By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Urinary incontinence is a common symptom in the elderly, and it can have a detrimental effect on quality of life. Sometimes it happens not because of a problem with the urinary system but rather as a consequence of other bodily functions, and typically these are the presentations that present as acute processes and that are rectified promptly with management of the primary concern. Examples of such situations could be the patient who has urinary incontinence secondary to polyuria (has the urinary incontinence been associated with a new increase in urine output), and/or the patient who has difficulty reaching a toilet in time to void, either because of mobility or environmental reasons. Sometimes drugs and alcohol can lead to impaired control over urinary function. And it's always important to rule out cauda equina syndrome, which presents as acute urinary incontinence due to nerve compression and is associated with low back pain, lower extremity weakness, bowel incontinence, and/or anesthesia of the perineal region. Acute urinary incontinence may also be secondary to a new urinary tract infection or constipation, and in the elderly population who may present with atypical presentations of common diseases, these could be how these diseases present. If clinical assessment raises concern for any of these issues, a workup and management plan must be considered accordingly (and for suspected cauda equina syndrome, this requires emergency care as it can result in permanent neurological impair).
In the patient with chronic urinary incontinence, the approach to clinical assessment is to conduct a history that susses out wether the urinary continence is due to stress incontinence (characterized by involuntary loss of urine with increases in abdominal pressure such as exercise, coughing, sneezing, or laughing), urgency incontinence (sudden compelling desire to pass urine that is difficult to defer), mixed incontinence (with features of both forms of incontinence), or overflow incontinence (typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying). It's also important to get a sense of their baseline level of functioning and of how the urinary incontinence is affecting their quality of life. There are screening tools that can help in this assessment, such as the 3 Incontinence Questionnaire (see below). Physical examination maneuvres will depend on what you think is going on, and may or may not include genitourinary examination (when patients have atypical symptoms, there is diagnostic uncertainty, there is a suspicion of pelvic pathology, or there is failure of initial therapy), digital rectal examination to assess for prostate enlargement or other abnormalities in males, and neurological examination in the setting of acute urinary incontinence.
As far as investigations go, besides a urinalysis there are no other necessary investigations. Urinary incontinence can largely be diagnosed and managed clinically. But this will depend on patient risk factors. If there is a suspicion for UTI, obtain a urine culture regardless of the results of urinalysis, and if there are risk factors for STI, obtain a urine NAAT for chlamydia and gonorrhea. If the patient has hematuria or risk factors for bladder cancer, order urine cytology. In males who are at risk of urinary retention due to an enlarged prostate, or if there are any concerns for urinary retention/overflow incontinence on history/exam, obtain a post-void residual bladder scan to look for this, and order a serum creatinine to ensure there is no secondary hydronephrosis induced kidney dysfunction if retention is present. Men should also have a PSA done in the setting of urinary incontinence to stratify the risk for prostate cancer. Another useful tool to send patients away with to have done is a voiding and fluid intake diary, which can help provide context for what is really going on (Are they drinking much caffeine, or drinking late at night and having nocturia? Or are they simply drinking boatloads of water or hardly any fluids at all?)
If the urinary incontinence is secondary to an easily treatable underlying cause, you treat the cause. But if it is attributed to stress, urgency, or mixed incontinence, you work with the patient to adopt whatever behavioural strategies they can tolerate and that they find helpful. First-line strategies to recommend include:
If these do not suffice, pessaries are a non-pharmacological and non-surgical option for women with stress incontinence.
Common medication options include vaginal estrogen in post-menopausal women, an alpha blocker in men with BPH, and in patients with urge or mixed incontinence, an anticholinergic or B3 agonist can be trialled (however these latter medications are not without insignificant side effects). If the above approaches are without good effect, consider a referral to a urologist for procedural repair.