Urinary Incontinence in the Elderly

Ivan Merkelj, MD, Department of Geriatric Medicine and Gerontology, College of Medicine, East Tennessee State University, and the Extended Care and Geriatric Department, James H. Quillen VA Medical Center, Mountain Home, Tenn

South Med J. 2001;94(10) 

In This Article

Types And Causes of Urinary Incontinence

The causes of incontinence are multifactorial and may involve factors both within and outside the lower urinary tract. Urologic, gynecologic, neurologic, psychologic, environmental, and iatrogenic factors may all play a role. Several potentially reversible causes may contribute to transient as well as to chronic incontinence.

Many reversible or transient causes of UI can be identified, especially in persons who have incontinence de novo and those who have worsening severity of established incontinence. These transient causes of UI are from external processes that act on the urinary tract to precipitate incontinence. A simple mnemonic, DIAPPERS (Table 2), summarizes these causes.

The four basic types of chronic incontinence are Detrusor overactivity (urge) incontinence, stress incontinence, overflow incontinence, and functional incontinence.

Detrusor overactivity is the most common cause of UI in the elderly, occurring in 40% to 70% of those who present to the physician with complaints of incontinence. Patients with detrusor overactivity have early, forceful detrusor contractions, which occur well before the bladder is full. This creates its clinical hallmark "the abrupt sensation that urination is imminent, whether or not leakage ensues" and frequency. Patients with detrusor overactivity describe frequent losses of small to moderate volumes of urine. The PVR urine volume is typically normal (<51 mL). Detrusor overactivity can be found in conditions of defective central nervous system inhibition or increased afferent sensory stimulation from the bladder. Examples of disorders, which impair the ability of the brain to send inhibitory signals, include strokes, masses (tumor, aneurysm, hemorrhage), demyelinating disease (multiple sclerosis), Alzheimer's disease, and Parkinson's disease. Increased afferent stimulation from the bladder can result from lower urinary tract infections (cystitis), atrophic urethritis, fecal impaction, or uterine prolapse. Benign prostatic hyperplasia is a common cause of detrusor overactivity in men. It can also produce symptoms of urinary outflow obstruction. Impaired detrusor contractility alone is an uncommon cause of UI, though it occurs in patients with diabetic neuropathy, spinal stenosis, and spinal cord injury. It has been diagnosed in conjunction with detrusor overactivity in almost one third of nursing home patients. Patients with detrusor hyperactivity with impaired contractility experience urge symptoms, but the PVR urine volume is high (>100 mL).

Stress incontinence is the most common type in early postmenopausal and younger elderly women. Although this type of incontinence can occur in men, it is usually limited to those who have had internal sphincter damage from various urologic procedures. The hallmark symptom is leakage of urine simultaneous with increases in intra-abdominal pressure caused by coughing, sneezing, laughing, bending, or exercising. In women, the etiology of urinary stress incontinence is usually pelvic relaxation resulting from multiple childbirths combined with the aging process. Drug-related causes of stress incontinence can include alpha-adrenergic antagonists.

Overflow incontinence is observed in 7% to 11% of incontinent elderly individuals and is characterized by a reduction in the force and caliber of the urinary stream, incomplete micturition, and the sensation of incomplete voiding. The two main sources of overflow incontinence are outlet obstruction and bladder contractile dysfunction, both of which lead to an increase in bladder volume. In the former condition, a physical blockage causes obstruction of urine flow, commonly caused by benign prostatic hypertrophy, urogenital cancers, severe genitourinary prolapses, and fecalomas. Dysfunction in bladder contractility can result from diabetic or alcoholic neuropathy, sacral spinal cord lesions, or the use of medications with anticholinergic properties, such as neuroleptics, narcotics, certain tricyclic antidepressants, and muscle relaxants.

Functional incontinence is a term used to describe incontinence that is predominantly related to chronic impairments of cognitive function and/or mobility that interfere with independent toileting skills. It should be a diagnosis of exclusion.[6,7,8]

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