Medical care of older persons in residential facilities

Incontinence - urinary

Assessment
Management

Urinary incontinence affects the physical, psychological and social wellbeing of older people, and is a major cause of admission to residential aged care. The incidence increases with age. It has been estimated to affect 70% of Australian aged care home residents and is more common in women than men.^175,176

Urinary incontinence is not a normal part of ageing. It is the loss of urine control due to a combination of genitourinary pathology, age related changes, comorbid conditions and environmental obstacles.¹⁷⁷

Urinary incontinence may be categorised according to symptoms as urge, stress, overflow, and functional or behavioural incontinence. Many patients have more than one type of incontinence.^178,179

Urge incontinence is an involuntary loss of urine associated with a strong urge to void. This is due to either detrusor instability (the brain knows the bladder is full, but cannot suppress bladder contractions) or detrusor hyperactivity (nerves are damaged so the brain doesn't realise the bladder is full and there is no suppression of bladder contraction). Common causes include age related atrophic changes, anxiety, dehydration, urinary tract infections, prostatic hypertrophy and neurological disease.

Stress incontinence is involuntary loss of urine with raised intra-abdominal pressure (eg. on laughing, sneezing, coughing and lifting). This is due to either bladder neck weakening, or hypermobility of the urethra and its consequent failure to close effectively. It occurs more commonly in patients who are overweight, have pelvic floor weakness after childbirth, or as a complication of prostatic surgery.

Overflow incontinence is the involuntary loss of urine associated with an overdistended bladder. Continuous or intermittent leakage may occur. This may be caused by an atonic bladder (eg. neurogenic bladder) or partial obstruction of urine flow from faecal impaction, prostatomegaly or pelvic mass.

Functional or behavioural incontinence occurs in otherwise continent people who are unable to get to the toilet in time. Common causes include mobility problems (eg. arthritis,insufficient assistance, medications, Parkinson disease) and mental disorders affecting recognition of the need to void (eg. dementia,depression,medications).

Assessment

Evaluate the lower urinary tract as well as general medical, functional and cognitive status. Identify reversible causes of incontinence (Table 9) before proceeding to a more detailed evaluation.¹⁸⁰

Table 9. Potentially reversible causes of incontinence in older people ¹⁸¹

D Delirium

I Infection (eg. UTI)

A Atrophic urethritis or vaginitis

P Psychological (eg. depression, pain)

P Pharmacological

E Excess urine output

R Restricted mobility

S Stool impaction

Take a detailed history including symptoms, fluid intake, and review of medical, locomotor and past surgical/obstetric conditions. Ask residents how they manage and are affected by their incontinence such as anxiety, low self esteem, embarrassment in social situations or problems with hygiene. Review medications that may cause or aggravate incontinence:¹⁸²

urge incontinence - diuretics, SSRIs, cholinergic and anticholinesterase agents
stress incontinence - selective alpha adrenergic blockers, and ACE inhibitors
overflow incontinence - anticholinergic agents, verapamil, pseudoephedrine, opioids, and many psychotropic medications
functional incontinence - psychotropic medications, analgesics, and antihypertensives.

Examine the abdomen (for enlarged bladder, pelvic masses), vagina (for atrophic changes, prolapse and stress incontinence on coughing) and rectum (for constipation, prostatic hypertrophy, anal tone and perineal sensation). Assess mobility, cognitive function, and signs of conditions associated with incontinence (eg. diabetes, neuropathy, cerebrovascular disease, Parkinson disease, depression).

Investigations include urinalysis, urine microscopy and culture, a bladder chart, and measurement of residual urine.

Use a bladder chart over 3 days to record voiding patterns and episodes of incontinence in four columns:¹⁸³

time
damp/wet/soaked
dry, and
volume.

Measurement of postvoid residual urine by ultrasound will exclude urinary retention and indicate total bladder capacity (voided volume plus residual volume). Normal bladder capacity is about 500 mL and no residual urine. A residual urine volume of more than 100 mL may require further investigation. Consider referral to aged care, urology or urogynaecology services for urodynamic studies or further investigations and management if indicated. Many regional aged care services offer continence clinics with access to a geriatrician, a continence nurse advisor and a physiotherapist. The National Continence Helpline (1800 330 066) can provide details of continence clinics, continence physiotherapists and nurse advisors.

Management

Urinary incontinence can often be managed successfully in the residential care setting with a planned multidisciplinary approach. In a stepped approach, treat all transient reversible causes first (DIAPPERS). Avoid caffeine and alcohol, and minimise evening fluid intake. Aim to achieve continence irrespective of the resident's frailty or functional status. This can be independent continence, dependent continence (dry with reminders or assistance from carers) or social continence (dry with the use of aids).¹⁸⁴

Nonmedication measures are the first line of treatment and may include:^185,186

appropriate fluid intake (1.5 L/day), limit caffeine intake
avoidance of constipation (increase fibre, increase fruit)
regular toileting habits with good posture, time for complete emptying
toileting assistance and prompting for regular voiding
mobility aids, bedside commode or urinary bottle at night
pelvic floor exercises for women, and men with detrusor instability¹⁸⁷
urethral massage for men with postmicturition dribble
bladder retraining for urge incontinence in residents with cognitive functioning
intermittent or permanent urinary catheterisation
continence aids such as disposable pants, absorbent bedding.

In some cases, medication may be indicated, eg. oestrogen cream for atrophic vagina; aperients, stool softeners and enemas for constipation; or antibiotic prophylaxis for recurrent urine infections. In urge incontinence, anticholinergics may relieve symptoms by relaxing the bladder and increasing its capacity. Start with oxybutynin 2.5 mg orally at night, increase slowly according to response and tolerability (maximum dose 5 mg tds), and stop if there is no benefit after 4-6 weeks. Tricyclic antidepressants are not well tolerated due to sedative hypotensive and cardiac side effects. Alpha adrenergic agonists are no longer recommended for stress incontinence due to lack of efficacy and poor tolerability.

Surgical treatments include:

dilation of urethral stricture, transurethral resection of prostate
repair of vaginal prolapse, pelvic floor repair (bladder neck suspension, sling and colposuspension)
urine outflow blockers (eg. pessaries, tampons,adhesive pads)
suprapubic catheter
cystoscopy (eg. for inflammation, polyps)
circumcision (for external catheter systems).