years)Community-dwelling older 10 to 15 men (age over 60 years)Younger adult women 10 to 30 (age 15 to 64 years)Younger adult men 1 to 5 (age 15 to 64 years)

Information from references 2 through 6.

Although urinary incontinence is common, it frequently is not identified because fewer than 50 percent of affected patients report the problem to their physicians.[7] Many patients believe incontinence is a normal result of aging--that nothing can be done about it or that nothing can be done except surgery (and they are not interested in surgery).[8] Thus, if urinary incontinence is to be detected, often physicians must ask about it.

Implications of Incontinence

Urinary incontinence has important medical, psychosocial and economic implications. Medically, incontinence is associated with decubitus ulcers, urinary tract infections, sepsis, renal failure and increased mortality. The social implications of incontinence include loss of self-esteem, restriction of social and sexual activities, depression and, in severe cases, dependence on caregivers.[9] Incontinence is often a key factor in the decision to place elderly persons in nursing homes. In the United States, the cost of managing urinary incontinence and its complications exceeds $1.5 billion per year.[10]

Physiology of Micturition

The physiologic systems that control micturition (urination) are quite complex. However, family physicians with a general understanding of the detrusor and sphincter mechanisms can manage most patients with urinary incontinence.

Detrusor Mechanism

The detrusor muscle is the multilayered contractile muscle of the urinary bladder. The detrusor mechanism involves the detrusor muscle, the pelvic nerves, the spinal cord and the cerebral centers that control micturition. When a person's bladder begins to fill with urine, neural impulses are transmitted through the pelvic nerves and spinal cord to subcortical and cortical cerebral centers. The subcortical centers (in the basal ganglia and the cerebellum) cause the bladder to relax (subconsciously) so that it can fill without causing the person to experience an urge to void. As filling continues, the sensation of bladder distention reaches consciousness, and the cortical centers (in the frontal lobe) permit volitional delay of urination. Impairment of these cortical or subcortical centers by medication or disease can diminish the ability to postpone urination.

When urination is desired, neural impulses from the cortex are transmitted through the spinal cord and pelvic nerves to the detrusor muscle. The cholinergic action of the pelvic nerves then causes the detrusor muscle to contract and the bladder to empty. Interference with the cholinergic activity of the pelvic nerves results in diminished contractility of this muscle.

Detrusor muscle contraction does not depend solely on cholinergic innervation by the pelvic nerves. The detrusor muscle also contains receptors for prostaglandins. Hence, prostaglandin-inhibiting drugs can impair detrusor contractions. Bladder contractions are also calcium channel dependent. Therefore, calcium channel blockers can also impair bladder contractions.

Sphincter Mechanism

Innervation of the internal and external urethral sphincters is also complex. However, to prescribe effective medications for the treatment of incontinence, family physicians need to understand the basic adrenergic innervation of these sphincters as well as the anatomic relationships of the urethra and the bladder.

Alpha-adrenergic: activity causes the urethral sphincter to contract. Therefore, medications with alpha-adrenergic agonist activity (e.g., pseudoephedrine) can strengthen sphincter contractions, whereas alpha-blocking agents (e.g., terazosin [Hytrin]) can impair sphincter closure. Beta-adrenergic innervation causes relaxation of the urethral sphincter. Therefore, beta-adrenergic blocking agents (e.g., propranolol [Inderal]) can interfere with urethral relaxation and leave alpha-adrenergic contractile activity unopposed.

The other important component of the sphincter mechanism is the anatomic relationship of the urethra to the bladder and the abdominal cavity. A continent sphincter mechanism requires proper angulation between the urethra and the bladder. Normal urethral sphincter function also depends on proper positioning of the urethra so that increases in intra-abdominal pressure are effectively transmitted to the urethra. When the urethra is in the correct position, urine is not lost with straining, coughing and other maneuvers that increase intra-abdominal pressure.

Basic Mechanisms

Three basic mechanisms serve as "final common pathways" in nearly all causes of incontinence: (1) urge incontinence, also referred to as "hyperactive bladder" or "irritable bladder," (2) stress incontinence, which results from poor urethral sphincter function (primary urethral incompetence) and (3) overflow bladder.

Urge incontinence is a common problem that increases in frequency and severity with advancing age and cognitive dysfunction. Overall, however, stress incontinence is the most prevalent form of incontinence in geriatric patients, largely because women predominate in this group)[11,12] Many elderly persons, particularly women, have "mixed incontinence," in which urge and stress incontinence coexist.[13]

Overflow bladder is relatively uncommon. However, it is an important problem because without treatment it can lead to hydronephrosis and renal damage. Urinary incontinence due to overflow bladder is more common in men because of the prevalence of obstructive prostate gland enlargement.

Urge Incontinence

Urge incontinence results from bladder contractions that overwhelm the ability of the cerebral centers to inhibit them. These uncontrollable contractions can occur because of inflammation or irritation within the bladder resulting from calculi, malignancy, infection or atrophic vaginitis-urethritis. They can also occur when the brain centers that inhibit bladder contractions are impaired by neurologic conditions such as stroke, Parkinson's disease or dementia, drugs such as hypnotics or narcotics, or metabolic disorders such as hypoxemia and encephalopathy.

Patients with uncontrolled bladder contractions can also develop incontinence when high urine volume; are introduced rapidly into the bladder (e.g., diuretic therapy, glycosuria-induced osmotic diuresis). Finally, urge incontinence can occur when mobility is impaired (for example, in patients with arthritis), making it difficult for patients to get to the bathroom in time. This condition is sometimes referred to as "functional" incontinence.

Stress Incontinence

(*)--Suggested first-, second- and third-line treatments may not be applicable in all patients. Clinical judgment, along with a patients medical condition, cognition and choice, should always be considered.

([dagger])--Because surgical treatments for stress incontinence are so much more effective than behavioral therapies and/or medications, many experts recommend surgical treatments as first-line therapy for stress incontinence in patients who are suitable candidates for surgery and who are proved by formal cystometric testing to have stress incontinence.

([double dagger])--Note that before overflow incontinence is treated with catheterization, the patient should undergo thorough evaluation to identify the cause of retained urine (ie., increased postvoid residual urine volume) and to exclude conditions that require surgical or other interventions, such as benign prostatic hyperplasia (see Table 3).

Mixed Incontinence

At times, patients have symptoms or findings suggesting both stress and urge incontinence. When mixed incontinence is identified, the physician should treat the type of incontinence for which symptoms predominate (i.e., stress or urge incontinence).

When No Presumptive Diagnosis Can Be Made

If no presumptive diagnosis can be made, the patient should undergo a more sophisticated evaluation. Useful tests include formal multichannel or subtracted cystometrography, urine flowmetry, urethral pressure profiles and urethral sphincter electromyography.[21] Endoscopic and imaging tests may be helpful in selected patients. These tests are usually conducted by a urologist or urogynecologist.

Treatment Failure

If a presumptive diagnosis is identified and treated, the patient should be monitored for improvement. If the desired clinical result does not occur, the patient should undergo further evaluation to ensure that the presumptive diagnosis was correct and that prescribed treatments are optimal. More sophisticated tests may reveal an unsuspected basis for the patient's incontinence and thereby further dictate treatment.

In some patients who have not responded to treatment, further testing reveals that the presumptive diagnosis was correct but the appropriate treatments were simply ineffective in alleviating the incontinence. When this occurs, the patient maybe managed with various measures, including pads, adult artificial sphincters and, in some situations, intermittent or indwelling urethral catheterization.

Figure 1 is adapted from Fantl JA, Newman DK, Coiling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline no. 2, 1996 update. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, March 1996. AHCPR publication no. 96-0682.

REFERENCES

[1.] Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline no. 2, 1996 update, Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, March 1996. AHCPR publication no. 96-0682.

[2.] Burgio K, Matthews KA, Engel BT. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J Urol 1991;146:1255-9.

[3.] Noelker L. Incontinence in elderly cared for by family. Gerontologist 1987;27:194-200.

[4.] Herzog AR, Fultz NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990;38:273-81.

[5.] Palmer MH, German PS, Ouslander JG. Risk factors for urinary incontinence one year after nursing home admission. Res Nurs Health 1991; 14:405-12.

[6.] Division of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. Urinary incontinence among hospitalized persons aged 65 years and older--United States, 1984-1987. MMWR Morb Mortal Wkly Rep 1991;40:433-6.

[7.] Burgio KL, Ives DG, Locher JL, Arena VC. Treatment seeking for urinary incontinence in adults. J Am Geriatr Soc 1994;42:208-12.

[8] Mitteness LS. Knowledge and beliefs about urinary incontinence in adulthood and old age. J Am Geriatr Soc 1990;38:374-8.

[9.] Wyman JF, Harkins SW, Fantl JA. Psychosocial impact of urinary incontinence in the community-dwelling population. J Am Geriatr Soc 1990;38:282-8.

[10.] Hu T. The economic impact of urinary incontinence on health-care costs. J Am Geriatr Soc 1990;38:292-5.

[11.] McDowell JB, Engberg SJ, Rodriguez E, Engberg R, Sereika S. Characteristics of urinary incontinence in homebound older adults. J Am Geriatr Soc 1996;44:963-8.

[12.] Diokno AC, Wells TJ, Brink CA. Urinary incontinence in elderly women: urodynamic evaluation. J Am Geriatr Soc 1987;35:940-6.

[13.] Fantl JA, Wyman JF, McClish DK, Bump RC. Urinary incontinence in community-dwelling women: clinical, urodynamic and severity characteristics. Am J Obstet Gynecol 1990;162:946-51.

[14.] Resnick NM. Initial evaluation of the incontinent patient. J Am Geriatr Soc 1990;38:311-6.

[15.] Burgio KL, Stutzman RE, Engel BT. Behavioral training for post-prostatectomy urinary incontinence. J Urol 1989;141:303-6.

[16.] Coombes GM, Millard RJ. The accuracy of portable ultrasound scanning in the measurement of residual urine volume. J Urol 1994;152;2083-5.

[17.] Fonda D, Brimage PJ, D'Astoli M. Simple screening for urinary incontinence in the elderly: comparison of simple and multichannel cystometry. Urology 1993;42:536-40.

[18.] Kadar N. The value of bladder filling in the clinical detection of urine loss and selection of patients for urodynamic testing. Br J Obstet Gynaecol 1988;95:698-704.

[19.] Weiss BD. Nonpharmacologic treatment of urinary incontinence. Am Fam Physician 1991;44:579-86.

[20.] Miller JL, Bavendam T. Treatment with the Reliance control insert: one-year experience. J Endourol 1996;10:287-92.

[21.] Diokno AC. Diagnostic categories of incontinence and the role of urodynamic testing. J Am Geriatr Soc 1990;38:300-5.

Each year members of a different family department develop articles for "Problem-Oriented Diagnosis." This series is coordinated by the Department of Family Practice at the University of Texas Health Science Center at San Antonio. Guest editors of the series are David A. Katerndahl, M.D., and Clinton Colmenares.

BARRY D. WEISS, M.D., is professor and chairman of the Department of Family Practice at the University of Texas Health Science Center in San Antonio. He is also the editor of Family Medicine, the journal of the Society of Teachers of Family Medicine. Dr Weiss served on the consensus panel of the U.S. Agency for Health Care Policy and Research (AHCPR), which developed the 1996 AHCPR practice guideline on urinary incontinence.

Address correspondence to Barry D. Weiss, M.D., Department of Family Practice, University of Texas Health Science Center in San Antonio, 7703 Floyd Curl Dr., Suite 610-L, San Antonio, TX 78284-7794. Reprints are not available from the author.

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