Urinary Incontinence
Definition
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Note: I copy the "definition" of something straight from the book. I find it's best to have an all-encompassing definition in order to better orient myself when I am studying.
(Show Definition)
Urinary incontinence (UI) is the involuntary loss of urine severe enough to have unpleasant social or hygienic consequences. UI is diagnosed primarily on history; inquire about UI at every interview. UI is a symptom of an underlying disease process in most cases; some cases are reversible with appropriate treatment.
Incontinence is not considered a part of normal aging. Morbidity related to incontinence includes urinary tract infections (UTIs), indwelling catheters, falls/ fractures, sleep interruption, social withdrawal, and depression.
Successful toileting depends on ready access to facilities, motivation to remain dry, mobility and manual dexterity, and the cognitive ability to recognize/react to the urge to void.
UI can be divided into the following categories:
functional, urge, overflow, stress, and mixed.
Each category has a unique etiology, pathophysiology, symptoms, and management.
Incidence/Prevalance
- Up to 10% of Canadians have it
- Peds:
- Day continence achieved by 4 years
- Night continence by 5 - 7 years
- More common in women and the elderly
Pathogenesis
Can be caused by physiologic, structural, or pathologic factors.
- Functional: Cannot reach bathroom due to impaired mobility.
- Urge: Cannot control urge to empty once sensation of fullness is present. Caused by:
- Detrusor hyperactivity or hyperreflexia which may be associated with:
- LUT disorders, such as tumors, stones, uterine prolapse, cystitis, urethritis, impaired bladder contractility.
- CNS disorders such as:
- Stroke, dementia, Parkinson's, spinal cord injury, and normal pressure hydrocephalus.
- Overflow: Bladder inappropriately distended. Caused by:
- Anatomic/Structural abnormalities associated with:
- Enlarged prostate, pelvic prolapse, acontractile bladder (diabetes), MS, spinal cord injury.
- Stress: involuntary leakage d/t maneuvers that increase intra-abdominal pressure.
- Most often caused by prostrate surgery in men, multiparous women.
- Mixed: Mixed.
Predisposing factors
There is a very long list of predisposing factors, they are listed directly from the book (below), but these are few I want to remember for the test:
- Female.
- Age.
- Menopause. Why? (Click to expand)
- Increased parity.
- Infection.
- Dementia.
- Medication Side Fx.
(Full list - click to expand)
- Age for both males and females.
- Female: 85% of cases are in women.
- Increased parity.
- Previous genitourinary (GU) surgeries (e.g., prostate surgery, hysterectomy).
- Restricted mobility.
- Menopause.
- Infections.
- Chronic illnesses (e.g., diabetes).
- Fecal impactions.
- Excessive urinary output.
- Delirium.
- Dementia.
- Neurologic disorders (e.g., stroke, spinal cord injury).
- Variety of medications (e.g., antihypertensive medicines, diuretics, sedatives).
- Pelvic trauma (e.g., episiotomy, forceps delivery).
- Obesity.
- Sleep apnea.
- Depression.
- High-impact exercise.
Common Findings
- Urinary Sx: urgency, frequency, leakage (via urge or stress), nocturia. (an overactive bladder does not need to be associated with incontinence.)
- Urgency maybe experienced when hearing or touching water, as well as exposure to cold, and rushing to the bathroom.
Other Signs and Symptoms
In addition to urgency/frequency/polyuria (i.e. daytime or nighttime [nocturia] frequency)/incontinence: dribbling, weak (maybe intermittent) stream, incomplete voiding sensation, straining.
History
- HPI:
- ROS:
- ALL/MEDS/HIITS: (What are HIITS? - Click to expand)
Cannot prescribe antimuscarinic if pt is being treated for glaucoma.
- PMH/FAMHx/OBGYN: inquire if menopausal, fecal incontinence/constipation may suggest retained stool pressing on the bladder.
- SOCHx: Inquire about sexual history.
Physical Exam
Coming Soon.
Diagnostic Tests
H&P sufficient to begin treatment.
- UA w/ culture if infection is suspected.
- Urine cytology/cystoscopy if hematuria.
- Post-void residual volume, esp. if neurologic in nature.
- Consider PSA.
DDx
Eight reversible causes of transient incontinence can be remembered by using the mnemonic: DIAPPERS.
- Delirium
- Infection (urinary)
- Atrophic urethritis and vaginitis
- Pharmacologicals
- Psychological disorders, especially depression
- Excessive urine output
- Restricted mobility
- Stool impaction
Plan
- General:
- Address funcitonal limitations, caregiver-assisted timed urination, bladder diary to help ascertain cause.
- If overflow, manual emptying or intermittent catheterization.
- Pelvic floor exercises.
- Weight loss
- May need surgical tx: pessary in woman.
- Pharmacologic:
- If overactive bladder, anticholinergics/antispasmodics: oxybutynin, tolterodine.
- C/I in narrow-angle glaucoma, urinary retention, gastric retention.
- α-adrenergic antagonists promote urethral contraction.
Follow-up
Not important.
Consultation/Referral
May refer for hematuria, urodynamic testing (actually the gold standard), gynecology for pessary fitting.
Individual Considerations
In pregnancy, treated with pelvic floor exercises.
Incontinence in the elderly is a risk for falls !!
In pediatric patients, it presents as enuresis.