Urinary Incontinence

Author: Shannon Pearce, DNP, APRN, Jennifer Larson, MSE, Kathleen Pace Murphy, PhD MS, GNP-BC

Overview

One of the greatest aging myths is that urinary incontinence (UI) is part of normal aging, when, in fact, it is not. UI is defined as the involuntary passage of urine. Older adults are often embarrassed by this problem and are reluctant to discuss this issue with their clinician.

The diagnosis and management of UI can be successfully achieved in the primary care setting and in consultation with an urologist (surgical interventions). It is highly treatable and even curable in many instances (Pompei & Murphy, 2006).

The two main UI etiologies are transient and established incontinence.

Transient incontinence (often reversible) etiologies can be summarized using the DIAPPERS Mnemonic.

Reversible Causes of Urinary Incontinence (DIAPPERS)

Delirium 

Infection (UTI) 

A
tropic 

Pharmacological 

Psychological 

Endocrine/excess urine output 

Restricted Mobility 

Stool Impaction

Reference: Danforth, Townsend, Lifford et al. (2006), DuBeau, Kuchel, Johnson et al, (2010), & Sampselle, Harlow, Skurnick, et al. (2002).

Established incontinence is caused by a persistent problem affecting nerves or muscles.

There are five types of incontinence:

 

Key Points

UI is NOT a normal aspect of aging.

There is a large prevalence variation of 8-72% in community based older adults (Zurcher, Saxer, & Schwendiamann, 2011).

UI is greater in women compared to men 80 years of age or younger; prevalence is equal in both genders after 80 years (Minassian, Stewart, & Wood, 2008); Markland, Goode, Redden et al. 2010).

Approximately 35-42% of hospitalized adults are affected by UI (Ko, Lin, Salmon & Bron, 2005).

UI in older adults is treatable and often curable.

 

Assessment

Under-reporting of UI is common in older adults. UI screening is an effective method to elicit this information. The following questions will help your assessment process (DeMaagd & Davenport, 2012):

 

Management

Successful UI management requires a stepwise approach

Step 1: Functional Management –Use assistive devices (urinals & bedside commode), medication review, eliminate environmental barriers in the path to the toilet, initiate timed voiding schedules (useful in cognitively/physically disabled patient).

Step 2: Hospitalized Older Adults - Complete a continence assessment early in the hospitalization process. Avoid unnecessary indwelling catheters and remove indwelling catheters as soon as possible. Involve interprofessional team members to assess the older adults’ functional abilities (physical & occupational therapy), home visit (nurse and social work assess home for safety and home health needs), and pharmacist (medication review to determine untoward side effects of medications that may be contributing to the older adults UI).

Step 3: Take a thorough history and implement behavioral strategies. Poor hydration causes bladder spasms & increases incidence. Obesity is well cited in the literature to increase urinary incontinence. If weight is an issue, think about a weight management program. Avoiding caffeine can reduce urine leakage 63% (Tomlinson et al., 1999). Other dietary modifications include avoiding alcohol, citrus and spicy foods (Wyman, 2000).

Step 4: Pharmacologic options are available based on the type of the diagnosed UI.

Step 5: Invasive non-surgical management includes Kegel exercises, life style modifications (smoking cessation, fluid restrictions, caffeine reduction, and alcohol reduction), intravaginal weighted cones, pessaries, pelvic floor electrical stimulation, sacral nerve stimulation, and biofeedback.

Step 6: Surgical interventions are also available. Surgical procedures will be determined based on the type of UI but include: sling procedures, other urethral suspension techniques (suprapubic arc, transobturator, and colposuspension [Burch] procedure).

 

References

Alhasso, M. & N'Dow, G. (2008). Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults (Review). The Cochrane Collaboration, 3, 1-54. 

Danforth, K.N., Townsend, M.K., Lifford, K., et al. (2006). Risk factors for urinary incontinence among middle-aged women. American Journal of Obstetrics and Gynecology, 194(2): 339-345. 

DeMaagd, G.A. & Davenport, T.C. (2012) Management of urinary incontinence. Pharmacy and Therapeutics 37(6), 361B-361H. 

DuBeau, C.E., Kuchel, G.A., Johnson, T., et al. (2010). Incontinence in the frail elderly: Report from the 4th International Consultation on Incontinence. Neurological Urodynamics, 29 (1): 165-178. 

Ko, Y., Lin, S.J., Salmon, W., & Bron M.S. (2005) The impact of urinary incontinence on quality of life in the elderly. American Journal of Managed Care, 11(4): S103-S111. 

Markland, A.D., Goode, P.S., Redden, D.T., et al. (2010). Prevalence of urinary incontinence in men: Results from the national health and nutrition examination survey. Journal of Urology, 84 (3): 1022-1027. 

Minassian, V.A., Stewart, W.F., Wood, G.C. (2008). Urinary incontinence in women: Variation in prevalence estimates and risk factors. Obstetrics and Gynecology, 111(2Part1): 324-331. 

Pompei, P., Murphy, J. (Eds.). (2006). Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, (6th Ed.). New York, NY: American Geriatrics Society. 

Sampselle, C.M., Harlow, S.D., Skurnick, J., et al. (2002). Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstetrics and Gynecology, 100(6): 1230-1238. 

Tomlinson, B.U., Dougherty, M.C., Pendergast, J.F., Boyington, A.R., Coffman, M.A., & Pickens, S.M. (1999). Dietary caffeine, fluid intake and urinary incontinence in older rural women. International Urogynecology, 10, 22-28. 

Wyman, J.F. (2000). Management of urinary incontinence in adult ambulatory care populations. In: Fitzpatrick, J.F., Geoppinger, J. (eds.). Annual review of nursing research (vol. 18, pp.171-195). New York, NY: Springer-Verlag. 

Zurcher, S., Saxer, S., & Schwendimann, R. (2011). Urinary incontinence in hospitalized elderly patients: Do nurses recognize and manage the problem? Nursing Research and Practice, 2011. Article ID 671302, doi:10.1155.2911.671302, http://dx.doi.org/10.1155/2011/671302