Clinical question

How should I assess my older patient who has urinary incontinence (UI)?

Bottom line

Urinary incontinence, the involuntary loss of any urine,1 is a common problem among people older than 65 or those living with frailty but should not be considered part of “normal” aging. The cornerstones of assessment are comprehensive history, basic physical examination, and focused investigations. Urinary incontinence is a multifactorial geriatric syndrome, not necessarily a disorder of the lower urinary tract itself.2 A detailed review of this topic was published in 2015 in the Canadian Geriatrics Society Journal of CME.3

Evidence

Patients older than 65 living with frailty, particularly those living in institutional care settings, have among the highest rates of UI of any group other than people with spinal cord injury.4

Brain changes (eg, white matter hyperintensities) are implicated in the pathogenesis of UI.5 It is unclear whether midlife interventions such as blood pressure control can prevent the development of lower urinary tract symptoms (LUTS), including UI.

Urinary incontinence is associated with social isolation, depression, and falls.6-8

Approach

Clinical classification of type of incontinence is relevant:

Overactive bladder (OAB). Overactive bladder is urinary urgency, usually accompanied by daytime frequency or nocturia, not caused by urinary tract infection or other disease. Overactive bladder may cause incontinence (OAB wet) or not (OAB dry).9 It is not synonymous with detrusor overactivity, the finding of detrusor contractions during cystometry.1 The correlation between OAB and detrusor overactivity in older adults is poor and cystometry is not usually necessary.2

Stress urinary incontinence. Stress urinary incontinence is the involuntary loss of urine on effort or physical exertion, or with sneezing or coughing.1 Risk factors include genetics, parity, obesity, and smoking. Stress urinary incontinence is due to urethral sphincter incompetence or excessive mobility of pelvic floor musculature decreasing the support necessary to protect against fluctuations in intra-abdominal pressure. Stress incontinence is rare in men who have not had prostatectomy.

Functional incontinence. Continence requires an individual to recognize the need to void and to locate, get to, and use a toilet. Failure to maintain continence due to behavioural, cognitive, environmental, or disease-related factors is termed “functional” or “disability associated” incontinence.1 An older person who is restrained by bedrails, is unable to gain access to their mobility aid, or moves to a facility with inadequate signage to the toilets may lose continence even with normal lower urinary tract function.

Overflow incontinence. Although postvoid residual volume rises with normal aging, the level at which this rise becomes of pathologic importance is dictated by outcomes or consequences rather than by an arbitrary cutoff.10 Overflow incontinence can be seen in patients with chronic painless urinary retention, when the intravesical pressure can no longer be contained by the urethral sphincter, classically leading to frequent small-volume voids and dribbling incontinence.11

It is common for more than one type of incontinence to be present (most commonly urgency and stress incontinence). The predominant type in terms of impact should be noted in the patient’s medical record (eg, “urgency predominant mixed incontinence”).

Assessment should include reviewing the following:

lower urinary tract symptoms;

storage symptoms (ie, urgency, frequency, nocturia, stress incontinence);

voiding symptoms (eg, straining, slow stream, terminal dribble);

postmicturition symptoms (eg, feeling of incomplete emptying, postvoid dribbling);

comorbidities (Table 1)12,13;

medications (Table 2)12,13;

function and cognition;

self-management strategies (eg, fluid intake, pad use); and

impact on quality of life.

Table 1.

Factors that can cause or contribute to UI in older adults living with frailty

Table 2.

Medications that may contribute to lower urinary tract symptoms and UI

Box 1 summarizes causes of more acute and subacute incontinence.12-14

Box 1. Assessment of acute and subacute urinary incontinence: DIAPPERS mnemonic.

In patients presenting with new-onset urinary incontinence the following potential causes, with the mnemonic DIAPPERS,14 should be considered:

Delirium

Infection*

Atrophic vaginitis (genitourinary syndrome of menopause)

Pharmaceuticals (Table 2)12,13

Psychological

Excess urine output

Reduced mobility

Stool impaction

*Avoid treatment of asymptomatic bacteriuria.

Implementation

Up to half of patients with UI never seek assistance for their symptoms.15,16 Patients may fail to seek help because of embarrassment, a belief that UI is a normal part of aging, or a belief that UI is untreatable.17 It is imperative that health care professionals dealing with those at risk actively identify UI through focused questioning and assessment. Unfortunately, many clinicians contribute to the care gap because of limited confidence and preconceptions about the efficacy of treatments or by prioritizing other “more important” conditions.18 Validated case-finding tools have been employed in primary care practice, including the Bladder Control Self-assessment Questionnaire and the Overactive Bladder Validated 8-question questionnaire.19,20

The minimal examination includes abdominal examination for palpable bladder, assessment of external genitalia for abnormalities (eg, phimosis, incontinence-related dermatitis), and basic examination for urogenital atrophy and pelvic organ prolapse in women. A rectal examination should be done to exclude fecal loading and to assess the prostate in men. In patients with evidence of neurologic disease, a screening examination is important. An essential part of the evaluation is noting the patient’s physical and cognitive abilities to get to the toilet, undress, void, and wash and dress afterward.

A bedside dipstick urinalysis (for hematuria, glycosuria, or bacteriuria) should be performed. In addition, if there are voiding symptoms a postvoid residual volume should be recorded using a hand-held ultrasound device or in-and-out catheterization if ultrasound is not available.21 Catheterization is, of course, associated with a small risk of infection.

If the concern is of stress urinary incontinence, a lying or standing cough test can be done. To perform a standing cough test, ask the patient to stand and to cough; the test is positive if any degree of urine leakage occurs. The Q-tip test or other tests of urethral hypermobility are of limited usefulness and guidelines recommend against their use.21

In the majority of cases investigations such as an ultrasound scan of the lower urinary tract, laboratory tests, or cystometry are not required. The presence of bacteriuria in a patient with chronic LUTS is of controversial importance; if the urine dip or symptoms suggests bacteriuria, a midstream urine sample should be sent for analysis and appropriate antibiotics should be prescribed based on the culture result. If LUTS are unaffected, a repeat prescription of antibiotics is not justified. For a more detailed review of this topic please see the previously mentioned article published in the Canadian Geriatrics Society Journal of CME.3

Notes

Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (http://www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.

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