Urinary incontinence in elderly women: the right assessment will tailor the correct treatment. (Incontinence).

URINARY INCONTINENCE (UI) AFFECTS APPROXIMATELY 13 million Americans, with the highest prevalence in the elderly. The cost is estimated to be approximately $16 billion annually and is expected to rise as the aging population grows. UI imposes a significant psychosocial impact on individuals, their families, and their caregivers; moreover, UI is a major cause of institutionalization in the elderly.

Prevalence of UT varies depending upon the population studied, the definition of incontinence, and the study methodology. For non-institutionalized people older than 60, the prevalence of UI ranges from 15 percent to 25 percent. Prevalence among the 1.5 million nursing home residents is at least 50 percent and is strongly associated with dementia, fecal incontinence, and the inability to walk or transfer independently. This article will concentrate on the assessment of the incontinent, elderly female age 65 years and older. Treatment options for this population will be discussed in detail in a future article.

The Agency for Health Care Policy and Research Clinical Guidelines Panel defines urinary incontinence as the involuntary loss of urine sufficient enough to be problematic. (1) Thus, urinary incontinence is a symptom, not a diagnosis. Medical history, physical examination, and assessment of impact on quality of life are all needed for a correct diagnosis and to tailor appropriate therapy.

UI can be classified according to symptomatology into four subtypes: urge, stress, overflow, and total incontinence. (See Table 1 "Types of urinary incontinence in elderly women," below.) Urinary urge incontinence (UUI) refers to involuntary loss of urine accompanied by a strong desire to void (urgency). Stress urinary incontinence (SUT) describes involuntary loss of urine due to increases in intra-abdominal pressure, e.g., coughing, straining, lifting, and abrupt positional changes.

Two major components contribute to the etiology of SUT: urethral hypermobility or intrinsic sphincteric deficiency (ISD). Many experts believe that a combination of these contributes to most cases of SUI. Urethral hypermobility results when there is loss of integrity of the vaginal musculofascial attachments that support the bladder neck and urethra in a retropubic position. Increase in abdominal pressure then causes a descent of the urethra and bladder neck into the vagina. ISD refers to a deficiency in the urethral sphincter function (unrelated to urethral support) that results in poor urethral mucosal seal and leads to incontinence with minimal stress activities. (2)

Although rare, overflow and total incontinence are two additional types of UI seen in the elderly. Overflow incontinence denotes loss of urine in association with an over-distended bladder, which may occur when the patient loses perception of a full bladder. Total incontinence refers to complete and constant loss of urine. The patient is unable to store urine for any significant amount of time because of a severely damaged external sphincter or a congenital abnormality.

Patient evaluation

The two most common categories of urinary incontinence are UUI and SUI, and often coexist in the same patient. The predominant symptom dictates which treatment is selected. Therefore, a detailed history, physical examination, and appropriate diagnostic studies are required.

History. The history is the most important aspect of the patient assessment. Often, elderly patients cannot give a detailed history, and the family or caregiver must be interviewed. Particular attention must be paid to the onset of ill and its relation to other events (such as deaths, altered mental status, newly diagnosed illnesses, and change in mobility).

A list of medications must be provided because some medications may aggravate symptoms (e.g., diuretics, sedatives, muscle relaxants). Co-morbidities also must be assessed carefully. Reversible conditions should be identified and managed prior to initiating treatment for UI. (3) (See "Reversible Conditions Associated with UI [DIAPPERS]," right.) It is also important to identify behaviors that may contribute to the patient's condition, especially excess fluid intake and consumption of caffeinated beverages.

Previous incontinence therapies and their outcome(s) should be delineated. It is also important to identify any symptoms of primary urologic problems--infections, stones, bladder tumors, and bladder outlet obstruction--that may contribute to the incontinent episodes. These symptoms include hematuria, dysuria, hesitancy, diminished flow, and suprapubic pain.

Timing of incontinent episodes (daytime vs. nighttime) and the amount of incontinence must be evaluated. Most of this information may be obtained from a voiding diary (maintained for 24 to 72 hours). This is an excellent way to quantify the severity of the incontinence. (See Fig. 1, "Sample voiding diary," page 20.) The amount and type of pad usage during this time serves as a valuable supplement to the voiding diary.

Physical examination. Physical evaluation of the elderly must include a pelvic examination, limited mental status exam, mobility evaluation, and neurological evaluation. The examining physician should palpate the abdomen and flanks to identify any areas of tenderness or mass effect. A lower midline abdominal mass may represent a distended bladder. If so, the patient should be asked to void followed by a bladder scan or urethral catheterization to assess post-void residual (PVR).

Pelvic examination should identify presence of atrophic vaginitis (dry, pale vaginal mucosa), pelvic pro-lapse (cystocele, enterocele, vaginal vault prolapse, or rectocele), vaginal lesions, cervical or uterine masses, and pelvic floor tone. SUI and urethral hypermobility at rest or with straining can be detected at this time. The rectum should also be evaluated, with emphasis on the presence of palpable rectal masses and quality of rectal tone.

Neurological exam. The important areas of the neurologic system that regulate bladder function are the pons (pontine micturition center) and the sacral cord (sacral micturition center). These two centers divide the neural axis into three primary areas: (1) intracranial/suprapontine, (2) spinal/suprasacral, and (3) peripheral/infrasacral. Neurologic lesions may occur anywhere along this axis and alter bladder function. "Common neurologic diseases associated with voiding dysfunction," Table 2 above, illustrates common neurological diseases, their location along the neural axis, and associated voiding dysfunction.

Because UT is a symptom and therefore may be the presenting feature or complication of almost any neurological or psychiatric disease, the neurological exam should assess the patient's gait and manual dexterity. The urinary system is primarily innervated by nerves that originate from the S2 through S4 sacral segments of the spinal cord. If the patient can flex and spread her toes, S3 efferent segments are intact. The examining physician can also gain important information regarding the patient's neurological status (specifically sacral roots 2 through 4) from the rectal exam. A flaccid anal sphincter may indicate poor detrusor muscle function. The presence of an anal wink and bulbocavemosus reflex suggests an intact S2 through S4 reflex arc.

A mental status assessment must be performed to rule out the presence of dementia. Prevalence of UT in individuals with dementia is 22 percent to 90 percent, but rises with the severity of the confusion. (3,4) The etiology of UI in this population is poorly understood and may also reflect the patient's immobility or inability to communicate.

Urodynamic studies. More detailed in formation regarding bladder function may be required, especially in patients with neurological impairment. It is important to determine the presence of bladder outlet obstruction that may be secondary to prior anti-incontinence procedures. This information may be obtained via non-invasive studies, including urine flow rates and post-void residual assessment. Urodynamic studies (UDS) give the physician the most detailed information regarding bladder function. The test involves the placement of a multichannel, small caliber urethral catheter and a rectal catheter to record bladder and abdominal pressures. Because this test is invasive, it is not necessary or feasible for every patient. However, UDS are important in patients with neurologic diseases, persistent or recurrent incontinence following surgical procedures, and in patients with associated pelvic prolapse who are considering surgical repair.

It is important to identify the etiology of UI in elderly patients. The condition can lead to isolation, loss of independence, and depression. Every older person should be given the opportunity to achieve continence irrespective of fragility or disability. However treatment should be individualized and tailored toward the goals of the patient and her caregivers.

Next month Part II of this article will discuss the available treatments and postoperative care for female patients age 65 and older.

[FIGURE 1 OMITTED]

TABLE 1

Types of urinary incontinence in elderly women

Type of       Common           Physical           Urodynamic
incontinence  symptoms         findings           findings

Urge          Loss of urine    Spontaneous        Uninhibited
incontinence  associated       leakage not        detrusor
              with strong      associated with    contraction
              desire to void   straining, or      associated
                               immediately        with leakage
                               following
                               straining

Stress        Leakage with     Visible leakage    Leakage with
incontinence  increased        with straining     straining in
              abdominal                           the absence of
              pressures                           a detrusor
              (cough, strain)                     contraction

Overflow      Incontinence     Distended          Areflexic
incontinence  associated       bladder; elevated  bladder, large
              with infrequent  post-void          capacity
              voiding          residual (PVR)

Total         Constant,        Constant           Small capacity
incontinence  spontaneous      leakage            bladder;
              loss of urine                       severe urethral
                                                  sphincter
                                                  damage

Type of       Common
incontinence  causes

Urge          Neurological diseases; UTI;
incontinence  caffeine






Stress        Urethral hypermobility;
incontinence  intrinsic sphincteric
              deficiency (ISD) caused by
              pelvic radiation; prior vaginal
              surgery; vaginal child birth

Overflow      Immobility; dementia
incontinence



Total         Pelvic radiation; urethral
incontinence  trauma; fistula; ectopic ureter
TABLE 2

Common neurologic diseases associated with voiding dysfunction

Location of lesion         Effect on bladder  Common symptoms

Intracranial/Suprapontine
CVA                        Overactive         F, U, UI
Parkinson's disease        Overactive         F, U, UI
Dementia                   Variable           OI

Spinal/suprasacral
Spinal card injury         Overactive         F, U, UI
Spinal cord tumor          Overactive         F, U, UI
Multiple Sclerosis         Overactive         F, U, UI

Peripheral/Infrasacral
Disc disease               Underactive        Retention
Diabetes Mellitus          Underactive        Retention, OI
Multiple Sclerosis         Underactive        Retention

F=Frequency, U=Urgency, UI=Urge incontinence, OI=Overflow in
incontinence

References

(1.) Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline, No. 2, 1996 Update. Rockville, Md., U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0682. March 1996.

(2.) Leach GE, Dmochowski RR, Appell RA, et al. Report on the surgical management of female stress urinary incontinence clinical practice guidelines. Baltimore, American Urological Association, 1997.

(3.) Abrams P, Lowry SK, Wein AJ, et al. Assessment and treatment of urinary incontinence. Scientific Committee of the First international Consultation on Incontinence. Lancet. 2000;355(9221):2153-2158

(4.) Woodward S. Impact of neurological problems on urinary continence. Br J Nurs. 1996;5:906-913.

(5.) Skelly J, Flint AJ. urinary incontinence associated with dementia. J Am Geriatr Soc. 1995;43:286-294.

Reversible conditions associated with UI {DIAPPERS)

D - delerium

I - infection

A - atrophic vaginitis

P - pharmaceuticals

P - psychological

E - excess fluids

R - restricted mobility

S - stool (constipation)

Tracey Small Wilson, MD, is fellow in female urology, urodynamics, and pelvic reconstruction; and Phillipe F. Zimmern, MD, is professor of urology and director of Bladder Incontinence Center; both at University of Texas Southwestern Medical Center, Dallas.