Year : 2020 | Volume
: 18 | Issue : 3 | Page : 240--244
Primary care approach to urinary incontinence in the elderly
Department of General Medicine, G. Kuppuswamy Naidu Memorial hospital, Coimbatore, Tamil Nadu, India
Dr. Alka Ganesh
Department of General Medicine, G. Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu
Urinary incontinence, which is the involuntary leakage of urine, is very common in the elderly. Temporally, incontinence can appear suddenly (transient), or be chronic in nature (established). Transient incontinence is usually due to the appearance of a new identifiable problem, the causes are embodied in the mnemonic DIAPPERS: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excessive urine, Restricted mobility, Stool impaction. Established Incontinence is one that persists even after correction of precipitating factors, or, lack of identifiable factors. The types are: stress, urge, and overflow, mixed, and functional. Stress incontinence: A weakened pelvic floor in females, leads to prolapsed pelvic organs, causing sphincter dysfunction. The role of pelvic floor exercises (Kegels exercises) and newer surgical interventions is discussed. Urge incontinence: The disturbance in cortical control of the pontine centers of micturition is highlighted. The use of anti-muscarinic agents, sympathetic receptor blockers, and agonists is explained. Overflow incontinence: The role of removing obstruction to urine flow, or catheterization in atonic bladders is discussed.
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Ganesh A. Primary care approach to urinary incontinence in the elderly.Curr Med Issues 2020;18:240-244
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Ganesh A. Primary care approach to urinary incontinence in the elderly. Curr Med Issues [serial online] 2020 [cited 2020 Dec 2 ];18:240-244
Available from: https://www.cmijournal.org/text.asp?2020/18/3/240/289409
Urinary incontinence is defined as the involuntary leakage of urine, which causes inconvenience and embarrassment to the patient. It is a common problem in the elderly, particularly in women, and the prevalence rises with aging. It causes great social discomfort as well as a detriment in health status. Yet, older patients often fail to mention it to the doctor for fear of embarrassment, or because they have been told that it is a burden of aging, and that no remedies are available. This is far from the truth in most cases. A great deal can be done by the general practitioner. Routinely asking every older person about incontinence, even when they seek consultation for an unrelated problem, is advisable. Having ascertained the presence of incontinence, a focused clinical evaluation, and a few laboratory tests will aid in the diagnosis of the type of incontinence. Relevant therapy, and encouraging a coping strategy, can go a long way in alleviating this socially restrictive problem.
Types of Urinary Incontinence in the Older Person
Urinary incontinence can be classified by the temporal profile of its onset: (a) of recent onset or (b) of a chronic nature. Recent sudden onset is often related to an identifiable correctable cause and is, therefore, also known as transient incontinence. The more chronic form is called established incontinence and is due to intrinsic disease in the structures involved in the voiding process.
The following problems can lead to the abrupt onset of incontinence, in a previously continent person, or sudden worsening in a person with milder degrees of urinary leakage. The causes are numerous and can be best remembered by the time-honored appropriately-coined mnemonic “DIAPPERS.”
D: Delirium/dementia; I: Infection; A: Atrophic vaginitis; P: Pharmaceuticals; P: Psychological; E: Excessive urine (polyuria); R: Restricted mobility; S: Stool impaction.
Clinical evaluation and management of transient incontinence
Given these causes of transient incontinence, how does one go about identifying the causes when confronted with a patient who was previously continent and is now leaking urine?
The first step is to exclude a urinary tract infection by routine microscopy, and if there are >10 pus cells, urine culture and starting antibiotics are prudent, especially if there are classical symptoms of frequency, dysuria, and suprapubic pain.
Polyuria has to be ascertained and can be presumed in cases of uncontrolled diabetes and in those instances where a diuretic has been recently prescribed. Sometimes, excessive intake of fluids may be responsible, especially when naturopathy and other alternative medicine systems advocate “plenty of fluids” as a panacea for many unrelated symptoms.
Elderly persons are likely to go into delirium with any acute infection, stroke, dyselectrolytemia, or the start of a new drug. Delirium can be accompanied by incontinence. Hence if the patient appears agitated, confused, disorientated, and with poor attention span then efforts should be made to find out the precipitating factor, and appropriate treatment of the delirium will reverse the incontinence. Referral to a geriatrician or internal medicine specialist with experience in elder care can be extremely beneficial in quickly sorting out the precipitating cause.
The impacted stool is a common cause of urinary incontinence in the frail bedridden elderly. A digital rectal examination and stool disimpaction can relieve the problem. Constipation and stool impaction should be prevented in the first place by use of laxatives, hydration, and mobilization to the extent possible. It should be remembered that fecal impaction is sometimes confused as diarrhea, wherein the patient is noted to be constantly passing small quantities of semi-solid stool. This is known as spurious diarrhea and can be reliably ascertained by a digital rectal examination.
Atrophic vaginitis, though chronic in nature, can present acutely. The patient may have symptoms of local itching, dryness, frequency, dysuria, dyspareunia, malodorous discharge, without pus cells on microscopy. External genitalia examination will reveal small introitus, pale, smooth and shiny mucosa with atrophic labia, erythema, petechiae, and increased friability may be noted.
The treatment is by local vaginal estrogen cream application, taking care to avoid in patients with breast or genital cancer. Two methods of local vaginal estrogen have been advocated; (a) cyclical daily for 3 weeks, then the gap of 1 week. (b) intermittent treatment twice weekly. Both forms can be given up to 1 year and then reassessed.
The hormones available in India are:
Premarin vaginal cream, which contains conjugated estrogen 0.625 mg/doseEvalon vaginal cream 0.1% estriol.
Thickening and normal vaginal secretions start to appear in 3–4 weeks with marked improvement in symptoms.
An elderly person who is immobilized due to pain, acute illness, or surgery can develop incontinence. Early mobilization, and increased fluid intake, will reverse the problem.
Psychological factors such as anxiety and depression can be complicated by urinary incontinence. In the absence of recognizable factors mentioned above, one should look for insomnia, anorexia, low mood, irritability, worthlessness, feelings of guilt, and suicidal ideation. These may lead to a diagnosis of anxiety/depression, which could respond to appropriate drug treatment.
It is wise to take a complete drug inventory and stop those drugs, which may contribute to incontinence. Common offenders are alpha-adrenergic agents (prazosin, tamsulosin, etc.), diuretics, sedatives, alcohol, tricyclics, antihistamines, and calcium channel blockers.
After exclusion of all precipitating factors for incontinence, many patients have persistent problems of involuntary, socially unacceptable, leakage of urine. A careful history and a few investigations will help to identify the five types of incontinence:
StressUrgeOverflowMixed urge and stressFunctional.
The pelvic organs are kept in proper anatomical relationship to each other by the pelvic floor. This comprises of the levator ani muscles and its attachments from the pubic bone anteriorly to the sacrococcygeal vertebrae posteriorly. Along with this, the endopelvic fascia and associated ligaments form a hammock-like sling preventing descent of the organs during straining or any maneuver which increases intra-abdominal pressure. Weakening of the pelvic floor muscles is common in the aging female and results in descent of the pelvic organs giving rise to stress incontinence.
The patient will describe the loss of small quantities of urine whenever she coughs, sneezes, or gets up from the floor or low chair. This rarely occurs in men, except after prostatic surgery, trauma, or neurological pelvic disease.
Stress incontinence is confirmed in doubtful cases by observing a spurt of urine when a woman in the erect position leaks a small volume of urine immediately and transiently after coughing. If the leak is prolonged and delayed, then additional bladder over-activity (urge incontinence) may be associated.
This is the most common form of urinary incontinence. Hospital-based Indian studies have shown 73% of urinary incontinence in females is due to stress type.
Stress leak is managed by a hierarchy of treatments:
Lifestyle changes: Avoiding heavy lifting, weight reduction, and prevention of straining at stool, and treatment of persistent cough if presentPelvic floor exercises (Kegels exercises). There is evidence to show that clinical improvement is significant when there is no sphincteric component to the leak. Kegels exercises can be taught by the physician and reinforced by physiotherapists. They consist of contraction of the glutei and pelvic muscles as if one is trying to stop the flow of urine. The contraction is to be maintained for a few seconds and then slowly released. This must be repeated at least ten times a session, with at least three sessions/day. The patient can be instructed to do these in any position but should be cautioned not to do these during the act of micturitionMechanical support: If there is uterine prolapse, then pushing it upwards into the pelvis will also pull up the bladder neck. This can be done by the use of ring pessaries by referral to the gynecologist. Pessaries require changing every 2–3 months and are quite effective in some patients.
Surgical repair: A variety of surgical procedures are available. The time-honored surgical procedure performed by gynecologists is colposuspension. The anterior vaginal wall is pulled up and tethered to the anterior abdominal wall thus raising the bladder neck and preventing leakage of urine. Colposuspension, being an invasive procedure, can now be supplanted by a variety of urethral sling operations. The current widely used procedure is the tension-free transvaginal tape procedure which has shown long-term cure rates and can be done in a daycare setting
Drug management with duloxetine etc., has been tried but is currently controversial and inadvisable in the primary care setting.
Involuntary voiding which is immediately preceded by an urgent desire to void, in the absence of infection, is termed as urge incontinence. This is said to affect almost 30% of elderly. The term overactive bladder is interchangeably used to describe this problem. A review of the physiology of micturition is helpful in understanding urge incontinence.
Neural control of the bladder
The lower motor neuron pathway:
The bladder can empty automatically by the sequential action of the autonomic nerves.
Sympathetic nerves from spinal segments L3 to L5, synapse with β3 adrenergic receptors on the detrusor muscles and the internal sphincter. Stimulation causes detrusor muscle relaxation and sphincter contraction. During the resting state, sympathetic nerves are tonically stimulatedParasympathetic supply comes from S2 to S4 segments of the spinal cord and synapse on the μ3 muscarinic receptors on the detrusor; stimulation causes detrusor contraction and relaxation of the internal sphincter, resulting in the act of voidingSomatic fibers from S2 to S3 segments innervate the external sphincter of the bladder via the pudendal nerve and are under voluntary control.
The upper motor neuron pathway:
The act of micturition in the adult is under voluntary control. Once the bladder gets distended, impulses reach the pontine centers (pontine micturition center) and the midbrain (peri-aqueductal gray). They then “switch on “the micturition “order” resulting in voiding, by stimulation of the parasympathetic fibers. These two brain stem centers can be over-ridden by conscious control from the cortex, mainly the prefrontal lobe and cingulate gyrus. These cortical centers keep the pontine centers suppressed; this is relaxed only when it is convenient to void urine
Aging process weakens the cortical suppression of the pontine centers. In patients with Parkinson's disease, stroke, delirium, and dementia, the cortical control is further reduced, leading to disabling urgency and incontinence due to an overactive bladder.
Diagnosis of urge incontinence is suspected from the characteristic history and a normal urinalysis. However, an alternative diagnosis has to be considered if there is hematuria, dysuria, dyspareunia, pain, or prolapse of pelvic organs.
Bladder diary can be informative. The patient keeps a record of the volume of every void and the time of void. In typical urge incontinence, the patient will void every 1–3 h, with volumes ranging from 50 to 200 ml.
Canadian Urological Association guidelines for management are:
First line: Behavioral:
Diet: This involves a “bladder diet” which includes decrease in caffeine, stopping smokingBladder training: The patient tries to delay micturition with the goals of increasing the time interval between voidsPelvic floor exercises.
Second line: Pharmacological: (a) anticholinergics, selective μ2 and μ3 receptor antagonists. The currently used drugs in order of availability and costs are oxybutynin, tolterodine, darifenacin, and solifenacin. The latter drugs are more selective and have less anticholinergic side effects of mouth dryness, blurred vision, etc., (b) The second group of drugs is β3 agonists, which stimulate the sympathetic fibers and cause further detrusor relaxation. The drug in common usage is mirabegron and can be prescribed for those who have side effects with anticholinergic drugs
A combination of μ3 antagonists and β3 agonists has been shown to have additive effects.
Neuromodulation: In refractory cases, sacral nerves are stimulated by a device in the buttock region, which delivers impulses to the sacral nerves. Alternatively, the posterior tibial nerve is stimulated at the ankles (fibers from this nerve supply the bladder) are stimulated in several sessionsBotlinium toxin A is injected in the bladder walls causing partial paralysis of the detrusor. However, this may cause urinary retention, and patient would then have to self-catheterize.
This refers to patients who have urine leakage with coughing and sneezing, and also experience sudden urge to void without these activities. Treatment should focus on drugs for urge incontinence as well as pelvic floor exercises, failing which specialist intervention for possible surgical management of stress leak can be addressed.
When there is an outflow obstruction as in prostatic enlargement, the bladder is unable to completely empty and gradually becomes over-distended. At this point, the pressure within the bladder exceeds the pressure in the urethra, resulting in dribbling of urine. Often, the bladder is palpable even after the patient has voided, provided the patient is not obese. This can be confirmed by ultrasonography where the postvoid residue exceeds 75 ml and can be as high as 250 ml.
Sometimes, a similar situation develops without obstruction to the flow of urine. The detrusor can become less contractile when the parasympathetic fibers are damaged, as occurs in diabetic neuropathy. The bladder continues to distend, there is the poor sensation of bladder fullness, and even after attempted voiding, a large volume is retained.
Patients with overflow incontinence need a referral to the urologist who would advise surgical resection of the prostate, or, catheterization, as appropriate.
This refers to a patient who leaks urine solely or partly due to factors outside the urinary tract. The presence of poor mobility due to co-morbidities such as osteoarthritis, Parkinsons' disease, or heart failure may make it difficult to reach the toilet in time. These problems may be compounded by urgency. Recognition and suitable advice to improve access to the toilet (such as the provision of a bedside commode or urinal) can improve quality of life. Recognition and amelioration of polyuria, and other factors outlined under the mnemonic “DIAPPERS” would also improve continence in these patients.
Practice Case Scenario
The following scenario occurs commonly in the elderly and will help to illustrate the multi-factorial pathogenesis in the elderly patient with incontinence. An 80-year-old male with Parkinsons' disease and poorly controlled diabetes (HBA1c of 10%), has difficulty with incontinence at night for 6 months. A year ago, he was seen by an urologist for poor urinary flow, moderately enlarged prostate, with no significant residual urine, and was asked to restrict fluid intake after 6 pm. He was also prescribed tamsulosin, an alpha-blocker.
On examination, you note that his mobility is poor due to rigidity and osteoarthritis of the knees.
How can this man be helped?
The several points at which the incontinence can be tackled are as follows:
Diabetic control can be improved, thus decreasing polyuria. The caveat here is that too strict a control with resultant hypoglycemia would be more dangerous in the older personAnti-Parkinsons' drugs can be reviewed to see if changes in timings, dosages or formulation (controlled release/addition of escapone) of levodopa will improve mobility. A neurology specialist opinion is warranted in some patientsUrology consultation to enquire if Tamsulosin could be withdrawn as it is an α-blocker and would add to incontinence. However, inappropriate withdrawal may lead to urinary retentionPhysiotherapy, analgesics, and use of walking devices to improve mobility due to osteoarthritis. The provision of a bedside urinal or commode could be usefulAs a last resort, self-sealing condoms (Coloplast) are helpful in the male, while a diaper is suitable to improve quality of life in a woman. Continous bladder may have to be done with care to avoid recurrent catheter-associated infections.
This case highlights one of the underpinnings of eldercare; small changes in several problems can have a synergistic improvement in patient well-being without an actual cure. “What cannot be cured, must be endured.”
It also shows how consultations with specialists for specific focused issues may be very useful.
Urinary leakage in the older person is a common symptom causing markedly decreased quality of life. It is under-reported and hence often left untreated. Clinical history taking, and simple focused examination, can help to delineate the pathophysiology and a clinical classification can be arrived at. Treatment guidelines for each type of incontinence have been formulated and adherence to these will be of benefit. Specialist referral to the urologist or gynecologist is required in some cases. With the help of a team of nurse and physiotherapist, most patients can be helped to become dry.
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Conflicts of interest
There are no conflicts of interest.
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