Honing in on varied causes of urinary incontinence

Scenario

A 72-year-old woman comes to your office with the complaint of increasing urinary incontinence. She feels embarrassed and devastated, and hasn't been able to participate in her usual activities. She needs to run to the bathroom every two to three hours and, quite frequently, a few drops fall on her clothes before she is able to get there. She had one episode of large-volume incontinence after waiting to get tickets for a concert. At night she gets up two to three times. As a result, her sleep has been poor, and she feels tired and depressed. She is frightened about how this condition will affect her and looks to you for answers.

The patient has had type 2 diabetes for the last three years. It is very well controlled with diet and exercise. She also has a history of constipation.

Her only medications are calcium with vitamin D twice daily and Metamucil as needed. She is married and had three normal pregnancies and deliveries.

Her physical exam shows a woman looking younger than her age. Her vitals are normal, and her heart, lung and abdominal exam is within normal limits. She has trace pitting edema in both feet and ankles. Her external genitalia is normal but you notice some vaginal dryness and a questionable mild uterine prolapse.

Discussion

The problem of urinary incontinence affects millions of people and can happen to anyone, but becomes more common among older people. According to the National Institute on Aging, at least one in 10 people 65 or older has UI. And, although it is most common among women in this age group, men who have prostate disease also are at increased risk.

The condition's severity can range from occasional leakage when coughing or sneezing to more sudden, extreme and unpredictable episodes. Regardless, urinary incontinence should never be viewed as a normal and regular part of aging or, for women, an inevitable consequence of childbirth or changes after menopause. Instead, it is a medical condition with many possible causes, some of which are treated very easily. Patients who receive treatment generally experience some improvement but getting to a positive resolution can be a challenge.

The psychological effects of incontinence can be significant. It can deeply impact a patient's day-to-day habits and quality of life. In this particular case, the problem is beginning to undermine the patient's ability to participate in the activities she enjoys and undercut her self-confidence. She is seeking a medical solution. But for many patients, incontinence is hard to discuss -- even with a physician.

Findings from a 2001 survey by the National Assn. for Continence, which are included in Food and Drug Administration information, found only a quarter of respondents who had symptoms discussed them with a doctor. Also, a 2004 survey showed women live with their symptoms for an average of 6½ years before they seek medical attention.

Based on this patient's history, she appears mostly to be urge incontinent with detrusor muscle overactivity and small to large volume loss. However, there may be a degree of stress incontinence as well. Anatomical changes could contribute to failure of the sphincter to remain closed during bladder filling. She had three normal childbirths, which can lead to weakened pelvic muscles. In addition, atrophic vaginitis with the characteristic thinning and drying of the vaginal and urethral mucosa after menopause may be another cause of her condition. For this patient, a referral to a gynecology/urology specialist is warranted.

Lastly, this patient is a diabetic. One should not overlook diabetes as a possible contributing factor, causing her to have some degree of neurogenic bladder with impaired detrusor contractility, which can lead to overflow incontinence.

Overall, UI risk factors involve a number of elements beyond age and sex. They include obesity, smoking, chronic obstructive pulmonary disease and heart failure, dementia, and impaired mobilization. Constipation and urinary tract infections also can cause incontinence.

Multiple medications are associated with UI, including but not limited to alpha-adrenergic agonists, anticholinergics, diuretics and sedative hypnotics. In such situations, discontinuation of the medication or adjustment of time or dose can bring relief.

For physicians, diagnosing and treating urinary incontinence need not be an intense process. The DIAPPERS mnemonic -- drugs, infections (UTI), atrophic vaginitis, pharmaceuticals, psychological factors, endocrine causes, restricted mobility and stool impaction -- can prove very helpful in guiding doctors through the key concerns and causes that should be investigated.

Patients should be asked to keep a bladder diary recording incontinent and continent voids as well as volume and time of fluid intake. A urinary analysis and urine culture, as well as renal function, glucose and calcium levels if there is polyuria, are always indicated. If available, bladder ultrasound after voiding to determine postvoid residuals is preferred to catheterization. Consider referral for urodynamic testing if postvoid residual is greater than 200-300 cc; when diagnosis is unclear; or when empiric treatment has been ineffective.

Nonpharmacological therapies should be considered first. Behavioral techniques, such as regular voiding -- creating and following a bathroom schedule, can lead to improvements. Weight loss sometimes eliminates the problem. Also, doing exercises to strengthen the pelvic floor muscles, known as Kegel exercises, can improve control as well as physical therapy. As mentioned above, eliminate if possible a patient's drug therapies that contribute to UI.

Other treatment categories include surgery, devices such as pessaries and medications. Oxybutynin, tolterodine and trospium are indicated for the treatment of urge and mixed (urge/stress) UI. But it is important to remember these agents may cause significant side effects, such as dry mouth, blurry vision, and delirium and confusion in older patients.

In most cases, it is best to explore the least-invasive options first.