Download Urinary Incontinence in the Elderly Population

in the ElderlyPopulation
Urinary Incontinence
Dannyl S. CHurx,r,M.D., KsvIr C. Fl-n,rnnc,M.D., Manv P. BvnNs,M.D., JoNnru,tNM. EvnNs,M.D.,
,lxt KaRnNL. ANnnews,M.D.
. Ob.iective:To describethe causes,evaluation,and
managementof urinary incontinence in the elderly
population.
. Design: We reviewed pertinent articles in the
medicalliterature and summarizedthe typesof incontinenceand contributing factors.
o Results: Urinary incontinenceis common in elderly patients and often has a major role in determining whether a person can remain independentin the
cornmunit-y
or requiresnursing home placement.Urinary incontinence is not a single entity but rather
severaldifferent conditions,each with specificsymptoms, findings on examination, and recommended
treatment. Thus, accurateclassificationis important
for appropriate management. Becauseof the com-
plexity of urinary incontinence,many physiciansare
u n c o m f o r t a b l e w i t h u n d e r t a k i n g a s s e s s m e n ta n d
treatment. Hence,many patientsare not askedabout
incontinence,and the condition remains untreated
and often considered a natural consequenceof the
aging process. Urinary incontinencecan be treated
and either cured or alleviatedwith treatment.
c Conclusion: Elderly patients should be asked
about symptomsof urinary incontinencebecauseappropriate assessment
and treatment can usually provide relief.
(Mayo Clin Proc 1996; 7I:93-I0l)
B P H = b e n i g n p r o s t a l i c h y p e r p l a s i a ;U I = u r i n a r y i n c o n t i n e n c e
Urinaryincontinence(UI) is a common but poorly underUl can resultin skin irritationand can contributeto skin
instoodproblemin theelderlypopulation.rAn estimatedl57o breakdownor pressuresores. The socialconsequences
persons
to
of community-dwelling
guilt
some
elderly
are
afraid
and
isolation;
persons
clude
and50Voof instituelderly
tionalizedelderly personshave severe urinary inconti- leavetheir homes.r"Absorbentundergarments
may reduce
nence.2.s
increases, this fearbut areexpensiveand can delayevaluatton.
As the degreeof functionaldependence
thefrequencyof incontinenceinc-reases
feawell.
The prevaIn this article,we will review the pathophysiologic
as
lenceof incontinencemay be appreciablyunderestimated turesand evaluationof UI and discussmanagement
issues.
because
physiciansrarely ask patientsabout the problem, Older adultsneedto be assuredthat,for most patients,diagandpatientsseldominitiatediscussions
about incontinence n o s i sa n d t r e a t m e not p t i o n sa r e i n c x p e n s i v en. o n i n v a s i v c .
withtheirphysician.6Olderpatientsmay assumethat UI is a and successful.
normalconsequence
of aging. Somepatientsmay be embarrassed
by their incontinence
or may fear invasivetestingand URINARY ANATOMIC AND
thusavoid evaluation.
PHYSIOLOGIC FEATURES
UI cornmonlyresultsin medical,social.and economic For a betterunderstandingof urinary incontinencein elderly
consequences.Ts
Incontinence
is a commonreasonfor insti- persons,one needs to appreciatethe anatomic and physifutionalizationamongelderly persons. The care of inconti- ologicchangesthat resultfrom aging." The urinarybladder
nentnursinghomeresidents
more expensive is a muscularreservoirwith two functions. When the musis considerably
thanof continent residentsand necessitatesmore nursing cular wall (detrusor)relaxes.urine stora,ee
results:when it
timeand tiequent linen and clothing changes.e
wall
of the bladderis
contracts,micturition occurs. The
composedof interlacingbundlesof smoothmuscle,which
allows the detrusorto expandandcontractandtherebyfaciliFrotn the
t h e S e c t i o n o f G e r i a t r i c s( D . S . C . .K . C . F . . J . M . E . ) . D e p a r t m e n to f
tate both urine storageand emptying.
t r i c sa n d G y n c c ol o g y t M .P . E ;. . a n d D e p a r t m e not f P h y si c a l M e d i ci n e
t Obstetrics
Sensorystretchreceptorslocatedwithin the bladderwall
andRehatl
R e h a b r l i t a r i o(nK . t - . A . ) .M a v o C l i n i cR o c h e s t e rR. o c h e s t e rM
. innesota.
help
to assessthe degreeof bladderfullness. This informaI n d i v i d u ar e
Individual
l p r i n t so f t h i s a r l i c l ea r en o r a v a i l a b l e .T h e e n t i r eS y m p o s i u m
is transrnittedup the spinal cord through the spinotion
on Oeriatr
l n C e r i a t r i . r w i l l b e a v a i l a b l cf o r p u r c h a s ea s a b o u n d b o o k l e t f r o m t h e
Proceeditltu,
Proceedin
thalamictracts to the centralnervoussystem. The brain
c,,.u[i,"^ ofi:i.c ara lor., drre
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94
Mayo Clin Proc,January 1996'Vol 7l
URINARY INCONTINENCE IN ELDERLY PERSONS
sendsinhibitory signals when detrusor relaxation is desired
and excitatory signals when detrusor conffaction is desired.
This information from the brain is transmitted down the
spinal cord to the urinary bladder through the dorsal columns
and corticospinal tracts. The bladder has somatic,parasympathetic, and sympathelic innervation (Fig. 1).
The pudendal nerve is the somatic component of bladder
innervation and innervates the external sphincter. When
stimulated, it produces contraction of the extemal urethral
sphincter. The extemal sphincter has an infrequent role in
maintaining continence becauseit is able to remain tightly
contracted for only a brief period. This sphincter normally
contractsduring transient increasesin intra-abdominalpressure,suchas occur with coughing,sneezing,and laughing'
The parasympatheticnerve fibers arise from the second
through the fourth segments of the sacral spinal cord and
innervate the detrusor muscle. Stimulation occurs when
micturition is desired. When stimulated, the detrusor contracts;the result is increasedintravesicularpressure.
The intemal urinary sphincteris innervatedby the sympathetic nervous system. These nerves originate from the
lower thoracicand upperlumbar segmentsof the spinalcordWhen these nerves are stimulated, the intemal sphincter
relaxes.
The physiologicdetailsof micturition are complex;however, a basic understanding is necessaryto appreciatethe
causesand treatmentof incontinehce.r2As urine fills the
o
o
o
o
C)
o
bladder through the ureters,the detrusorstretchesand allows
the bladder to expand. As the bladder fills, stretch receptors
within the bladder wall are stimulated,and the brain is given
information about the amount of urine within the bladder.
Approximately 300 mL of urine must be in the bladder
before the intravesical pressure increases enough for the
brain to recognize a senseof bladder fullness. With low
bladdervolumes, the sympatheticnervous system is stimulated and the parasympatheticsystem is inhibited; thus, the
intemal sphincter contracts and the detrusor relaxes. When
the bladder is full and micturition is desired, the inhibitory
signalsfrom the brain are replacedby impulsesthat stimulate the parasympatheticsystem(and result in detrusorcontraction) and that inhibit the sympatheticsystem (and cause
intemal sphincterrelaxation).The intravesicalpressurethen
increasesto a point at which it exceedsthe resistancewithin
the urethra. and urine flows out of the bladder.
Once the bladder has emptied, the brain again sends
impulsesthat result in parasympatheticinhibition and sympatheticstimulation;hence,detrusorrelaxation and intemal
sphincter contraction occur. The urinary bladder is again
readyto be filled with urine.
CAUSES OF INCONTINENCE
Although the anatomicand physiologic changesin the urinary tract that resultfrom normal agingdo not causeUI, they
do createa situationthat allows incontinenceto occur more
Sympathetic
nerves
ParasymPathetic
nervgs
Cholinergic
receptors
Beta-adrenergic
receptors
Detrusor
muscle
Alpha-adrenergic
receptors
nerve
Somatic(pudendal)
External
sphincter
Fig. 1. Diagram showinginnervationof urinary bladder.
Mayo Clin Proc,.lanuary 1996' Vol 7l
with decreased
sizeof
easily.Advancingageis associated
bladdervolume: therefore,
theurinary bladderanddecreased
morefrequentbladderemptying(urinary frequency)is commonin the geriatricpopulation.Many elderlypersonsexpeeven at low bladdervolrienceearly detrusorcontractions,
umes,and have difficulty suppressingsuch contracrions.
Theoutcome is a senseof urgencyto empty the bladder.
In additionto thesechangesof normal aging.many diseasestatescommonlyexperiencedby elderly personscan
contributeto the problemof UI. Urinary tract infections,
prostatism,immobility.pelvic floor dysfunction,and fecal
impactionsare typical examples. Although age-related
can contributeto incontinence
changes
and theleforeneedto
in the evaluation,one must neverassumethat
be considered
UI in an elderlypatientis dueto agingalone.For appropriate
assessment,
classificationby history,examination,and resultsof testingis important.
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TYPES OF INCONTINENCE
EstablishedUI can usually be divided into one of fbur
types-detrusor oreractivi4, (urge incor.rtinence),
ot'etJlou,
incontitte
(outleLincompetence),
rtce. stressitl(otltinence
or
functional incontinenc'e.Patientswith thesedisordersoften
haveclassichistoriesor typicalphysicalfindings. Unfortunately,elderlypatientsmay havemore rhanone type of UI;
accordingly,the historyand physicalfindingsmay be difficult to interpret.
D etr uso r O veractivity (Urg e I nconti nence).-Detrusor
overactivityis a commoncauseof UI in the elderlypopulatton,occurringin 40 to 70Vcof cases.This type of incontinenceis also known as detrusorinstability, detrusor
hyperreflexia,
or uninhibitedbladder.Patientswith derrusor
overactivityhaveearly,forcefuldetrusorcontractions,well
beforethe bladder is full. This situation crealesa stateof
urinary urgency and frequency. Patients with detrusor
overactivitytendto losesmallto lnoderatevolumesof urine.
If thedetrusorcontractionis strongenoughto overcomethe
urethralresistance,
inconlinence
occurs.
Detrusoroveractivitycanbe foundin conditionsofdefective centlal nervoussysteminhibition or increasedafferent
sensorystimulationfronr the bladder. Examplesof disorders
that impair the ability of the centralnervoussystemto send
inhibitory signals are strokes,masses(tumor, aneurysm,
hemorrhage),demyelinatingdisease(multiple sclerosis),
andParkinson'sdisease.Increased
afferentstimulationfrom
the bladder can result from lower urinary tract infections.
atrophicurethritis, fecal impaction,uterine prolapse,or benign prostarichyperplasia
(BPH).
The diagnosisof detrusoroveracriviryis primarily based
on thehistory. Patientshaveno pathognomonic
findingson
physicalexamination,althougha careful pelvic and rectal
examinationand neurologicscreeningcan occasionallyre-
U R I N A R Y I N C O N T I N E N C EI N E L D E R L Y P E R S O N S
95
veal anatomicabnormalities(for example,uterine prolapse
or fecal impaction)or evidenceof neurologicdisease.The
clinician shouldcarefullyassessthe symptomsof patients
with BPH. Many patientswill describeboth obstructive
symptoms(suchas weakurinarystreamor incompleteblad,
der emptying) from the enlargedprostateand the irritative
symptoms (urgency or frequency) from the detrusor
overactivity.Althoughsurgicaltreatmentalleviatesthe obstructivesymptoms,it often has no effect on relievingthe
irritativesymptoms.
OverflowIncontinence.-Overflow incontinenceis less
commonthandetrusoroveractivity;it is estimatedto occur
in 7 to ll7o of incontinentelderly parients. Patientswith
overflow incontinencecommonly have symptomsof substantiallyreducedurinarystream,incompleteor unsuccessful voiding, and fiequentor even continuousurinary dribbling. Overflow incontinenceis generallydue to a bladder
with contractiledysfunction(hypotonicor atonicbladder)or
obstructedurinary outflow. In either case,large bladder
volumesresultin an intravesicular
pressurethatexceedsthe
intraurethralresistance
and ultimatelyin symptomsof urinary dribbling.
Overflow incontinencesecondaryto an atonic bladderis
often transient after general or regional anesthesia.after
bladderinstrumentation,
or with the useof variousmedicationssuchas narcotics.Contractiledysfunctionof the bladder can be causedby diseaseof the peripheralnervgr-1ot
example, diabetic peripheral neuropathy---orsacral nerve
roots. Bladderoutletobstructionin men is usuallyattributableto an enlargedprostatefrom BPH. It may alsobe caused
by pelvic neoplasmor fecal impaction. Physicalexamrnation often revealsa distendedbladder,and measurementof
urine volume after voiding revealsan increasedresidual
volume. Patientsalso have low urinary flow rateson urodynamictests.
Stress Incontinence (Outlet Incompetence).-Urinary
stressincontinence,
also known as outlet incompetence,
is
common in women. Patientsdescribelossesof small volumes of urine with activities that transiently increasethe
intra-abdominal
pressure(suchas coughing,sneezing,running, or laughing). Loss of urine can resultfrom a reduced
tone of the internal and the extemal urinary sphincter. Although this type of incontinencecan occur in men, it is
usually limited to those who have had intemal sphincter
damagefrom urologic procedures.
In women, the cause of urinary stress incontinenceis
usually pelvic relaxationas a result of childbirth and the
aging process. These changesbecome more pronounced
after menopause,when estrogendeficiency allows atrophy
of the genitourinarytissues. Pelvic relaxation,including
uterineprolapseand cystocele.allows descentof the normal
urethrovesical
angle (Fig. 2). This anatomicdistortional-
:
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URINARY INCONTINENCE IN ELDERLY PERSONS
(from aging,childbirth' a
Fig. 2. Dagrams depictingposteriorurethrovesicalangle. A, Normal relationship. B, With pelvic relaxation
other factors), angle is increased.
lows the urethral sphincter to be more vulnerable to increasedintravesical pressurefrom any activity that results in
increased intra-abdominal pressirre. Loss of urine then results. Other less common causesinclude cauda equina lesions or peripheral neuropathy, Physical examination may
reveal evidence of pelvic relaxation, such as cystocele,
rectocele, or uterine prolapse. Loss of urine can usually be
demonstratedby having the patient cough while in the supine position.
F unc tio nal I n contin en ce.-Patients with functional incontinence are those who would otherwise be continent but,
becauseofphysical or cognitiveproblemsor use ofvarious
medications, are unable to reach the toilet facilities in time.
This result may be ascribed to decreasedmobility due to
severe arthritis, weakness(from strokes or deconditioning),
contractures, or the use of physical restraints. Functional
incontinence may also be causedby medications, impaired
cognition (for example, from delirium or dementia), or excessive distance of the patient from the toilet facilities. Patients with peripheral edemafrom any causeoften have fluid
shifts at night from recumbency,resulting in nocturia. This
situation can exacerbateUI of any causeor can contribute to
its development when presentin combination with cognitive
impairment, immobility, or the effect of various medications. Generally, patients with functional incontinencehave
normally functioning urinary systems,and the incontinence
is a result of some external factor. Consequently,no typical
findings will be noted on physical examination. Finally,
some medications can affect urinary continence (Table l
either as a result of urine production (diuretics) or by dire
effects on the detrusormuscle (anticholinergics)or interr
sphincter(sympatheticagonistsor antagonists).1r
EVALUATION OF INCONTINENCE
Assessmentof the patientwith establishedUI involveselir
tation of a thorough medical history and performance ol
physical examination. Occasionally,various simple labor
tory tests are necessary. More elaborate tests, includi
urodynamic studies,are sometimesneededto determine t
type of incontinence that is present.
History.-The history is the most irnportant part of t
evaluationof UI. Patientsshouldbe asked how frequen
incontinenceis a problem and how much urine is lost w
each episodeof incontinence. Small volumes of urine i
lost in overflow incontinence and outlet incornpetenr
whereas moderate volumes are lost in detrusor overactivi
Patientsshouldbe askedwhat activitiesproducean episo
of incontinence. Precipitating factors such as coughing
sneezing are highly suggestiveof outlet incompetence,I
these activities may also trigger prematuredetrusor contri
tions. Patients should be questioned about whether and
what degree their incontinence limits their lifestyle ar
specifically, whether any degree of social isolation has
sulted becauseof the incontinence. Other important qu'
tions include whether they use protective absorbentund
garments or pads, and how frequently they need to char
U R I N A R Y I N C O N T I N E N C EI N E L D E R L Y P E R S O N S
Vol 7l
M a y oC l i n P r o c , . J a n u a r y1 9 9 6 '
Tatrlc l.-Medications That Can Affect Continence
T1,peLrldrug
s
Drureltc
Anticholinergics
or h1'Pnotics
Sedative
Narcotics
ic agonists
g-Adreut-rg
tc antagonlsts
g-Adrenerg
chlrtnelLrlockers
Calcrunr
Potential action
Causebrisk fillirtg of bladder
Impair detrusorcontraction
Causeconfusiotr
Impairdetrusorcontfaction
toneof intentalsphincter
Increase
toneof intemalsphincter
Decrease
rlettusol'conlraction
Decrease
theirclothesbecauseof lcakageof ul'ine. The nurnberof
of nocturiashouldbe recorded,as well as whether
episodes
occurs.
noctumali nctlt-ttinence
of urinary urgencyshould suggestthe presSyrnpir>nrs
urinaryfrequencyis
enceof dr-trusoroveractivlty.Increased
often no(ed irr patientswith overflclw incontinenceand
detrusoroleractivity. Patietltswho describedil'ficultyinitiforceof their
atingurinlt ion.strainingto void,or a decreased
may havea bladderoutlet obstruction.The
urinarystrL-ant
frequencl'and scverityof loss of' urine can be lrlolc accuratelydocuntcntedby havingtlrepatientcompletea weekly
diaryol krg. ir-rwhich lhe alnountsand types of lluids consumed.the liequency and volunles of voidings, and the
voluntesof inconlinentepisodesare
frequenc-rnndcstinratcd
recordecl.
C)l'tenwithirronly a week or two, a pattemof the
9'7
also be doneto discloseany neurolo-licdeficiency.pl'ostate
or pelvic pathologiccondit-ecalirr.rpaction,
abnormalities,
may
be useful lor detectionof
exanriliafion
Pelvic
tion.
of atrophicurogenital
prolapse.
rcctocele.
uterine
cystocele.
can be assessedby
weakness
sphincter
Intenral
tissues.
otl the exatnilrrrlying
supine
whilc
patient
cough
havingthe
of
is suggestive
posititln
this
urinc
in
of
tion table. Leakage
tc'r
e
xarninatiott
neurolo-Eic
A
thorough
outletincompetence.
tlr
spitrltl.
systeln.
nervous
of
central
assessfcrr evidcnce
peripheralnervediseaseshouldalso be per'lbrmed.
Laboratory Te.sl.r.-selectedlaboratory tests may be of
isay
u s e i n t h e e v a l u a l i o no f U I . R e s u l t so l u r i r . r a l y s m
A
lesion.
or
a
malignant
inflarnmatiorr.
suggestinfection.
shows
if
urinalysis
the
obtaincd
be
urine culture should
the possibility
ol'infectionor if theliistorysuggests
evicience
tractinlecul'illary
acute
Although
of urinarytractinf'ection.
indicates
evidence
no
firrn
incontinence,
tions can producc
i
s
a
ssociated
b
a
c
t
e
r
i
u
l
i
a
a
s
y
r
l
p
t
o
l
n
a
t
i
c
that long-standing.
(
)
r
o
l
'
u
s
y
n
t
plt)nlatic
t
r
e
a
t
l
n
e
n
t
t
l
l
J
l
with incontinencc
' r7s B l o o d t e s t s
i
t
t
c
o
n
t
i
n
e
n
c
e
.
w
i
l
l
a
l
l
e
v
i
a
t
e
bacteriuria
shouldincludea measureof renalfunction,stlchas a serum
creatinineor blootl urea nitrogcn. Becauscclf rcduced
unrnusclcmass.however,thescmeasurescan substantially
If
patients.
elder'ly
in
fut.tctiorr
renal
actual
the
dercslimate
and
calcium
serum
polyuric
condition,
a
suggests
the history
glucosevaluesshouldalsobe dctennincd.A sinrpletestthat
can yield useful intbrmationis a postvoidingurinary tt'act
to recordthc resiclualvolunre. A urine volcatheterization
50 mL may indicateurinaryobstruetionor
cxceeds
that
ume
typeof L)l enrerges.
The durationthat thc incontinencehas beenpresentand
theprogression
of symptomsnrayprovidesomecluesabout
thelikelihootlclf reversibility.The patient'sfunctiona|aand
cognitiveslatusshouldbe dctermirled.Severeconstipation, a hypotonicbladder.
IJrodynamic Testittg.-The specific cause of Ul in a
diarrhea,or l'ecaliucontinencenlay suggestneurologicor
p a t i e n t c a n u s u a l l v b e e s t a b l i s h e dw i t h o u t t o r n i a l u r o autonomicdysfunctiotr
or a fecal impaction.
are freThe past rnedicalhistoryshouldalso be reviewed. The dynamic testing. Although urodynamic studies
little
incontinence.
of
evaluation
irr
the
performed
quently
presence
crl diabetesmellitus (especiallywith known neufor
testing'
indications
specific
about
exists
ropathy),BPH. neurologicdisease.recun'enturinary tract information
genitourinary Urodynamictestittglnustbc performedby traincdpersonnel
infections.
andpostmenopausal
pr-lvic disease.
results.Nevertheless'
atrophymar.,pr'giisplvse
or contributeto incontinence.Prior in orderto providcvalid.reproducible
nornlalurodynanric
will
have
with
UI
persons
elderly
pelvicor iil.rdonrinal
or radiationtreatmentshould some
operations
have abnormal
incontinence
without
others
and
bedocumente<1.
previtlusbladdersuspenslon findings,
Hysterectomy,
problems,
urodynamtcs
these
Despitc
results.
procedures.iind prostateoperatiol'lscan be importanthistol'i- urodynamic
re They
incontinence.rs
of
assessrnent
lhe
in
cal clues, Women shouldbe askedabout their childbirth can be helpful
r.norethanone type
experience:s.
inasnruchas niultiparity,largebabies,and pro- may be especiallyusefulin patientswith
history.
it'tconsistent
or
confusing
with
a
or of incontinence,
longedlabor rlay predispose
to sphincterincompetence
with
no imol
procedures'
sphincter
or
pelvicfloor tlysfunction.Previousattemptsat modification with prior blatlcler
testing
Urodynamic
treatment.
standard
of UI shoLrlclbe reviewed: Was modification ever at- provementfiorn
urethral
nreasurement.
flow
urinary
includes cystometry,
tempted?Was it successful?Why was it discontinued?
studies.
Physico,t
Examinatiott-A complete,thoroughphysical pressureprofile.and selectedirnaging
m
e
a
s
u
r e sp r e s s r l r e ds u l i n g
Cystometry.-Cystometry
examinatir-,r
on all patientswith inconshouldbe perforrned
contrrtction\'A
detrusor
early
tinence. Flr.rininationof the abdomenshould attempt to bladderfiiling andcan detect
bladderis iilled
the
and
bladder.
evaluatehltiritlerdistention. A clistendecl
bladderis otien caiheteris insertedinto the
as the
is
measured
pressure
palpabiein pltients witlr overf-lowincontinence. Assess- with saline. The intravesical
urothe
all
Of
mentof tht jiiruiwink reflexand a rectalexaminationshould volume within thc bladder is increased.
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t :
N l a v o C l i n P r o c .. l a n u a r r i . r ' ! n .V o l 7 l
IN ELDERLYPERSONS
L ] R I N A R } 'I N C - ' ] N T I N E N C E
- -
c o n s u l t a t i o ni n 1 ' . r x i g n 1 5
T r b i c l . I n d i c a t i o n sf o r l - r r o l o g i C
dynamicstudies.cystontetryis probablythc rntlsttlselul ln
I
n
c
o
ntinence
W
i
t
h
U
r
i
n
a
r
r
overactivity.
patient
witl'r
cletrusor
of the
the assessment
and
detrusorcotitractions
Such patientswill cien.ronstrate
Diagnosisis unclear(for cxample.nore thanone 1)[r! ; l incontinenceis descnbed)'i
pressureincreaseswell beforethe bladderis
characteristic
is documentcd
ow ir.rcontinence
Overfl
f i l l e d . M u l t i c h a n n eul r o d y n a n r i ct e s t i n - sa l l o w s s i n r L r l t a and
of intravesical,intra-abdominal.
Paticntdoesnot responcito treatment
neousmeasurenrents
nlaneuvcrs,
during resting,provocativLurethralpressrtres
Grossor nticroscopichelnaturiais present
among various typc'sof
and voiding and can distin-euish
F i n d i n g s o n p r o s t a t ce x a m i n a t i o ns u g g e s tI n l a l i g n a n t l r s i o n
incontinence.
*[lrodynarnic
testinsntaybenecessarl'.
Urinary Flow Measurement.-Occasionally.a lnellsurenrentof urinary flow is used lbr detectinga urirlary
Detrusor ()veractivity.-Paticnts with detrusor overobstruction.The flow patternwill be abnormalin patients
with a poorly contractingbladder. Bclth mean anclpeak a c t i v i t yo f t e n r c s p o n dt o b e h a v i o r atlh e r a p yc o r r s i s t i nogf
urinaryflows arenteasured.A meanurinaryflow can easily bladclerrctraining.if they are mcltivatedto clo stl lrnd are
be determinedwithout elaborateequipmentsinrplyby mea- c o - s n i t i v c l iyn t a c t . r r : t F o Le x a m p l e s, u c h p a t i e n t sl i r c ri n suringthevolumeof voidedurineandclividingby thetime of structeclin a scheclulefor intake of tlLricls.voiding techurination. A norrnalurinarytlow rate shouldbe at Ieastl() n i t l u e sa. n c sl c h e d u l evdo i c l i n gl.n s t i t r - r t i o n a l i zp ea dt i ci r t sc a n
also bcrrel-itfrom bchavioraltraining by using scht:ciuled
mL/s.
t o i l e t i n go r p r o m p t e dv o i d i n g . rrt" S u c h m e t h o t l sa r e
Llrethral PressureProfile.-The urethralpressurelroritedto
and requirea nursingstaf't'detlie
['ilc nrcasuresthe pressurervithin the urethraanclits tunc- care-tiver-clepenclent
with
patients
incontinence.
of
is thc nranagenrent
tionallen-gth.This profilc indicatcswhetherthe resistlirtcc
Delmsor overaclivityalso respondsto vatriouspliarmasuff icientto preventleakageof urine tiorl the urinaryblado f ' u r i n a r Ys t r e s s c e L r t i c aalg e n t s( T a b l e3 ) . A c e t y l c h o l i nies t h e n e u r ( ) t r a n s c l e r .T h i s t e s tm a y b e u s e f u l o r c v a l u a t i o n
rnitterthat mecliatesdetrusorcontraction.Therelbrc.antilncontlnence.
are often used to suppressthese
I m a g i n g S t u d i e s . - l m a g i n g s t u d i e sf o r u r o d y t r a n l i c cholinergicnreclications
ttseclagentsinclutlo oxyCotrrnronly
contriictions.
a n a l y s e si n c l u d e t w o r a c l i o l o g i ct e s t s - i n t r a v e n o u s carly
and imipr,rmine
hycirochloride.
chloride.
flavoxate
Intravenotts butl'nin
pyelographyand voidirrgc1'stourethrography.
w
i
t
h
t
l
.
r
e
sder u g si s r n i t i W
h
e
n
t
h
e
r
a
p
y
p y e l o g r a p h iys o c c a s i o n a l luy s e f u li t ' s t r u c t u l aal b n o r n r a l i - h y c l r o c h l o r i d e . s r ' r r
gradually
inct'eascd
to
low
and
shoirld
be
the
dosage
may detcct atecl.
Voiding cystourethrography
Iiesaresuspccted.r')
surch
as
dry
adverse
et't.ects.
to
minimizc
level
therapeutic
hladclercliverticula,pelvic tloor relaxation,bladdertlutlet
hypoconfusion.orthc)stiltic
mouth,clry eyes.constipation,
urinaryretlux,or outletobstruction.
inconrpetence,
spccifiapproved
Although
not
and
tachycardia.
tension,
Imaging of the genitourinarytract by ultrasonography
niay be cloneto measureresidualblacldervolltmc whcn c a l l yt b r r - r sien i n c o n t i n e n c cea, l c i u mc h a n n cbl l o c k c r sh a v e
cannot be pertbrmedor to assesstor the b e e n s h o r v n t o b e u s e f u l i n t h e t r e a t t n e n to f d e t r u s o r
catheterization
in patientswith high rcsiclual overactivitybecauseof theirdirecteff'ecton smoothmuscle
presenceof hyclronephrosis
r
r
r c l a x a t i o n . tS5p e c i acl a r em u s tb e t a k e nw h c nt h e s cm e d i c a u r i n ev o l u m e s . r l
cltn tionsare used-especiallyin patientsrvhomay haveurrnary
Urologic Evaluation.-Most casesof incorttinencc
evaluatedby thc primary-carephysician.For outflow obstruction-becausethese drugs can precipitate
be el'f'ectively
oI
c e r t a i n p a t i e n t s ,h o w e v e r . a u r o l o g i s t ,g y n e c o l o g i s to. r urinaryretention.In patientswith a urinarytractinf.ection
postvoiding
restdual
a
obstruction.
of
outflow
(Table
symptoms
by a
2). Assessment
physratrist
shouldbe consulted
aspartof the evaluittion.
g yn c e o l o r i sw
t i t h l n i n t c r c sot r t r a i r t i n gi n i n c o n t i n c n emc i . i v urinevolumeshouldbe determined
with
stresslnconttnence
I
ncontinence.-Patients
Stress
be useful in women with prior bladdersuspensiotr
1lt'tlceanclurethralresisintemal
sphincter
tone
c l u r e s .p e l v i c f l o o r r e l a x a t i o n( f o r e x a m p l e ,c y s t o c e l e , have inadequate
rectocele,or uterineprolapse),or pelvic filasses.ln sot.ne
and
r c g i o n sp, h y s i a t r i s thsa v es p e c i a l i z eidn t h e e v a l u a t i o n
l'able 3.-Nledications Usei'ulfor Treating
lreatmentof Ul. especiallytn thosepatientswith functional
I)etrusor Overactivit-yor StressIncontinence
( ) rc L ) g n i t i vl iem i t a t i o n s .
TREATMENT OF INCONTINENCE
Most casesof UI can be eff'ectivelytreatedand the sympprescnti\
provideclthe type of incontinence
tomsalleviirted.
determined.
Drug
Dosage
Oryhutyninchloriclc
Flavoratehydrochloride
Imiprarrine hydrochloride
bromicle
Propantheline
5 rng 3-.1timcs/day
100-200mg 3-.1tirnes/dai
25-5t)mg2 3 times/day
7.5-l5 mg -l-:l times/da)
MayoClin Proc,January1996,Vol 7l
U R I N A R Y I N C O N T I N E N C EI N E L D E R L Y P E R S O N S
99
tanceto prevent loss of urine when bladder pressuretran- surgical candidates. a-Adrenergic antagonistssuch as
sientlyincreases.The goal in nonsurgicaltreatmentis to prazosin hydrochloride,terazosinhydrochloride,or doxazosinmesylatereduceintemal sphinctertone and can imincreaseinternalsphinctertone.
Pelvic floor exercises(for example,Kegel exercisesor prove the flow of urine. Theseagentsmust be used cauvaginalcones)can be effective in motivatedpatients.r6r8tiously in elderly patientsbecauseof their propensityto
Theseexercises strengthenboth the periurethral and the causeorthostatichypotension.Dosesshouldbe low initially
pelvicfloor muscles. They are easyto perform but must be and gradually increasedas tolerated. Finasteridemay dedonefrequentlythroughoutthe day and continuedfor long- creasethe size of the prostategland in some men such that
rermeffect. Patientscan identify the pelvic floor musclesby urinary flow will improve, althoughno immediateeffect
attemptinginterruptionof voiding or by digital palpation shouldbe anticipated.Its efficacyin the treatmentof UI is
duringcontraction. Most proponentsrecommend l0 to 20 unclear.
for 10 secondseach,3 timesa day.
Patientswith overflow incontinenceresultingfrom a hypelvicfloor contractions
Beneficialeffects may not be noted until theseexercises potonicor atonicbladdercan benefitfrom medicationswith
however,
havebeendone for 6 to 8 weeks. Reportedimprovementor cholinergicagonistactivity,suchas bethanechol;
curerateshavebeenas high asJJo/o.Theseresultscompare little evidencesuggeststhat long-termsuccesscan be exshouldbe adrninisfavorablyto treatmentwith medications.Continuedbenefit pected. For optimaleffect,bethanechol
depends tered20 minutesbeforevoiding is attempted.Postoperative
afterimprovementwith pelvic floor strengthening
onthepatient'smotivationand ability to continuepracticing patientsare the most likely to benefit from short-termuseof
this medication. Patientswith overflow incontinencecan
thepelvic floor exercises.
cr-Adrenergicagonists such as phenylpropanolamine also be instructedin assistivevoiding techniques(for exhydrochlorideand pseudoephedrine
increasethe internal ample,abdominalstrainor Cred6maneuver).
IntermitPatientswith overflow incontinencemay also be mansphinctertone and bladderoutflow resistance.3e
or indwelling
tentuseof thesemedications(for example,for plannedac- aged with intermittentself-catheterization
ln patientswho have new-onset
tivities)can be beneficial. These drugs should be used bladdercatheterization.a6
from a transienthypotonicor atonicbladder,as
cautiouslyin patientswith hypertension
or a historyof car- incontinence
in the
diac arrhythmias.
is occasionallynotedafter indwellingcatheterization
Estrogenreplacement
therapycan be helpful in improv- hospital,intermittentbladdercatheterizationshould be used
ing periurethraland vaginaltissuethicknessand quality.a0al until the bladdertonereturns.Initially, a cathetershouldbe
Topical,oral, or transdermalpreparationsof estrogenare all insertedevery 4 to 6 hours after a prompted or attempted
effective
. Topical homonal therapyis generallyadequate void in orderto keepthe bladdervolumeslessthan400 mL.
unlessother systemiceffectsaredesired.
Subsequently,the frequency of catheterizationsshould be
Severalsurgicalproceduresmay also prove helpful for basedon the residualurinevolumes.As theresidualvolume
stressincontinenceattributable
to pelvic relaxationor inter- of urine decreases,the frequencyof catheterizationsshould
nal sphincterinsufficiency.a2{3
In women. correctionof alsodecrease.
pelvicrelaxationand reestablishment
Intermittent self-catheterizationmay also be used for
of the normal urethrovesicalanglecan improveurinaryretention.The placement long-term managementof patients with overflow incontiof an artificialsphincter,
usuallyas a lastresort,may alsobe nencewho are cognitively intact and have adequatemanual
beneficialin femalepatientsor in men in whom complete dexterity.lT Most of thesepatientscan be taught safe selfsphincterinsufficiencyhas developed.{{5 Local collagen catheterization
techniqueswith clean catheters(sterility is
injectionshavealsobeenusedrecentlyin selectedpatientsto unnecessary).In the managementof nursinghome residents
h e l pa l l e v i a t eu r i n a r ys t r e s si n c o n t i n e n c e .
with long-term UI, intermittentcatheterizationby the nursof assoOverflov' Incontinence.-Patients with overflow in- ing staff is usuallyprohibitivelyexpensive(because
continencehave difficulty emptying their bladder;therefore, ciatednursingand supplycosts).
the goal of treatmentis to improve bladderdrainage. OccaLong-term, indwelling urinary catheterizationis indisionally,ne$,onsetof overflow incontinence
is precipitated catedfor patientswho are unableto empty their bladderand
by a neu' mc'tiication.anesthesia,or surgical procedure. have not respondedto other treatmentmeasures. Selected
Thesepatientsoften benefit from bladderdrainagefbr a few groups of patientssuch as the teminally ill or those for
days,after n,hichnormalbladderfunction resumes.Inconti- whom frequentcatheterizations
would be difficult or uncomnentpersonr.u'ith long-standing
obstructionto urinaryout- fortable may also benefit from indwelling catheterizalion.
flow and orc.r'flowincontinenceshould be consideredfor Extemal (condom) cathetersfor male patientscan also be
surgtcalconeetionunlessbladderatonyis evident. Pharma- helpful, aithough their use may be limited by improper fit,
cologic age:rrs.lte also availablefbr patientswho are not leakage,and skin initation or breakdolr'rt.
1
il
E
lOO
M a y o C l i n P r u c . , l a n u a r . r1 9 q 6 , V o l ? l
URINARY INCONTINENCE IN*ELDERLY PERSONS
$
\i
*
*
I
most patientswith incontinencewould benefit fiom assessment and appropriatetreatment,the majority do not seek
medical evaluation. Severaldifferent typesof incontinence
exist,and the history is usuallythe mostimportantpart of ths
evaluation.Only rarely areelaboratetestsnecessary.With a
combinationof behavioral,pharmacologic,and occasionally
canexperiencesubstantial
surgicaltrealments.mostPatients
improvement or cure of their symptoms of incontinence.
Most casesof UI can be evaluatedand treatedby the pripatlents.
should be conUI associatedwith delirium usually resolveswith treat- mary-care physician, although a specialist
ment of the underlyingcauseof the confusionalstate. Man- sultedfor selectedPatients.
agementof peripheraledemamay decreasenocturia and its
contributionto UI. Patientswith dementiamay benefit from
promptedvoiding, scheduledvoids, and attentionto behav- REFERENCES
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on Geriatrics,PartVll.
Endof Symposium
issue.
P a rV
t l l l w i l l a p P e airn the February