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urinary incontinence (UI)

Involuntary loss of urine sufficient to be a problem. There are several types of UI, but all are characterized by an inability to restrain or control urinary voiding (see mixed urinary incontinence, nocturnal enuresis, overflow incontinence, stress incontinence, transient urinary incontinence, urge incontinence). Classification: 1) transient (reversible) urinary incontinence 2) stress incontinence 3) urge incontinence 4) overflow incontinence 5) mixed urinary incontinence 6) functional (idiopathic) incontinence Etiology: 1) reversible factors (DRIP) D: delirium, dementia, depression R: restricted mobility, urinary retention I: infection, inflammation (atrophic vaginitis), fecal impactation P: pharmaceuticals, polyuria (glycosuria, CHF) 2) reversible factors (DIAPPERS) D: delirium I: infection A: atrophic vaginitis P: pharmaceuticals P: psychologic factors (depression or behavioral disturbance) E: excess urine output (excess fluid intake, diuretics, edema) R: restricted mobility S: stool impactation 3) see more specific type a) urge incontinence b) stress urinary incontinence c) overflow incontinence d) mixed urinary incontinence e) transient urinary incontinence f) functional incontinence 4) see pharmaceutical causes of urinary incontinence 5) seizures Epidemiology: 1) 15-30% of elderly in the community a) 25-30% of women > 60 years; 30-50% of women > 65 years -> more common in whites than blacks [6,8] b) 10-15% of men > 60 years 2) 50-70% of nursing home patients [37] -> strong association with dementia 3) 10% of young, nulligravid women [17] 4) incidence increases with age a) NOT part of normal aging b) NOT associated with menopause [4,13] or HRT [13] c) common in nulliparous as well as parous women 5) underdiagnosed & under-reported (63% report to physicans) [8] 6) common reason for nursing home placement History: - malignancies, neuroendocrine disorder, pelvic surgery or irradiation, parity, frequency, dysuria, hematuria, fever, polydipsia, weight gain, change in bowel habits, fecal incontinence, sexual dysfunction, sensory or motor symptoms - AUA symptom index (men) Clinical manifestations: 1) loss of perineal sensation 2) loss of bulbocavernosus reflex 3) palpable bladder 4) urine loss with Valsalva maneuver 5) enlarged prostate 6) decreased rectal sphincter tone 7) impactation 8) signs of estrogen deprivation Laboratory: 1) urinalysis with reflex urine culture 2) serum chemistries a) serum urea nitrogen b) serum creatinine c) serum electrolytes d) serum glucose 3) urine cytology (if hematuria) Special laboratory: 1) postvoid residual (PVR) in men (prior to discontinuation of medications) [16] 2) urodynamic testing - failure of initial therapy, not reccommended (MKSAP19) [2] 3) pad test of standardized duration & activity protocol [33] Radiology: 1) pelvic or abdominal ultrasound 2) intravenous pyelography (IVP) 3) computed tomography (CT) of pelvis Complications: - urinary tract infections - skin breakdown: incontinence-associated dermatitis - falls - psychologic distress [6] - depression [21] - work disability [21] Management: 1) general a) treat reversible causes - discontinue offending medications b) try the least invasive intervention 1st c) weight reduction & fluid restriction can improve urinary incontinence in selected women [2,9,14] d) voiding diary if etiology is unclear e) limit caffeine intake f) treat constipation g) enhance mobility h) prompted voiding in demented elderly [2] i) bedside commode if mobility impaired j) catheterization - indications - urinary obstruction - acontractile bladder - avoid chronic catheterization if possible 2) see specific type of urinary incontinence 3) stable symptoms - no benefit of treating bacteriuria even with pyuria 4) indications for urology referral a) unclear diagnosis after simple bedside tests b) recurrent symptomatic urinary tract infection c) hematuria d) previous lower urinary tract surgical procedures e) trauma f) irradiation g) prostate abnormality with symptomatic obstruction h) marked pelvic prolapse i) inability to pass urethral catheter j) significant urinary retention (> 200 mL PVR*) k) abnormal renal function with symptoms of retention l) lack of response to treatment 5) devices a) pessary (see pessary) b) occlusive devices (see occlusive devices ...) c) absorbent products (diapers, pads, briefs) - most common non-pharmaceutical intervention [6] 6) periurethral bulking injection (see periurthethral ...) - not effective [36] 7) pelvic muscle exercises (stress & urge incontinence) 8) screening for urinary incontinence recommended annually at preventive health visits for all women of all ages [34] 9) prevention (see prevention of fecal & urinary incontinence) * PVR = post-void residual

Interactions

disease interactions

Related

incontinence-associated dermatitis office evaluation of urinary incontinence pharmaceutical causes of urinary incontinence pharmaceuticals used to treat urinary incontinence prevention of fecal & urinary incontinence

Specific

enuresis functional incontinence involuntary detrusor contraction mixed urinary incontinence overflow incontinence stress urinary incontinence transient (reversible) urinary incontinence urge incontinence

General

incontinence urologic disease

References

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