Urinary incontinence

CHAPTER 31 Urinary incontinence


Urinary incontinence is any involuntary loss of urine. It occurs as a result of pathological, anatomical, psychological, or physiological factors that produce obstruction, bladder irritability, or interference with neurological functioning. Environmental factors, such as decreased mobility or inaccessibility of toilet facilities, may also produce periodic incontinence.


Urinary incontinence is a common problem, particularly in older adults. It is so common in older women that some think of it as “normal.” The prevalence in U.S. women is 26% during reproductive years and 30% to 40% in postmenopausal years. In noninstitutionalized elderly women, the prevalence is 15% to 30%, and in men it is 8% to 22%. In elderly persons in nursing homes, the rate rises to almost 50%.


Urinary incontinence in adults is categorized according to the underlying anatomical or physiological impairment—specifically, stress incontinence, urge incontinence (overactive bladder), overflow incontinence, and incontinence from reversible causes.


Stress incontinence is leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, laughing, or other physical activities. It occurs most often in females and is caused by hypermotility at the base of the bladder and urethra associated with pelvic floor relaxation or intrinsic urethral weakness.


Urge incontinence is an abrupt and strong desire to void with the inability to delay urination and is caused by bladder hyperactivity or hypersensitive bladder. Detrusor muscle overactivity occurs when pathological brain disorders interfere with central inhibitory centers and fail to prevent detrusor muscle contractions.


Overflow incontinence occurs with overdistention of the bladder caused by an underactive or acontractile detrusor muscle; by sphincter-detrusor dyssynergia, which is loss of the synergistic urinary sphincter relaxation that normally occurs with bladder detrusor muscle contraction; or from bladder outlet or urethral obstruction. Sphincter weakness can occur from damage to the urethra or its innervation or from pelvic floor muscle relaxation.


Incontinence from reversible factors originates outside of the lower urinary tract and is caused by mental status impairment, immobility, or medication. Some sources term this functional or transient incontinence.


A final category of incontinence is called mixed incontinence. This occurs when the incontinence is produced as the result of several anatomical, physiological, or functional factors. Involuntary discharge of urine in children is abnormal beyond the age of 4 years for daytime wetting and beyond the age of 6 for nighttime wetting. Daytime wetting constitutes diurnal enuresis; nighttime wetting is known as nocturnal or sleep enuresis. In children, enuresis may be organic or nonorganic; nonorganic enuresis can be primary or secondary. Primary nonorganic enuresis occurs in 75% to 90% of children. This enuresis is defined as wetting that has continued since infancy without an established pattern of dryness. Secondary nonorganic enuresis occurs in 10% to 25% of children and is defined as recurrence of wetting after continence has been established for at least 6 months. The possibility of abnormal urinary anatomy is high in young children who present with urinary tract symptoms.



Diagnostic reasoning: focused history



Adults





Could this be the result of reversible factors (see box 31-1)?



Key questions




image What medications are you taking?


image Do you have any of the following urinary symptoms: urgency, frequency, burning, pain, blood in the urine, flank pain?


image Do you have vaginal dryness or itching?


image Do you have pain/discomfort with sexual activity?


image Have you had changes in bowel function?


image When was your last bowel movement?


image Are you feeling depressed or “blue”?


image Are you aware of incontinence?


image How active are you?


image Are you able to get to the toilet easily?


image Do you have any chronic health problems?



Box 31-1 Reversible Factors that Can Cause Urinary Incontinence in Adults


























D Delirium, dementia, depression
I Infection
A Atrophic vaginitis/urethritis
P Pharmaceuticals
E Endocrine/excess urine production
R Restricted mobility, retention
S Stool impaction

Modified from Resnick NM: Initial evaluation of the incontinent patient, J Am Geriatr Soc 38:311, 1990.



Medications


Hypnotic-sedatives, diuretics, anticholinergic agents, adrenergic agents, and calcium channel blockers can cause incontinence. α-Adrenergic agonists and β-adrenergic agonists increase sphincter tone and may cause retention. Anticholinergics, prostaglandin inhibitors, calcium channel blockers, and narcotic analgesics decrease detrusor tone. Diuretics can cause incontinence because of increased production of urine. Central nervous system (CNS) depressants, such as hypnotic-sedatives, can interfere with functional ability.


Table 31-1 lists categories of medications and their mechanism of action in urinary incontinence.


Table 31-1 Medications that Can Cause or Contribute to Urinary Incontinence



































































MEDICATION CATEGORY TYPE OF INCONTINENCE MECHANISM OF ACTION
Anticholinergics Overflow Decreased bladder contractions with retention
Antidepressants Overflow Decreased bladder contractions with retention
Antipsychotics Overflow Decreased bladder contractions with retention
Sedative-hypnotics Overflow Decreased bladder contractions with retention
Antihistamines Overflow Decreased bladder contractions with retention
Narcotics Overflow Decreased bladder contractions with retention
Alcohol Overflow Decreased bladder contractions with retention
Calcium channel blockers Overflow Decreased bladder contractions with retention
β-Adrenergic agonists Overflow Decreased bladder contractions with retention
α-Adrenergic agonists Overflow Sphincter contraction with outflow obstruction
α-Adrenergic antagonists Stress Sphincter relaxation with urinary leakage
Diuretics Urge Contractions stimulated by high urine flow
Caffeine Urge Diuretic effect
Sedative-hypnotics Urge Depressed CNS inhibition of micturition
Alcohol Urge Diuretic effect and depressed CNS inhibition

Adapted from Weiss BD: Diagnostic evaluation of urinary incontinence in geriatric patients, Am Fam Physician 57:2675, 2688, 1998.



Urinary tract infection, vaginal dryness, and dyspareunia


Urinary tract infection (UTI) and atrophic vaginitis can cause incontinence through local irritation and loss of muscle tone.



Bowel function


Fecal impaction can cause incontinence through mechanical obstruction of the urethra.



Mental status, mobility, and chronic health problems


Excessive urine production may be a problem if mobility is restricted, health is poor, or orientation is variable. Chronic health problems, psychological factors, and restricted mobility can result in incontinence because of loss of functional ability and/or mentation.





What do the presenting symptoms tell me?



Key questions



image What is the primary symptom (e.g., urgency; dribbling; lack of sensation; nocturia; abdominal discomfort; leakage with laughing, coughing, or sneezing)?


image How frequently do you urinate?


image How much urine is voided each time?


image Do you have difficulty starting to urinate?


image Does your urine stream start and stop while you are urinating?



Primary symptom


Urgency is the primary symptom of detrusor instability. Dribbling indicates overflow incontinence, and sphincter weakness usually increases with postural changes. Men often report nocturia and dribbling with overflow incontinence. Abdominal discomfort often occurs with overflow incontinence because of bladder distention. Incontinence with an increase in intraabdominal pressure is usually stress incontinence but can also be the result of detrusor overactivity and bladder irritability.



Frequency of voiding


Increase in frequency of voiding occurs with detrusor instability or hyperactivity and may occur with some transient causes such as use of diuretics or large-volume fluid intake. Decreased frequency is common in overflow incontinence.



Amount of urine lost with each episode


Involuntary loss of small amounts of urine occurs with stress incontinence and overflow incontinence.



Character of stream


Voiding a small-caliber or intermittent stream or difficulty in starting the stream indicates obstructive uropathy. In males, this may be secondary to an enlarged prostate.





Are there any other symptoms that will point me in the right direction?



Key questions



image How much fluid do you drink in a day?


image How much caffeine and alcohol do you drink?


image What time of day do you drink fluids?


image How thirsty are you?


image Have you lost or gained weight recently?



Fluid intake


A significant increase in the amount of fluid intake or an unusually large volume may indicate diabetes mellitus (DM). Caffeine and alcohol can act as diuretics and may be a cause of reversible incontinence. Caffeine can also be a bladder irritant and either produce or exacerbate urge incontinence. A large volume of fluid intake may produce enuresis secondary to a large urine volume, particularly if fluids are consumed in the evening before bedtime.



Thirst


Unusual thirst accompanied by an unusually large intake of fluid may indicate DM.



Weight loss or gain


Weight loss may indicate a chronic health problem, tumor, or dementia. Weight gain may indicate congestive heart failure, DM, or loss of mobility.



Children





Is this primary or secondary enuresis?



Key question




image Has the child ever had consistent dryness for at least 6 months?


Primary enuresis occurs when a child has never achieved consistent dryness. Secondary enuresis is involuntary voiding of urine in a child who has had a period of dryness of more than 6 months. Secondary enuresis is often indicative of some other form of voiding dysfunction or significant underlying pathology. In children, daytime urinary incontinence beyond the age of 4 years may indicate congenital abnormalities in the urinary tract or nervous system.





Is this organic enuresis?



Key questions




image Does the child have pain on urination?


image Does the child have intermittent daytime wetness?


image Does the child seem thirsty and urinate a lot?


image Has the child had nervous system trauma?


image Does the child have constipation or encopresis?


image Does the child have constant wetness or dribbling throughout the day?


image Does the child have an abnormal stream, such as dribbling or hesitancy?


image Has the child had a change in gait?


image Has the child had a recent lumbar puncture?


image Does the child snore or have apnea at night?


image Does the child report rectal itching at night?

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Apr 10, 2017 | Posted by in NURSING | Comments Off on Urinary incontinence

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