Urinary Incontinence

Richard Rathe

Urinary incontinence (UI) in adults is one of the most prevalent and underdiagnosed afflictions in the United States (>25 million effected individuals, >50% of nursing home residents). The economic impact is estimated to be more than $16 billion (1). It is a major cause of social withdrawal and loss of independent living. Patients are often too embarrassed to discuss this problem, even with their physician. Some even view it as a natural part of aging, but this is not the case. Urinary incontinence is a symptom, not a disease. Understanding the types of disorders that cause incontinence is the key to correct diagnosis and effective treatment (2–5).

Approach

A. Definition. Urinary incontinence is the involuntary loss of urine at times and in amounts that interfere with hygiene and activities of daily living.

B. Classification. The classification of urinary incontinence is presented in Table 10.1.

 C. Urinary incontinence can be acute or chronic. Acute causes include infection, medications, delirium, and exacerbation of systemic diseases (e.g., diabetes mellitus, diabetes insipidus, congestive heart failure, or stroke). Chronic conditions that are associated with UI fall into two categories: (a) local (pelvic floor weakness following childbirth, bladder tumor or deformity, tumors, obstruction by an enlarged prostate or cystocele, postsurgical) and (b) systemic [menopause, neuropathy (diabetes, alcoholism), dementia, depression, stroke, tumor, Parkinson’s disease].

 D. The DRIP mnemonic is often cited as a way to remember the reversible (and curable) causes of UI:

1. D: Delirium and drugs

2. R: Restricted mobility and retention

3. I: Infection, inflammation, and (fecal) impaction

4. P: Polyuria from uncontrolled diabetes and other conditions

History

A. Voiding history. It is important to fully characterize the patient’s problem by taking a detailed history, including the duration of the symptoms, timing of voluntary or involuntary voiding, amounts voided involuntarily, and the relationship to voluntary voiding. Focus on the following areas:

1. Need for pads or diapers (measure of severity)

2. Loss of urine with coughing or laughing (suggests stress type)

 3. Inability to hold urine after having the urge to urinate (suggests urge type)

 4. Pain or discomfort (suggests infection or inflammation) (Chapter 10.1)

5. Inability to fully empty bladder (suggests obstruction)

6. Decreased urinary stream (suggests obstruction)

7. What impact does UI have on the patient’s life?

8. What does the patient think is going on?

B. Major medical problems. Does the patient have any known condition that is associated with UI? These include diabetes, heart failure, menopause, and neurologic problems. Does the patient have other genitourinary symptoms? In female patients, be sure to take a detailed obstetric history.

 C. Medication history. Since medications are a major cause of incontinence, a thorough medication history is essential. Offending agents include diuretics, older antidepressants, antihypertensives, narcotics, and alcohol.

 D. Special concern. Central and nephrogenic diabetes insipidus can present with UI because of increased urine output (many liters per day). These patients frequently have a concomitant polydypsia that closely matches their water loss (Chapter 14.5). Consider this diagnosis when the patient gives a history of voiding large volumes of urine.

Physical examination

 The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):

A. General. Is the patient physically capable of getting to the toilet?

B. Mental status. Can the patient understand and act on the urge to void?

 C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.

 D. Abdominal examination. Is the bladder distended?

E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?

 F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.

Testing

 A. Voiding journal. A voiding journal is a good way to get additional information about the patient’s problem. Have the patient record the time and approximate amount of each voiding, and whether they were wet or dry.

 B. Urinalysis. Be cautious when interpreting the urine analysis: in the absence of other symptoms, bacteriuria is seldom the primary cause of UI. Treat cystitis or urethritis when the rest of the clinical picture confirms them. Unexplained, persistent microhematuria requires investigation (Chapter 10.2).

 C. Postvoiding urine volume. The patient should be catheterized immediately after voiding. In general, the postvoid urine volume should be less than 50 ml. Volumes in the range of 100 to 200 ml may suggest impaired bladder contractility or obstruction. Volumes greater than 200 ml strongly suggest obstruction.

D. Blood urea nitrogen, creatinine, and glucose are simple blood tests that help rule out underlying renal disease and diabetes.

 E. Special tests are available via urologic consultation to further delineate the cause of UI. These include cystoscopy, cystometry, and other voiding studies. Up to two-thirds of patients can be successfully treated without urologic referral.

Diagnostic assessment

 The clinical history is the most important factor leading to the correct diagnosis and successful treatment of urinary incontinence. However, it is an imperfect tool at best. In one review, clinical history had a sensitivity and specificity for stress incontinence of 0.90 and 0.50, respectively. For detrusor instability, the figures were 0.74 and 0.55 (2).

The task becomes even more problematic when considering the reluctance of patients to talk about their symptoms and the tendency for UI to be of a mixed type. Response to therapy (or lack thereof) often drives the practical management of this condition. Lack of response to multiple trials of therapy is a good indication for consulting a urologist. Remember, that your initial assessment will often be incorrect, so keep an open mind and consider all possible diagnoses. Finally, recall that UI frequently involves more than one causal factor. For example, many elderly people have a functional component (can’t get to the toilet quickly) in addition to one of the other types.

References

1. Urinary incontinence in adults: acute and chronic management. AHCPR Clinical Practice Guideline, No. 2 (1996 Update) Accessed August 1999; http://text.nlm.nih.gov/
ftrs/gateway/

2. Jensen JK, Nielsen FR, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994;83(5):904–910.

3. Finding out about incontinence. AAFP Patient Information Handout (1998) Accessed August 1999; http://www.aafp.org/patientinfo/incont.html

4. Goode PS, Burgio KL. Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients. Am J Med Sci 1997;314(4):262–267.

5. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician 1998;57(11):2665–2687. Accessed August 1999; http://www.aafp.org/afp/
980600ap/weiss.html

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Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.

More About Causes of Frequent urination

• Back to symptom: Frequent urination: Introduction (review 148 causes)
• Next Book Extract About Frequent urination: Oliguria and Anuria (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

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