Urinary Incontinence Flashcards
prevalence of UI
o The prevalence of UI increases with age
o Affects more women than men (2:1)
o Affects men & women equally after age 80
Impact of UI on older adults
o Morbidity
o Cellulitis, pressure ulcers, UTIs
o Sleep deprivation, falls with fractures, sexual dysfunction
o Depression, social withdrawal, impaired quality of life
o Costs: $26 billion annually
Continence requires
o Mobility
o Manual dexterity
o Cognitive ability to recognize and react to bladder sensation
o Motivation to stay dry
o Absence of medical conditions and factors affecting bladder and general function
o Balance and coordination of bladder smooth muscle & urethral sphincter mechanisms, and their central & peripheral control
Normal micturition
Bladder smooth muscle (detrusor)
-Contracts via parasympathetic nerves (S2–S4)
Urethral sphincter
- Proximal urethral smooth muscle contracts via sympathetic stimulation (T11–L2)
- Distal urethral striated muscle contracts via cholinergic somatic stimulation (S2–S4)
- In women: musculofascia supports and compresses the urethra when abdominal pressure increases
Central nervous system coordination:
- Parietal lobes & thalamus receive and coordinate detrusor afferent stimuli
- Frontal lobes & basal ganglia provide signals to inhibit voiding
- Pontine micturition center integrates these inputs to coordinate urethral & detrusor function
Urine storage is under sympathetic control
- Inhibits detrusor contraction
- Increases sphincter contraction
Voiding is under parasympathetic control
- Induces detrusor contraction
- Induces sphincter relaxation
Age related changes that may lead to UI
o Detrusor overactivity o Benign prostatic hyperplasia o More urine output later in the day → taking more Lasix later in the day, etc. o Atrophic vaginitis and urethritis o Increased postvoid residual (PVR) o Decreased ability to postpone voiding o Decreased total bladder capacity o Decreased detrusor contractility
UI: comorbid disease
- Diabetes – polyuria
- Congestive heart failure – Lasix is tx – polyuria
- Degenerative joint disease – too painful to walk to toilet
- Sleep apnea
- Severe constipation – whenever there’s constipation there’s an increase in intraabdominal pressure
UI: function and environment
- Impaired cognition
- Impaired mobility
- Inaccessible toilets
- Lack of caregivers
UI: neurological/psychiatric
- Stroke
- Parkinson’s disease
- Normal pressure hydrocephalus
- Dementias
- Depression
medications commonly associated with UI
o Alcohol o α-adrenergic agonists o α-adrenergic blockers o ACE inhibitors o Anticholinergics o Antidepressants o Antipsychotics o Calcium-channel blockers o Loop diuretics o Narcotic analgesics o NSAIDs o Sedative hypnotics o Thiazolidinediones
clinical types of UI
3 types
- Urge – testing procedure for urge is the STRESS test (yes, confusing)
- Stress
- Mixed
- Overflow: Outlet obstruction, Detrusor underactivity
- This is a spectrum – everyone here has had urge incontinence but not everyone has had stress incontinence (The spectrum is urge → stress → mixed)
urge incontinence
- Most common type of UI in older persons
- Signs and symptoms: Abrupt urgency, Frequency, Nocturia, Volume of leakage may be large or small
- Note: “Overactive bladder” refers to a condition with urgency, usually with frequency and nocturia, with or without UI
causes of urge incontinence
- Detrusor overactivity may be: Age-related, Idiopathic, Secondary to lesion in central inhibitory pathways (eg, stroke, cervical stenosis), Due to local bladder irritation (eg, bladder stones, infection, inflammation, tumors), Stress-related (occurs after a several-second delay following a stress maneuver)
- Less common causes: Interstitial cystitis, Spinal cord injury (Impaired detrusor compliance, Detrusor-sphincter dyssynergia)
- Urge incontinence triggered by stress related maneuvers
Stress incontinence
- Second most common type in older women
- Results from failure of sphincter mechanisms to preserve outlet closure during bladder filling – failure to close: Women do not have a prostate – the prostate acts as a secondary sphincter for men
- Occurs with increased intra-abdominal pressure, in the absence of a bladder contraction
- Often coexists with urge UI (mixed UI)
- Leakage is due to one or both mechanisms: Impaired pelvic supports (“Genuine” stress incontinence, Episodic leakage with increased abdominal pressure), Failure of urethral closure (Intrinsic sphincter deficiency from trauma; scarring from anti-incontinence surgery in women and prostatectomy in men, Continual leakage may occur while sitting or standing)
overflow incontinence
o Results from detrusor underactivity, bladder outlet obstruction, or both
o Leakage is small but continual; PVR is elevated
o Symptoms: dribbling, weak urinary stream, intermittency, hesitancy, frequency, nocturia
o Associated urge and stress leakage may occur
o Associated with bladder capacity, not control
outlet obstruction
o Second most common cause of UI in older men
o Most obstructed men are not incontinent
o Causes (men): BPH, prostate cancer, urethral stricture
o Uncommon in women; usually due to previous anti-UI surgery or large cystocele
detrusor underactivity
- Causes UI in 5%–10% of older adults
- Results from: Replacement of detrusor smooth muscle by fibrosis and connective tissue (eg, with chronic outlet obstruction), Neurologic causes (eg, peripheral neuropathy), Damage to spinal detrusor efferents (eg, from disc herniation, spinal stenosis, tumor)
Comprehensive assessment of UI includes
o History: including quality of life
o Physical examination: include cardiovascular, abdominal, musculoskeletal, neurologic, & genitourinary exams
o Testing: bladder diary, stress test, PVR, urinalysis, renal function
o Optional: urodynamics, cytology, other lab tests
Assessment: history
o Initiate discussion (50% do not report UI)
o Ask about specific symptoms: urgency (eg, with running water), frequency, nocturia, slow stream, terminal dribbling
o Determine UI characteristics: type (with urgency, stress maneuvers, insensate), onset, frequency, volume, timing, precipitants
o Identify associated factors: bowel & sexual function, medical conditions, medications
o Ask about quality of life: patient’s, caregiver’s
Assessment: physical
- General: cognitive and functional status
- Cardiovascular: volume overload, peripheral edema, congestive heart failure: Rales and edema
- Abdominal & rectal: masses, tenderness, rectal masses or impaction, rectal tone: Musculoskeletal: mobility, manual dexterity, Neurologic: cervical disease suggested by limited lateral rotation & lateral flexion, interossei wasting, Hoffmann’s or Babinski’s sign; lower extremity motor or sensory deficits, Genitourinary: Men: prostate consistency, masses; if uncircumcised, check for phimosis, paraphimosis, balanitis, Women: vaginal mucosa for atrophy, pelvic support, prolapse, Sacral reflexes (Anal wink, Bulbocavernosus reflex)
testing sacral reflexes
reflexes assesses the integrity of roots S2-S4, the site of the sacral micturition center and the original of the pelvic and pudendal nerves. To do the anal wink, instruct the patient to relax his/her perineum, then lightly scratch along the side of the rectum. You should see the anus contract (“the wink”). Repeat on the other side. False-negative results can be due to the patient’s failing to relax. If the anal wink is negative, then the bulbocavernosus reflex can be done as a backup. The stimulus for the BC is to lightly squeeze the clitoris in a woman or the glans penis in a man; you are looking for the same reflex anal contraction as in the anal wink. If the BC is negative, it can be double-checked by palpation: insert a finger in the patient’s rectum, repeat the BC stimulus, and assess for anal contraction.
Assessing pelvic floor support in women
- assessed by using only the bottom blade of the speculum. First, insert the bottom blade and pull it down slightly to support the posterior vaginal wall. This will give you a good view of the urethra and anterior vaginal wall. Have the patient cough or strain.
- anterior vaginal wall prolapses into and through the vaginal introitus; this is a cystocele. Also note a small violaceous nodule at the urethral meatus—this is a urethral caruncle, a benign finding associated with vaginal atrophy. Note that the bottom of the tissues supporting the urethra are flat, and almost an inverted “U”; in women with intact pelvic support, these tissues would in fact be “U” shaped, and analogous to the musculofascial “hammock” that provides urethral support.
assess posterior vaginal wall
turn the single speculum blade around and use it to support the anterior wall. Again have the patient cough or strain. In the right-side photo, note bulging of the posterior wall, again just through the introitus. This is an example of a rectocele.
bladder diary
o Have patient keep record for least 2 days (3 preferable)
o For downloadable bladder diaries and other tools, see:
o A receptacle placed in the toilet (“hat”) can help patients gauge the amount voided
o In cases of leakage, have them estimate the amount (drops, tablespoon, soaked pad, soaked through clothes)
clinical stress test
o For women and post-prostatectomy men
o Best if bladder is full, patient relaxes perineum, and single vigorous cough is used
o Specific for stress incontinence if leakage is instantaneous with cough
o Insensitive if patient cannot cooperate, is inhibited, or if bladder volume is low
o Several-second delay before leakage suggests stress-induced detrusor overactivity
