Urinary Incontinence

Types of Urinary Incontinence

Low Pressure Urethra (Type 3)

1. Urethral tone loss (<60 cm H20)
2. Causes: trauma, surgery

Overflow Incontinence (urinary retention)

1. Bladder overdistention with urinary retention
2. Post-void residual >200 cc of urine
3. Less common in women
4. Causes: Neuropathy, BPH, or pelvic mass
5. Requires evaluation for tumor mass

Urge Incontinence (Overly sensitive bladder)

1. Loss of large bladder volumes (contrast with stress)
2. Associated with urinary urgency, frequency, nocturia
3. Causes: CNS, Cystitis, Bladder Cancer, stones

Stress Incontinence (Loss of pelvic support at urethra)

1. Loss of small bladder volumes (contrast with urge)
2. Occurs with coughing, sneezing, lifting
3. Causes: Urethral hypermobility, Sphincter damage

Functional Incontinence

1. Normal bladder with decreased access to toilet

Differential Diagnosis: (Mneumonic: “DIAPPERS”)

1. Delirium
2. Infection or Inflammation

1. Recurrent Urinary Tract Infection
2. Infectious Vaginitis
3. Interstitial Cystitis
4. Carcinoma-in-situ of the bladder

3. Atrophic urethritis or Atrophic Vaginitis
4. Pharmaceuticals

1. Diuretics
2. Sedative-Hypnotic Medications
3. Antipsychotic medications
4. Muscle relaxants
5. Sympathetic blockers
6. Psychological causes
7. Excessive urine output (e.g. Diabetes Mellitus)
8. Restricted Mobility (i.e. difficult ambulation)
9. Stool Impaction

Exam

1. Spontaneous loss of urine

1. Detrussor Instability
2. Urge Incontinence
3. Provocation with cough, valsalva, or bearing down

1. Suggests Stress Incontinence
2. Perform Pelvic exam, lifting anterior vaginal wall

1. Changes bladder neck position
2. Retest with cough or valsalva
3. Spontaneous uncontrolled large volume bladder emptying
4. Suggests Urge Incontinence

Evaluation

1. Rule-out reversible cause

1. Medication adverse effects
2. Atrophic Vaginitis
3. Benign Prostatic Hyperplasia (BPH)
4. Polyuria

1. Medication
2. Diabetes Mellitus

5. Fecal Impaction
6. Urinary Tract Infection
7. Functional Incontinence

1. Limited mobility
2. Altered Level of Consciousness
3. Rule-out Overflow Incontinence

1. Check post-void residual if indicated by history
2. Consider neurologic or post-surgical cause
3. See Low Pressure Urethra
4. Distinguish Urge Incontinence from Stress Incontinence
5. If secondary cause is unlikely

  Management: General

1. Management is per specific incontinence cause
2. Make toilets more accessible

1. Higher toilets
2. Well lit floors
3. Change bedroom to be close to bathroom
4. Consider bedside commode

3. Wear clothes that are removed easily
4. Use moderation in fluid intake
5. Lose weight (if obese)
6. Smoking Cessation
7. Avoid Diuretics

1. Avoid alcohol
2. Avoid caffeine