Urinary incontinence is the involuntary leakage of urine. This medical condition is common in the elderly, especially in nursing homes, but it can affect younger adult males and females as well. Urinary incontinence can impact both patient health and quality of life. The prevalence may be underestimated as some patients do not inform health care providers of having issues with urinary incontinence for various reasons.
Several different types of urinary incontinence exist, including stress urinary incontinence, urge urinary incontinence, functional incontinence, mixed incontinence, and overflow incontinence. In most cases, urologic or gynecologic assessment is not necessary during the initial evaluation, but reversible causes should be ruled out. The management of urinary incontinence depends upon which type of incontinence is present and the severity of the symptoms.
It is estimated that around 423 million people (20 years and older) worldwide experience some form of urinary incontinence.
Approximately 13 million Americans experience urinary incontinence. The prevalence is 50% or greater among residents of nursing facilities. Caregivers report that 53% of the homebound elderly are incontinent. A random sampling of hospitalized elderly patients reports that 11% of patients have persistent urinary incontinence at admission, and 23% at discharge.
24% to 45% of women report some degree of urinary incontinence. 7% to 37% of women ages 20 to 39 report some degree of urinary incontinence. Daily urinary incontinence is reported by 9% to 39% of women over age 60. Increased risk of urinary incontinence was associated with pregnancy, childbirth, diabetes, and increased body mass index. 11% to 34% of older men report urinary incontinence, with 2 to 11% reporting daily occurrences. Increased risk is associated with prostate surgery. In general, the prevalence of men is about half that of women.
The estimated prevalence for the types of urinary incontinence are as follows:
The history should be used to determine the type, severity, burden, and duration of urinary incontinence. Voiding diaries may help provide details about episodes of incontinence. Signs and symptoms pertaining to emergent conditions (such as cauda equina syndrome) and reversible causes should be queried.
The type of urinary incontinence can often be determined by the history:
The 3 incontinence questions (3IQ) is a brief questionnaire that may be useful to distinguish among stress, urge, mixed urinary incontinence, and other causes. The 3IQ predicts stress urinary incontinence with a specificity of up to 92%, but its utility may depend on the population studied.
Patients should be asked about medical conditions such as chronic obstructive pulmonary disease and asthma (which can cause cough), heart failure (with related fluid overload and diuresis), neurologic conditions (which may suggest dysregulated bladder innervation), musculoskeletal conditions (which may contribute to toileting barriers), etc.
The surgical history should also be assessed as the involved anatomy and innervation may have been affected.
For females, a gynecologic history should be obtained to assess for the number of births, whether births were vaginal or by c-section, and whether or not they are currently pregnant. In addition, estrogen status should be determined as atrophic vaginitis and urethritis may contribute to reversible urinary incontinence during perimenopause.
Patients should be asked about medication and substance use (e.g., diuretics, alcohol, caffeine), as they can either directly or indirectly contribute to incontinence. Potential adverse effects include impairment of cognition, alteration of bladder tone or sphincter function, inducement of cough, promotion of diuresis, etc.
The history should guide the practitioner toward an appropriate physical exam. Again, emergent conditions and reversible causes should be explored.
Tests and maneuvers to consider, but are not necessary, are:
Treatment and management are dependent on the type of urinary incontinence. Conservative, pharmacologic, and surgical modalities exist. Treatment and management should begin with the least invasive methods and then escalate as appropriate:
Medications should be reconciled, and substances such as caffeine and alcohol should be avoided if they are contributing to incontinence.
Urinary incontinence in end of life care can be difficult to manage and should be handled on a case by case basis. In some instances, an indwelling catheter or condom catheter may need to be used to maximize comfort for the patient in the last stages of their life.
The mnemonic DIAPPERS can be used as an aid to develop a differential diagnosis for reversible causes of urinary incontinence:
Other conditions to consider include:
Response to treatment and management is variable among patients. In those whose symptoms cannot be completely eliminated, optimal symptom control should be sought by multiple treatment modalities. Median cure rates for stress, urge, and mixed urinary incontinence by select modalities can be seen below:
Several inventories and tools exist that may be used to monitor symptoms and treatment effectiveness:
A urologic referral is recommended in the following situations:
Patients should be informed that although urinary incontinence is highly prevalent in older adults, it is not a normal part of aging. They should be aware that some causes of urinary incontinence are reversible. Information should be available to patients regarding the various treatment and management options that are available, which include conservative, pharmacologic, and surgical modalities.
Despite being a highly prevalent condition, urinary incontinence is inadequately screened for by health care providers. As a result, a large number of patients with urinary incontinence are without treatment, having to tolerate suboptimal health and quality of life. Health care providers in various settings such as hospitals, clinics, and nursing homes can better screen for and communicate findings of patient urinary incontinence with one another to better facilitate patient care. In a collaborative approach, nurses and medical assistants can help screen patients for urinary incontinence. Pharmacists can provide assistance with medication reconciliation in relevant cases. In more complicated cases of urinary incontinence, collaboration among primary care clinicians and specialists is needed to deliver the seamless, quality care to patients. A study intended to increase screening and management of urinary incontinence by primary care clinicians was unsuccessful despite additional training and support offered to them. The study focused primarily on clinicians and not other health care providers. [Level 3]
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