Incontinence

Incontinence: Excerpt from In a Page: Signs and Symptoms

Incontinence, defined as the involuntary loss of urine, is one of the ten most common medical problems in the U.S. However, most patients do not seek treatment despite the significant effects on self-esteem and social interactions. Prevalence is estimated at 13–60 million Americans (men and women) and affects especially geriatric patients. Associated costs approach $16 billion per year.

Differential Diagnosis

Transient, acute incontinence (DIAPPERS)

• Delirium
• Infections of urinary tract
• Atrophic urethritis or vaginitis
• Pharmaceuticals [e.g., diuretics, sedatives, anxiolytics, alcohol, β-blockers (cause urethral relaxation), ACE inhibitors (chronic cough increases abdominal pressure), antidepressants, antipsychotics]
• Psychiatric conditions (e.g., depression)
• Endocrine disorders (e.g., hypercalcemia, hyperglycemia)
• Restricted mobility or (urinary)
• Retention
• Stool (fecal impaction)
  Persistent, chronic incontinence
• Stress incontinence
  –Loss of urine upon increases in intra-abdominal pressure (e.g., laughing, coughing, change in position, exercise)
  –Women <60 years after vaginal births
  –Urethral trauma (e.g., prostate surgery)
• Urge incontinence (“overactive bladder”)
  –Strong urge to urinate before reaching the toilet; usually in people >60
  –Commonly associated with reversible causes, increased fluid intake, or poor bladder contractility
  –Idiopathic causes, neurologic causes, hyperreflexia, neuropathies, poor bladder contractility, increased sphincter relaxation, and reversible causes (e.g., UTI, increased fluid intake)
• Overflow incontinence
  –Outlet obstruction: BPH, GU prolapse, tumors
  –Bladder contractility dysfunction: Neurologic disorder (e.g., diabetic or alcoholic neuropathy), sacral spinal cord lesions, anticholinergic medications

• Functional incontinence
  –Normal urinary system affected by external factors (e.g., age, mental status decline, poor mobility)
• Mixed incontinence
  –Combined elements of stress and urge incontinence is common in older females
  –Combined elements of overflow and urge incontinence are most common in men and frail nursing-home patients

Workup and Diagnosis

• History should include whether the patient has problems holding urine versus emptying bladder; leakage of urine with cough, exercise, sneezing, laughing, lifting; frequency of urination; nocturnal urination; strong urge to urinate; loss of urine before reaching toilet; hesitancy, dribbling, slow stream, incomplete voiding, dysuria; bowel habits (e.g., constipation); medications; fluid intake; and medical and surgical history
• Physical exam should include full neurologic and mental status examinations, assessment of physical frailness (e.g., use of walking aids, dysfunction secondary to stroke), abdominal exam (e.g., lower quadrant distension, pregnancy, fecal impaction), and genital and rectal exam (evaluate for cystocele, vaginal atrophy, strength of pelvic muscles in women; rectal tone, abnormalities of glans penis and prostate in men)
• Cough stress test: Immediate leakage indicates stress incontinence; delayed leakage indicates urge incontinence
• Voiding diaries may be used to track urinary habits
• Initial labs may include electrolytes, calcium, glucose, urinalysis, and urine culture
• Measurement of postvoid residual volume by catheterization and/or pelvic ultrasound (>100 mL of residual urine is abnormal)
• Specialized urodynamic tests are reserved for ambiguous results or treatment failure

Treatment

• Treat reversible causes appropriately (e.g., antibiotics for UTI, discontinue offending medications)
• Stress incontinence
  –Pelvic exercises (Kegel's) or electrical stimulation
  –α-adrenergic medications to increase urethral tone
  –Local estrogen replacement treatment
  –Pessaries prevent urine loss during stress maneuvers
  –Surgical therapy may be indicated

• Overflow incontinence
  –Improve bladder contractility
  –Remove outlet obstruction (enlarged prostate, defects in penis, prolapsed uterus or urethra)
  –Neuropathic conditions may require intermittent catheterization to improve symptoms

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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