Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Unintentional loss of urine.
B.Types.
1.Stress urinary incontinence (SUI): Occurs during physical exertion (sneezing, coughing, exercise).
2.Urgency incontinence (UI): Involuntary loss of urine associated with urgency (bladder spasms).
3.Mixed urinary incontinence: Combination of SUI and UI.
4.Overflow incontinence (OI): Occurs with urinary retention or high post void residuals. The overdistended bladder leads to leakage.
5.Functional incontinence: Loss of urine due to deficits of cognition and mobility.
Incidence
A.Urinary incontinence has been reported to affect 12% to 43% of women and 3% to 11% of men.
B.Prevalence rapidly increases in both genders after the age of 70, but severe incontinence in men is reported at about half that in women.
Pathogenesis
A.SUI: Hypermobility of the urethra and/or intrinsic sphincter deficiencies.
1.Women: Related to the number of vaginal deliveries.
2.Men: Rare, unless history of prostatectomy, trauma, or neurological disorder.
B.UI: Detrusor muscle over-activity.
1.Detrusor myopathy.
2.Detrusor neuropathy.
C.OI: Overdistention of the bladder with subsequent leakage from either impaired detrusor contractility or bladder outlet obstruction.
1.Diabetes mellitus.
2.Lumbosacral nerve disease.
3.Multiple sclerosis.
4.Spinal cord injuries.
5.Prolapsed intervertebral discs.
6.Severe cases of bladder outflow obstruction.
Predisposing Factors
A.Sex (female > male).
B.Advanced age.
C.Vaginal childbirth.
D.Cognitive impairment.
E.Chronic obstructive pulmonary disease (COPD).
F.Obesity.
G.Pelvic organ prolapse.
H.Smoking.
I.Pregnancy.
J.Previous history of pelvic surgery (hysterectomy, prostatectomy) or pelvic radiation.
K.Poor mobility.
L.Neurological disorders.
M.Anatomical disorders (e.g., vesicovaginal fistula).
N.Certain medications (diuretics, narcotic pain medication).
O.History of pelvic trauma.
Subjective Data
A.Common complaints/symptoms.
1.SUI: Leakage of urine involuntarily when laughing, coughing, or sneezing.
2.UI: Uncontrollable urge to urinate with associated leakage; occurs frequently.
3.OI: Dribbling of urine, weak stream, and incomplete bladder emptying.
B.Common/typical scenario.
1.Onset of symptoms: Gradual versus sudden.
2.Associated pain with incontinence.
3.Severity: Minimal amount of leakage versus large amount of leakage and soaking through clothes.
4.Timing and frequency of the incontinence (after sneezing, only occurs at night).
5.Aggravating factors (e.g., caffeine, citrus).
6.Alleviating factors (pessary).
7.Risk factors (vaginal prolapse, recent urinary tract infection [UTI], benign prostatic hypertrophy [BPH], neurological disorders, trauma).
C.Family and social history.
1.Smoking.
a.Tobacco: Irritant to the bladder, causing UI.
b.Tobacco addiction: Possibly leading to a chronic cough and increased intra-abdominal pressure, damaging the muscles of the pelvic floor and resulting in SUI.
2.Alcohol: Diuretic affect/central nervous system (CNS) depressant causing OI and UI.
3.Illicit drugs: Abuse of prescription drugs such as opioids/sedatives causing OI or functional incontinence.
D.Review of systems.
1.Constitutional: Fevers, chills, and weight gain.
2.Neurological: Confusion, altered speech, altered mental status, lower extremity weakness, dizziness, tremors, decreased mobility, and paresthesia (saddle anesthesia).
3.Respiratory: Chronic cough and chronic bronchitis.
4.Cardiovascular: Shortness of breath or edema associated with congestive heart failure (CHF).
5.Abdominal: Constipation, obstipation, or reflux that causes cough.
6.Genitourinary: Frequency, urgency, hematuria, retention, incomplete bladder emptying, or suprapubic pain.
7.Gynecologic: Pelvic organ prolapse or leakage of urine from vagina.
8.Musculoskeletal: Lower back pain.
Physical Examination
A.Neurological.
1.Assess mental status, motor strength, and sensory status, as well as deep tendon reflexes.
2.Observe gait.
B.Respiratory: Assess for rhonchi and barrel chest.
C.Cardiovascular: Assess for JVD and edema.
D.Abdomen: Assess for suprapubic tenderness, palpable bladder, and abdominal/pelvic masses.
E.Genitourinary.
1.Perform digital rectal examination (DRE) to evaluate for BPH, prostatitis, and prostate nodules.
2.Evaluate for rectal fissures and/or fecal impaction.
F.Gynecologic.
1.Perform Q-tip test: Used to demonstrate urethral hypermobility, which may indicate SUI.
a.A sterile, well-lubricated Q-tip is placed into the urethra, and the patient is then told to cough or strain.
b.The degree of Q-tip movement is measured. The test is considered positive if the Q-tip moves more than 30°.
2.Evaluate for vaginal atrophy.
3.Evaluate for pelvic organ prolapse.
G.Dermatological: Assess for excoriated skin due to incontinence or presence of fungal infection.
Diagnostic Tests
A.Urinalysis and urine culture: Evaluate for infectious source.
B.Blood work: Basic metabolic panel to evaluate renal function, which may indicate obstructive source.
C.Imaging: Generally not indicated.
D.Urodynamic studies/video-urodynamic studies.
1.Filling study: Detrusor overactivity, leak point pressure.
2.Voiding study: Urinary flow rate, post void residual, detrusor sphincter synergy.
E.Cystoscopy: If there is concern for fistula or malignancy.
Differential Diagnosis
A.UTI (Cystitis, prostatitis).
B.Interstitial cystitis.
C.Nocturnal enuresis.
D.Urethral diverticulum.
E.Vesicovaginal fistula.
F.Cauda equina syndrome.
G.Constipation/obstipation.
H.Bladder cancer.
I.Bladder outlet obstruction.
Evaluation and Management Plan
A.General plan.
1.Obtain thorough history to determine type of urinary incontinence to target treatment.
2.Obtain laboratory studies such as urinalysis, urine culture, and basic metabolic panel.
3.If possible, obtain post void residual with bladder scan.
B.Patient/family teaching points.
1.Encourage smoking cessation and avoidance of alcohol/caffeine.
2.Encourage keeping a 24-hour voiding diary to help patients understand voiding patterns.
3.Educate patient about timed voiding, which will help avoid significant bladder distention.
4.Educate patients with SUI about how to perform Kegel exercises to strengthen pelvic floor muscles. Discuss the role of biofeedback in helping control these muscles.
5.Educate patients with UI about bladder training (delay voiding for increasing periods of time by inhibiting the desire to void).
6.Encourage weight loss in obese patients.
7.Teach patients with overflow incontinence about how to perform clean intermittent catheterization if necessary.
C.Pharmacotherapy.
1.SUI.
a.Currently, no Food and Drug Administration (FDA) approved medication for SUI.
b.Topical estrogen in post menopausal women: Mild benefit.
2.UI.
a.Anticholinergic medications: Act to inhibit bladder contractions and increase capacity.
i.Most common: Oxybutynin and tolterodine.
ii.Others: Trospium chloride, solifenacin, darifenacin, and fesoterodine.
b.Tricyclic antidepressants.
i.Direct relaxant effect on bladder muscle.
ii.Not commonly used due to side effects.
c.Beta 3-adrenergic receptor agonist (mirabegron): Associated with much less dry mouth and constipation (side effects of anticholinergic medications) but may cause hypertension.
D.Discharge instructions.
1.Discuss with the patient to call with side effects of medication such as dry mouth, constipation, confusion, or vision changes.
2.Instruct the patient to seek medical attention with any fevers, chills, flank pain, or hematuria, which may indicate UTI.
3.Advise the patient about appropriate care of the skin due to incontinence. Keep the skin clean and dry. Wearing pads may help to protect the skin.
4.Mention that stool softeners or mild laxatives may be needed to prevent constipation.
Follow-Up
A.Follow-up in 3 to 4 weeks for symptom assessment/response to therapy.
B.Biofeedback often requires multiple visits.
C.Instruct the patient to bring his or her voiding diary to follow-up appointment.
D.For patients on an anticholinergic, check post void residual to monitor for urinary retention.
Consultation/Referral
A.Refer to urologist/urogynecologist for persistent symptoms or concern for malignancy or anatomic abnormality.