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Editors: Kane, Robert L.; Ouslander, Joseph G.; Abrass, Itamar B.

Title: Essentials of Clinical Geriatrics, 5th Edition

> Table of Contents > Part II - Differential Diagnosis and Management > Chapter 8 - Incontinence

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Chapter 8

Incontinence

Incontinence is a common, disruptive, and potentially disabling condition in the geriatric population. It is defined as the involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem. Figure 8-1 illustrates the prevalence of urinary incontinence. Incontinence is a heterogeneous condition, ranging in severity from occasional episodes of dribbling small amounts of urine to continuous urinary incontinence with concomitant fecal incontinence. Incontinent older persons are not always severely demented, bedridden, or in nursing homes. Many, both in institutions and in the community, are ambulatory and have good mental function.

FIGURE 8-1 Prevalence of urinary incontinence in the geriatric population. Regular UI is more often than weekly and/or the use of a pad.

Approximately 33 percent of women age 65 and above and 15 to 20 percent of men older than 65 years have some degree of urinary incontinence. Between 5 and 10 percent of community-dwelling older adults have incontinence more often than weekly and/or use a pad for protection from urinary accidents. The prevalence is as high as 60 to 80 percent in many long-term care institutions. In both community and institutional settings, incontinence is associated with both impaired mobility and poor cognition.

Physical health, psychological well-being, social status, and the costs of health care can all be adversely affected by incontinence (Table 8-1). Urinary incontinence is curable in many geriatric patients, especially those who have adequate mobility and mental functioning.

TABLE 8-1 POTENTIAL ADVERSE EFFECTS OF URINARY INCONTINENCE

Physical heath

Skin breakdown

Recurrent urinary tract infections

Falls (especially with nighttime incontinence)

Psychological health

Isolation

Depression

Dependency

Social consequences

Stress on family, friends, and caregivers

Predisposition to institutionalization

Economic costs

Supplies (padding, catheters, etc.)

Laundry

Labor (nurses, housekeepers)

Management of complications

Even when it is not curable, incontinence can always be managed in a manner that will keep patients comfortable, make life easier for caregivers, and minimize the costs of caring for the condition and its complications. Despite some change in the social perception of incontinence because of television advertisements and public media and educational efforts, many older patients are embarrassed and frustrated by their incontinence and either deny it or do not discuss it with a health professional. It is therefore essential that specific questions about incontinence be included in periodic assessments and that incontinence be noted as a problem when it is detected in institutional settings. Examples of such questions include the following:

Do you have trouble with your bladder?
Do you ever lose urine when you don't want to?
Do you ever wear padding to protect yourself in case you lose urine?

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This chapter briefly reviews the pathophysiology of geriatric incontinence and provides detailed information on the evaluation and management of this condition. Although most of the chapter focuses on urinary incontinence, much of the pathophysiology also applies to fecal incontinence, which is briefly addressed at the end of the chapter.

NORMAL URINATION

Continence requires effective functioning of the lower urinary tract, adequate cognitive and physical functioning, motivation, and an appropriate environment (Table 8-2). Thus, the pathophysiology of geriatric incontinence can relate to the anatomy and physiology of the lower urinary tract as well as to functional psychological and environmental factors. Several anatomic components participate in normal urination (Fig. 8-2). At the most basic level, urination is governed by reflexes centered in the sacral micturition center. Afferent pathways (via somatic and autonomic nerves) carry information on bladder volume to the spinal cord as the bladder fills. Motor output is adjusted accordingly (Fig. 8-3). Thus, as the

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bladder fills, sympathetic tone closes the bladder neck, relaxes the dome of the bladder, and inhibits parasympathetic tone; somatic innervation maintains tone in the pelvic floor musculature (including striated muscle around the urethra).

TABLE 8-2 REQUIREMENTS FOR CONTINENCE

Effective lower urinary tract function

Storage

Accommodation by bladder of increasing volumes of urine under low pressure

Closed bladder outlet

Appropriate sensation of bladder fullness

Absence of involuntary bladder contractions

Emptying

Bladder capable of contraction

Lack of anatomic obstruction to urine flow

Coordinated lowering of outlet resistance with bladder contractions

Adequate mobility and dexterity to use toilet or toilet substitute and to manage clothing

Adequate cognitive function to recognize toileting needs and to find a toilet or toilet substitute

Motivation to be continent

Absence of environmental and iatrogenic barriers such as inaccessible toilets or toilet substitutes, unavailable caregivers, or drug side effects

FIGURE 8-2 Structural components of normal micturition.

FIGURE 8-3 Peripheral nerves involved in micturition.

When urination occurs, sympathetic and somatic tones diminish, and parasympathetic cholinergically mediated impulses cause the bladder to contract. All these processes are under the influence of higher centers in the brainstem, cerebral cortex, and cerebellum. This is a simplified description of a very

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complex process, and the neurophysiology of urination remains incompletely understood. It appears, however, that the cerebral cortex exerts a predominantly inhibitory influence and the brainstem facilitates urination. Thus, loss of the central cortical inhibiting influences over the sacral micturition center from diseases such as dementia, stroke, and parkinsonism can produce incontinence in elderly patients. Disorders of the brainstem and suprasacral spinal cord can interfere with the coordination of bladder contractions and lowering of urethral resistance, and interruptions of the sacral innervation can cause impaired bladder contraction and problems with continence.

Normal urination is a dynamic process, requiring the coordination of several physiological processes. Figure 8-4 depicts a simplified schematic diagram of the pressure-volume relationships in the lower urinary tract, similar to measurements made in urodynamic studies. Under normal circumstances, as the bladder fills, bladder pressure remains low (e.g., <115 cm H₂O). The first urge to void is variable but generally occurs between 150 and 300 mL, and normal

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bladder capacity is 300 to 600 mL. When normal urination is initiated, true detrusor pressure (bladder pressure minus intraabdominal pressure) increases, urethral resistance decreases, and urine flow occurs when detrusor pressure exceeds urethral resistance. If at any time during bladder filling total intravesicular pressure (which includes intraabdominal pressure) exceeds outlet resistance, urinary leakage will occur. This will happen if, for example, intraabdominal pressure rises without a rise in true detrusor pressure when someone with low outlet or urethral sphincter weakness coughs or sneezes. This

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would be defined as genuine stress incontinence in urodynamic terminology. Alternatively, the bladder can contract involuntarily and cause urinary leakage. This would be defined as detrusor motor instability or detrusor hyperreflexia in patients with neurological disorders.

FIGURE 8-4 Schematic of the dynamic function of the lower urinary tract during bladder filling (left) and emptying (right). As the bladder fills, true detrusor pressure (thick line at bottom) remains low (less than 5 to 10 cm H₂O) and does not exceed urethral resistance pressure (thin line at bottom). As the bladder fills to capacity (generally 300 to 600 mL), pelvic floor and sphincter activity increase as measured by electromyography (EMG, top). Involuntary detrusor contractions (illustrated by dashed lines) occur commonly among incontinent geriatric patients (see text). They may be accompanied by increased EMG activity in attempts to prevent leakage (dashed lines at top). If detrusor pressure exceeds urethral pressure during an involuntary contraction, as shown, urine will flow. During bladder emptying, detrusor pressure rises, urethral pressure falls, and EMG activity ceases in order for normal urine flow to occur.

CAUSES AND TYPES OF INCONTINENCE

Basic Causes

There are four basic categories of causes for geriatric urinary incontinence (Fig. 8-5). Determining the cause(s) is essential to proper management.

FIGURE 8-5 Basic underlying causes of geriatric urinary incontinence.

It is very important to distinguish between urological and neurological disorders that cause incontinence and other problems (such as diminished mobility and/or mental function, inaccessible toilets, and psychological problems), which can cause or contribute to the condition. As is the case for a number of other common geriatric problems discussed in this text, multiple disorders often interact to cause urinary incontinence, as depicted in Fig. 8-5.

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Aging alone does not cause urinary incontinence. Several age-related changes can, however, contribute to its development.

In general, with age, bladder capacity declines, residual urine increases, and involuntary bladder contractions become more common (see Fig. 8-4). These contractions are found in up to 80 percent of older incontinent patients, as well as in 5 to 10 percent of older women and in 33 percent or more of older men with no or minimal urinary symptoms. Combined with impaired mobility, these contractions account for a substantial proportion of incontinence in frail geriatric patients.

Aging is associated with a decline in bladder outlet and urethral resistance pressure in women. This decline, which is related to diminished estrogen influence and laxity of pelvic structures associated with prior childbirths, surgeries, and deconditioned muscles, predisposes to the development of stress incontinence (Fig. 8-6). Decreased estrogen can also cause atrophic vaginitis and urethritis, which can, in turn, cause symptoms of dysuria and urgency and predispose to the development of urinary infection and urge incontinence. In men, prostatic enlargement is associated with decreased urine flow rates and detrusor motor instability and can lead to urge and/or overflow types of incontinence (see below). Aging is also associated with abnormalities of arginine vasopressin (AVP) levels. Lack of the normal diurnal rhythm of AVP secretion may contribute to nocturnal polyuria, and predispose many older people to nighttime incontinence.

FIGURE 8-6 Simplified schematic depicting age-associated changes in pelvic floor muscle, bladder, and urethra-vesicle position, predisposing to stress incontinence. Normally (left), the bladder and outlet remain anatomically inside the intraabdominal cavity, and rises in pressure contribute to bladder outlet closure. Age-associated changes (e.g., estrogen deficiency, surgeries, childbirth) can weaken the structures maintaining bladder position (right); in this situation, increases in intraabdominal pressure can cause urine loss (stress incontinence).

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Reversible Factors Causing or Contributing to Incontinence

Numerous potentially reversible conditions and medications may cause or contribute to geriatric incontinence (Tables 8-3 and 8-4).

TABLE 8-3 REVERSIBLE CONDITIONS THAT CAUSE OR CONTRIBUTE TO GERIATRIC URINARY INCONTINENCE

CONDITION	MANAGEMENT
Conditions affecting the lower urinary tract
Urinary tract infection (symptomatic with frequency, urgency, dysuria, etc.)	Antimicrobial therapy.
Atrophic vaginitis/urethritis	Oral or topical estrogen.
Postprostatectomy	Behavioral intervention. Avoid further surgical therapy until it is clear condition will not resolve.
Stool impaction	Disimpaction; appropriate use of stool softeners, bulk-forming agents, and laxatives if necessary; implement high fiber intake, adequate mobility, and fluid intake.
Drug side effect (see Table 8-4)	Discontinue or change therapy if clinically appropriate. Dosage reduction or modification (e.g., flexible scheduling of rapid-acting diuretics) may also help.
Increased urine production
Metabolic (hyperglycemia, hypercalcemia)	Better control of diabetes mellitus. Therapy for hypercalcemia depends on underlying cause.
Excess fluid intake	Reduction in intake of diuretic fluids (e.g., caffeinated beverages).
Volume overload	Support stockings.
Venous insufficiency with edema	Leg elevation. Sodium restriction. Diuretic therapy.
Congestive heart failure	Medical therapy.
Impaired ability or willingness to reach a toilet
Delirium	Diagnosis and treatment of underlying cause(s) of acute confusional state.
Chronic illness, injury, or restraint that interferes with mobility	Regular toileting. Use of toilet substitutes. Environmental alterations (e.g., bedside commode, urinal).
Psychological	Remove restraints if possible. Appropriate pharmacologic and/or nonpharmacologic treatment.
Source: From Fantl, Newman, et al., 1996a, with permission.

TABLE 8-4 MEDICATIONS THAT CAN AFFECT CONTINENCE

TYPE OF MEDICATION	POTENTIAL EFFECTS ON CONTINENCE
Diuretics	Polyuria, frequency, urgency
Anticholinergics	Urinary retention, overflow incontinence, stool impaction
Psychotropics
Tricyclic
Antidepressants	Anticholinergic actions, sedation
Antipsychotics	Anticholinergic actions, sedation, immobility
Sedative-hypnotics	Sedation, delirium, immobility, muscle relaxation
Narcotic analgesics	Urinary retention, fecal impaction, sedation, delirium
-Adrenergic blockers	Urethral relaxation
-adrenergic agonists	Urinary retention
Angiotensin-converting enzyme inhibitors	Cough precipitating stress incontinence
-Adrenergic agonists	Urinary retention
Calcium-channel blockers	Urinary retention
Alcohol	Polyuria, frequency, urgency, sedation, delirium, immobility
Caffeine	Polyuria, bladder irritation

The term acute incontinence refers to those situations in which the incontinence is of sudden onset, usually related to an acute illness or an iatrogenic problem, and subsides once the illness or medication problem has been resolved. Persistent incontinence refers to incontinence that is unrelated to an acute illness and persists over time.

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Potentially reversible conditions can play a role in both acute and persistent incontinence. A search for these factors should be undertaken in all incontinent geriatric patients.

The causes of acute and reversible forms of urinary incontinence can be remembered by the acronym DRIP (Table 8-5).

TABLE 8-5 ACRONYM FOR POTENTIALLY REVERSIBLE CONDITIONS*

D	Delirium
R	Restricted mobility, retention
I	Infection, inflammation, impaction
P	Polyuria, pharmaceuticals
* See Tables 8-3 and 8-4.

Many older persons, because of urinary frequency and urgency, especially when they are limited in mobility, carefully arrange their schedules (and may even limit social activities) in order to be close to a toilet. Thus, an acute illness (e.g., pneumonia, cardiac decompensation, stroke, lower extremity or vertebral fracture) can precipitate incontinence by disrupting this delicate balance.

Hospitalization, with its attendant environmental barriers (such as bed rails, poorly lit rooms), and the immobility that often accompanies acute illnesses can contribute to acute incontinence. Acute incontinence in these situations is likely to resolve with resolution of the underlying acute illness. Unless an indwelling or external catheter is necessary to record urine output accurately, this type of incontinence should be managed by environmental manipulations, scheduled toiletings,

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the appropriate use of toilet substitutes (e.g., urinals, bedside commodes) and pads, and careful attention to skin care. In a substantial proportion of patients, incontinence may persist for several weeks after hospitalization and should be evaluated as for persistent incontinence (see below).

Fecal impaction is a common problem in both acutely and chronically ill geriatric patients. Large impactions may cause mechanical obstruction of the bladder outlet in women and may stimulate involuntary bladder contractions induced by sensory input related to rectal distention. Whatever the underlying mechanism, relief of fecal impaction can lead to improvement and sometimes resolution of the urinary incontinence.

Urinary retention with overflow incontinence should be considered in any patient who suddenly develops urinary incontinence. Immobility, anticholinergic and narcotic drugs, and fecal impaction can all precipitate overflow incontinence in geriatric patients. In addition, this condition may be a manifestation of an underlying process causing spinal cord compression and presenting acutely.

Any acute inflammatory condition in the lower urinary tract that causes frequency and urgency can precipitate incontinence. Treatment of an acute cystitis, vaginitis, or urethritis can restore continence.

Conditions that cause polyuria, including hyperglycemia and hypercalcemia, as well as diuretics (especially the rapid-acting loop diuretics), can precipitate acute incontinence. Some older people drink excessive amounts of fluids, and others ingest a large amount of caffeine without understanding the prominent effects it can have on the bladder. Patients with volume-expanded states, such as congestive heart failure and lower extremity venous insufficiency, may have polyuria at night, which can contribute to nocturia and nocturnal incontinence.

As in the case of many other conditions discussed throughout this text, a wide variety of medications can play a role in the development of incontinence in elderly patients via several different mechanisms (see Table 8-4). Whether the incontinence is acute or persistent, the potential role of these medications in causing or contributing to the patients' incontinence should be considered. Whenever feasible, stopping the medication, switching to an alternative, or modifying the dosage schedule can be an important component (and possibly the only one necessary) of the treatment for incontinence.

Persistent Incontinence

Persistent forms of incontinence can be classified clinically into four basic types. As depicted in Fig. 8-7, these types can overlap. Thus, an individual patient may have more than one type simultaneously. While this classification does not include all the neurophysiological abnormalities associated with incontinence, it is helpful in approaching the clinical assessment and treatment of incontinence in the geriatric population.

FIGURE 8-7 Basic types of persistent geriatric urinary incontinence.

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Three of these types stress, urge, and overflow result from one or a combination of two basic abnormalities in lower genitourinary tract function: (1) Failure to store urine, caused by a hyperactive or poorly compliant bladder or by diminished outflow resistance (2) Failure to empty bladder, caused by a poorly contractile bladder or by increased outflow resistance. Table 8-6 shows the clinical definitions and common causes of persistent urinary incontinence. Stress incontinence is common in older women, especially in ambulatory clinic settings. It may be infrequent and involve very small amounts of urine and need no specific treatment in women who are not bothered by it. On the other hand, it may be so severe and bothersome that it necessitates surgical correction. It is most often associated with weakened supporting tissues and consequent hypermobility of the bladder outlet and urethra caused by lack of estrogen and/or previous vaginal deliveries or surgery (see Fig. 8-6). Obesity and chronic coughing can exacerbate this condition. Women who have had previous vaginal repair and/or surgical bladder neck suspension may develop a weak urethra (intrinsic sphincter deficiency [ISD]). These women generally present with severe incontinence and symptoms of constant wetting with any activity.

TABLE 8-6 BASIC TYPES AND CAUSES OF PERSISTENT URINARY INCONTINENCE

TYPES	DEFINITION	COMMON CAUSES
Stress	Involuntary loss of urine (usually small amounts) with increases in intraabdominal pressure (e.g., cough, laugh, exercise)	Weakness of pelvic floor musculature and urethral hypermobility Bladder outlet or urethral sphincter weakness
Urge	Leakage of urine (variable but often larger volumes) because of inability to delay voiding after sensation of bladder fullness is perceived	Detrusor overactivity, isolated or associated with one or more of the following: Local genitourinary condition such as tumors, stones, diverticuli, or outflow obstruction Central nervous system disorders such as stroke, dementia, parkinsonism, spinal cord injury
Overflow	Leakage of urine (usually small amounts) resulting from mechanical forces on an overdistended bladder or from other effects of urinary retention on bladder and sphincter function	Anatomic obstruction by prostate, stricture, cystocele Acontractile bladder associated with diabetes mellitus or spinal cord injury Neurogenic (detrusor-sphincter dyssynergy), associated with multiple sclerosis and other suprasacral spinal cord lesions
Functional	Urinary accidents associated with inability to toilet because of impairment of cognitive and/or physical functioning, psychological unwillingness, or environmental barriers	Severe dementia and other neurological disorders Psychological factors such as depression and hostility

This condition should be suspected during office evaluation if a woman loses urine involuntarily with coughing in the supine position during a pelvic examination when her bladder is relatively empty. In general, women with ISD are less responsive to nonsurgical treatment but may benefit from periurethral injections

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or a surgical sling procedure (see below). Stress incontinence is unusual in men but can occur after transurethral surgery and/or radiation therapy for lower urinary tract malignancy when the anatomic sphincters are damaged.

Urge incontinence can be caused by a variety of lower genitourinary and neurological disorders (see Table 8-6). Patients with urge incontinence typically present with irritative symptoms of an overactive bladder, including frequency (voiding more than every 2 hours), urgency, and nocturia (two or more voids during usual sleeping hours). Urge incontinence is most often, but not always, associated with detrusor motor instability or detrusor hyperreflexia (see Fig. 8-4). Some patients have a poorly compliant bladder without involuntary contractions (e.g., radiation or interstitial cystitis, both relatively unusual conditions).

Other patients have symptoms of an overactive bladder but do not exhibit detrusor motor instability on urodynamic testing. Some patients with neurological disorders have detrusor hyperreflexia on urodynamic testing but do not have urgency and are incontinent without any warning symptoms ( unconscious incontinence ). The above-described patients are generally treated as if they had urge incontinence if they empty their bladders and do not have other correctable genitourinary pathology. A subgroup of older incontinent patients with detrusor motor instability also have impaired bladder contractility emptying less than one-third of their bladder volume with involuntary contractions on urodynamic testing (Resnick and Yalla, 1987; Elbadawi et al., 1993). This condition has been termed detrusor hyperactivity with impaired contractility (DHIC). Patients with DHIC may present with symptoms that are not typical of urge incontinence and may strain to complete voiding. These patients may be difficult to manage because of their urinary retention.

Urinary retention with overflow incontinence can result from anatomic or neurogenic outflow obstruction, a hypotonic or acontractile bladder, or both. The most common causes include prostatic enlargement, diabetic neuropathic bladder, and urethral stricture. Low spinal cord injury and anatomic obstruction in females (caused by pelvic prolapse and urethral distortion) are less common causes of overflow incontinence. Several types of drugs can also contribute to this type of persistent incontinence (see Table 8-4). Some patients with suprasacral spinal cord lesions (e.g., multiple sclerosis) develop detrusor-sphincter dyssynergy and consequent urinary retention, which must be treated in a similar manner as overflow incontinence; in some instances a sphincterotomy is necessary. The symptoms of overflow incontinence are nonspecific and urinary retention is easily missed on physical examination. Thus, a postvoid residual determination must be performed to exclude this condition.

The term functional incontinence refers to incontinence associated with the inability or lack of motivation to reach a toilet on time. Factors that contribute to functional incontinence (such as inaccessible toilets and psychological disorders) can also exacerbate other types of persistent incontinence. Patients with incontinence that appears to be predominantly related to functional factors may also

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have abnormalities of the lower genitourinary tract. In some patients, it can be very difficult to determine whether the functional factors or the genitourinary factors predominate without a trial of specific types of treatment. However, no matter what specific treatments are prescribed, patients with functional incontinence require systematic toileting assistance as a component of their management plan.

These basic types of incontinence may occur in combination, as depicted by the overlap in Fig. 8-7. Older women commonly have a combination of stress and urge incontinence (generally referred to as mixed incontinence). Frail geriatric patients often have urge incontinence with detrusor instability as well as functional disabilities that contribute to their incontinence.

EVALUATION

Basic Evaluation

The first step in evaluating incontinent patients is to identify the incontinence by direct observation or the screening questions discussed earlier. In patients with the sudden onset of incontinence (especially when associated with an acute medical condition and hospitalization), the reversible factors that can cause acute incontinence (see Tables 8-3, 8-4, and 8-5) can be ruled out by a brief history, physical examination, postvoid residual determination, and basic laboratory studies (urinalysis, culture, serum glucose or calcium). Table 8-7 shows the basic components of the evaluation of persistent urinary incontinence. Practice guidelines suggest that the basic evaluation should include a focused history, targeted physical examination, urinalysis, and postvoiding residual (PVR) determination (Fantl, Newman, et al., 1996; American Medical Directors Association, 1996). The history should focus on the characteristics of the incontinence, current medical problems and medications, the most bothersome symptom(s), and the impact of the incontinence on the patient and caregivers (Table 8-8). Bladder records or voiding diaries such as those shown in Fig. 8-8 (for outpatients) and Fig. 8-9 (for institutionalized patients) can be helpful in initially characterizing symptoms as well as in following the response to treatment.

TABLE 8-7 COMPONENTS OF THE DIAGNOSTIC EVALUATION OF PERSISTENT URINARY INCONTINENCE

All patients
   History, including bladder record
   Physical examination
   Urinalysis
   Postvoid residual determination
Selected patients*
   Laboratory studies
      Urine culture
      Urine cytology
      Blood glucose, calcium
      Renal function tests
      Renal ultrasonography
   Gynecologic evaluation
   Urological evaluation
   Cystourethroscopy
   Urodynamic tests
      Simple
         Observation of voiding
         Cough test for stress incontinence
         Simple (single channel) cystometry
      Complex
         Urine flowmetry
         Multichannel cystometrogram
         Pressure-flow study
         Leak-point pressure
         Urethral pressure profilometry
         Sphincter electromyography
         Videourodynamics

* See text and Table 8-9.

TABLE 8-8 KEY ASPECTS OF AN INCONTINENT PATIENT'S HISTORY

Active medical conditions, especially neurologic disorders, diabetes mellitus, congestive heart failure, venous insufficiency

Medications (see Table 8-4)

Fluid intake pattern

Type and amount of fluid (especially before bedtime)

Past genitourinary history, especially childbirth, surgery, dilatations, urinary retention, recurrent urinary tract infections

Symptoms of incontinence

Onset and duration

Type stress vs. urge vs. mixed vs. other

Frequency, timing, and amount of incontinence episodes and of continent voids (see Figs. 8-8 and 8-9)

Other lower urinary tract symptoms

Irritative dysuria, frequency, urgency, nocturia

Voiding difficulty hesitancy, slow or interrupted stream, straining, incomplete emptying

Other hematuria, suprapubic discomfort

Other symptoms

Neurological (indicative of stroke, dementia, parkinsonism, normal pressure hydrocephalus, spinal cord compression, multiple sclerosis)

Psychological (depression)

Bowel (constipation, stool incontinence)

Symptoms suggestive of volume-expanded state (e.g., lower extremity edema, shortness of breath while horizontal or with exertion)

Environmental factors

Location and structure of bathroom

Availability of toilet substitutes

Perceptions of incontinence

Patient's concerns or ideas about underlying cause(s)

Most bothersome symptoms(s)

Interference with daily life

Severity (e.g., is it enough of a problem for you to consider surgery?)

FIGURE 8-8 Example of a bladder record for ambulatory care settings.

FIGURE 8-9 Example of a record to monitor bladder and bowel functions in institutional settings. This type of record is especially useful for implementing and following the results of various training procedures and other treatment protocols. (From Ouslander et al., 1986a, with permission.)

Physical examination should focus on abdominal, rectal, and genital examinations and an evaluation of lumbosacral innervation (Table 8-9). During the history and physical examination, special attention should be given to factors such as mobility, mental status, medications, and accessibility of toilets that may either be causing the incontinence or interacting with urological and neurological disorders to worsen the condition. The pelvic examination in women should include careful inspections of the labia and vagina for signs of inflammation suggestive of atrophic vaginitis and for pelvic prolapse. Most older women have some

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degree of pelvic prolapse (e.g., grade 1 or 2 cystocele as depicted in Fig. 8-10). Not all incontinent older women with these degrees of prolapse need gynecological evaluation (see below).

TABLE 8-9 KEY ASPECTS OF AN INCONTINENT PATIENT'S PHYSICAL EXAMINATION

Mobility and dexterity

Functional status compatible with ability to self-toilet

Gait disturbance (parkinsonism, normal-pressure hydrocephalus)

Mental status

Cognitive function compatible with ability to self-toilet

Motivation

Mood and effect

Neurological

Focal signs (especially in lower extremities)

Signs of parkinsonism

Sacral arc reflexes

Abdominal

Bladder distension

Suprapubic tenderness

Lower abdominal mass

Rectal

Perianal sensation

Sphincter tone (resting and active)

Impaction

Masses

Size and contour of prostate

Pelvic

Perineal skin condition

Perineal sensation

Atrophic vaginitis (friability, inflammation, bleeding)

Pelvic prolapse (i.e., cystocele, rectocele; see Fig. 8-10)

Pelvic mass

Other anatomic abnormality

Other

Lower extremity edema or signs of congestive heart failure (if nocturia is a prominent complaint)

FIGURE 8-10 Example of a grading system for cystoceles. (From Ouslander et al., 1989a, with permission.)

A clean urine sample should be collected for urinalysis. For men who are frequently incontinent, making a clean-catch specimen difficult to obtain, a clean specimen can be obtained using a condom catheter after cleaning the penis (Ouslander et al., 1987). For women, a clean specimen can be obtained by

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cleaning the urethral and perineal area and having the patient void into a disinfected bedpan (Ouslander et al., 1995d). Persistent microscopic hematuria (>5 red blood cells per high-power field) in the absence of infection is an indication for further evaluation to exclude a tumor or other urinary tract pathology.

Because the prevalence of asymptomatic bacteriuria roughly parallels the prevalence of incontinence, incontinent geriatric patients commonly have significant bacteriuria. In the initial evaluation of incontinent noninstitutionalized patients, especially those in whom the incontinence is new or worsening, otherwise asymptomatic bacteriuria should be treated before further evaluation is undertaken. In the nursing home population, we do not recommend eradicating

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bacteriuria unless symptoms of a urinary tract infection are present, because eradicating bacteriuria does not affect the severity of chronic, stable incontinence (Ouslander et al., 1995a). However, the new onset of incontinence, worsening incontinence, unexplained fever, and declines in mental and/or functional status may be the manifestations of a urinary tract infection in this population.

A PVR determination should be done either by catheterization or ultrasonogram to detect urinary retention, which cannot always be detected by physical examination. A portable ultrasonographic device that calculates residual urine is available (Diagnostic Ultrasound, Redmond, WA).

Patients with residual volumes of more than 200 mL should be considered for further evaluation. The need for further evaluation in patients with lesser degrees of retention should be determined on an individual basis, considering the patients' symptoms and the degree to which they complain of straining or are observed to strain with voiding.

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Further Evaluation

The need for further evaluation and the specific diagnostic procedures listed in Table 8-7 should be determined on an individual basis. Clinical practice guidelines state that not all incontinent geriatric patients require further evaluation. Patients who have unexplained polyuria should have their blood glucose and calcium levels determined. Patients with significant urinary retention should have renal function tests and be considered for renal ultrasound and urodynamic testing to determine whether obstruction, impaired bladder contractility, or both are present. Persistent microscopic hematuria in the absence of infection is an indication for urine cytology and urological evaluation, including cystoscopy. Even in the absence of hematuria, patients with the recent and sudden onset of irritative urinary symptoms who have risk factors for bladder cancer (heavy smoking, industrial exposure to aniline dyes) should be considered for these evaluations. Women with marked pelvic prolapse (see Fig. 8-10) should be referred for gynecological evaluation.

Complex urodynamic testing is essential to determine the cause(s) of urinary retention and for any older patient for whom surgical intervention is being considered. Simple urodynamic tests, which can be performed without expensive equipment (including observation for straining during voiding, a cough test for stress incontinence with a comfortably full bladder, and simple cystometry) may be helpful in determining the cause(s) of incontinence in settings in which access to complex urodynamic testing is limited.

Table 8-10 summarizes criteria for referral for further evaluation, and Fig. 8-11 summarizes the overall approach to the evaluation of geriatric urinary incontinence.

TABLE 8-10 CRITERIA FOR CONSIDERING REFERRAL OF INCONTINENT PATIENTS FOR UROLOGICAL, GYNECOLOGICAL, OR URODYNAMIC EVALUATION

CRITERIA	DEFINITION	RATIONALE
History
Recent history of lower urinary tract or pelvic surgery or irradiation	Surgery or irradiation involving the pelvic area or lower urinary tract within the past 6 months.	A structural abnormality relating to the recent procedure should be sought.
Recurrent symptomatic urinary tract infections	Two or more symptomatic episodes in a 12-month period.	A structural abnormality or or pathological condition in the urinary tract predisposing to infection should be excluded.
Risk factors for bladder cancer	Recent or sudden onset of irritative symptoms, history of heavy smoking, or exposure to aniline dyes.	Urine for cytology and cystoscopy to exclude bladder cancer should be considered.
Physical examination
Marked pelvic prolapse	A prominent cystocele that descends the entire height of the vaginal vault with coughing during speculum examination.	Anatomic abnormality may underlie the pathophysiology of the incontinence, and selected patients may benefit from surgical repair.
Marked prostatic enlargement and/or suspicion of cancer	Gross enlargement of the prostate on digital exam; prominent induration or asymmetry of the lobes.	An evaluation to exclude prostate cancer may be appropriate and have therapeutic implications.
Postvoid residual
Difficulty passing a 14-Fr straight catheter	Impossible catheter passage, or passage requiring considerable force, or a larger, more rigid catheter.	Anatomic blockage of the urethra or bladder neck may be present.
Postvoid residual volume >200	Volume of urine remaining in the bladder within a few minutes after the patient voids spontaneously in as normal a fashion as possible.	Anatomic or neurogenic obstruction or poor bladder contractility may be present.
Urinalysis
Hematuria	Greater than 5 red blood cells per high-power field on repeated microscopic exams in the absence of infection.	A pathological condition in the urinary tract should be excluded.
Therapeutic trial
Failure to respond	Persistent symptoms that are bothersome to the patient after adequate trials of behavioral and/or drug therapy.	Urodynamic evaluation may help guide specific therapy

FIGURE 8-11 Algorithm protocol for evaluating incontinence.

MANAGEMENT

General Principles

Several therapeutic modalities can be used in managing incontinent geriatric patients (Table 8-11). Treatment can be especially helpful if specific diagnoses are made and attention is paid to all factors that may be contributing to the incontinence in a given patient. Even when cure is not possible, the comfort and satisfaction of both patients and caregivers can almost always be enhanced.

TABLE 8-11 TREATMENT OPTIONS FOR GERIATRIC URINARY INCONTINENCE

Nonspecific supportive measures
   Education
   Modifications of fluid and medication intake
   Use of toilet substitutes
   Environmental manipulations
   Garments and pads
Behavioral interventions (see Table 8-13)
   Patient-dependent
      Pelvic muscle exercises
      Bladder training
      Bladder retraining (see Table 8-14)
   Caregiver-dependent
      Scheduled toileting
      Habit training
      Prompted voiding (see Table 8-15)
Drugs (see Table 8-16)
   Bladder relaxants
    -Agonists
    -Antagonists
   Estrogen
Periurethral injections
Surgery
   Bladder neck suspension or sling
   Removal of obstruction or pathological lesion
Mechanical devices
   Urethral plugs, clamps
   Artificial sphincters
Catheters
   External
   Intermittent
   Indwelling

Special attention should be given to the management of acute incontinence, which is most common among older patients in acute care hospitals. Acute incontinence may be transient if managed appropriately; on the other hand, inappropriate management may lead to a permanent problem. The most common approach to incontinent geriatric patients in acute care hospitals is indwelling catheterization.

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In some instances, this is justified by the necessity for accurate measurement of urine output during the acute phase of an illness. In many instances, however, it is unnecessary and poses a substantial and unwarranted risk of catheter-induced infection. Although it may be more difficult and time-consuming, making toilets and toilet substitutes accessible and combining this with some form of scheduled toileting is probably a more appropriate approach in patients who do not require indwelling catheterization. Newer launderable or disposable and highly absorbent bed pads and undergarments may also be helpful in managing these patients. These products may be more costly than catheters but probably result in less morbidity (and, therefore, overall cost) in the long run. All of the potential reversible factors that can cause or contribute

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to incontinence (see Tables 8-3, 8-4, and 8-5) should be attended to in order to maximize the potential for regaining continence.

Supportive measures are critical in managing all forms of incontinence and should be used in conjunction with other, more specific treatment modalities. A positive attitude, education, environmental manipulations, the appropriate use of toilet substitutes, avoidance of iatrogenic contributions to incontinence, modifications of diuretic and fluid intake patterns, and good skin care are all important.

Specially designed incontinence undergarments and pads can be very helpful in many patients but must be used appropriately. They are now being marketed on television and are readily available in stores. Although they can be effective, several caveats should be noted:

Garments and pads are a nonspecific treatment. They should not be used as the first response to incontinence or before some type of diagnostic evaluation is done.
Many patients are curable if treated with specific therapies, and some have potentially serious factors underlying their incontinence that must be diagnosed and treated.
Pants and pads can interfere with attempts at behavioral intervention and thereby foster dependency.
Many disposable products are relatively expensive and are not covered by Medicare or other insurance.

To a large extent the optimal treatment of persistent incontinence depends on identifying the type(s). Table 8-12 outlines the primary treatments for the basic types of persistent incontinence in the geriatric population. Each treatment modality is briefly discussed below. Behavioral interventions have been well studied in the geriatric population. These interventions are recommended by guidelines as an initial approach to therapy in many patients because they are generally noninvasive and nonspecific (i.e., patients with stress and/or urge incontinence respond equally well) (Fantl et al., 1991; Ouslander et al., 1995a).

TABLE 8-12 PRIMARY TREATMENTS FOR DIFFERENT TYPES OF GERIATRIC URINARY INCONTINENCE

TYPE OF INCONTINENCE	PRIMARY TREATMENTS
Stress	Pelvic muscle (Kegel) exercises Other behavioral interventions (see Table 8-13) -Adrenergic agonists Estrogen Periurethral injections Surgical bladder neck suspension or sling
Urge	Bladder relaxants Estrogen (if atrophic vaginitis present) Bladder training (including pelvic muscle exercises)
Overflow	Surgical removal of obstruction Bladder retraining (see Table 8-14) Intermittent catheterization Indwelling catheterization
Functional	Behavioral interventions (caregiver dependent; see Tables 8-13 and 8-15) Environmental manipulations Incontinence undergarments and pads

Behavioral Interventions

Many types of behavioral interventions have been described for the management of urinary incontinence. The term bladder training has been used to encompass a wide variety of techniques. It is, however, important to distinguish between procedures that are patient dependent (i.e., necessitate adequate function, learning capability, and motivation of the patient), in which the goal is to restore a normal pattern of voiding and continence, and procedures that are caregiver dependent that can be used for functionally disabled patients, in which the goal is to keep the patient and environment dry. Table 8-13 summarizes behavioral interventions. All the patient-dependent procedures generally involve the patient's

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continuous self-monitoring, using a record such as the one depicted in Fig. 8-8; the caregiver-dependent procedures usually involve a record such as the one shown in Fig. 8-9.

TABLE 8-13 EXAMPLES OF BEHAVIORAL INTERVENTIONS FOR URINARY INCONTINENCE

PROCEDURE	DEFINITION	TYPES OF INCONTINENCE	COMMENTS
Patient dependent
Pelvic muscle (Kegel) exercises	Repetitive contraction and relaxation of pelvic floor muscles	Stress and urge	Requires adequate function and motivation. Biofeedback often helpful in teaching the exercise
Bladder training	Use of education, bladder records, pelvic muscle, and other behavioral techniques	Stress and urge	Requires trained therapist, adequate cognitive and physical functioning, and motivation.
Bladder retraining	Progressive lengthening or shortening of intervoiding interval, with intermittent catheterization used in patients recovering from overdistention injuries with persistent retention (see Table 8-14)	Acute (e.g., postcatheterization with urge or overflow, poststroke)	Goal is to restore normal pattern of voiding and continence. Requires adequate cognitive and physical function and motivation.
Caregiver dependent
Scheduled toileting	Routine toileting at regular intervals (scheduled toileting)	Urge and functional	Goal is to prevent wetting episodes. Can be used in patients with impaired cognitive or physical functioning. Requires staff or caregiver availability and motivation.
Habit training	Variable toileting schedule based on patient's voiding patterns	Urge and functional	Goal is to prevent wetting episodes. Can be used in patients with impaired cognitive or physical functioning. Requires staff or caregiver availability and motivation.
Prompted voiding	Offer opportunity to toilet every 2 h during the day; toilet only on request; social reinforcement; routine offering of fluids (see Table 8-15)	Urge, stress, mixed, functional	Same as above. 25 40% of nursing home residents respond well during the day and can be identified during a 3-day trial (see text and Table 8-15)

Pelvic muscle (Kegel) exercises are an essential component of patient-dependent behavioral interventions. These exercises consist of repetitive contractions and relaxations of the pelvic floor muscles.

The exercises may be taught by having the patient interrupt voiding to get a sense of the muscles being used or by having women squeeze the examiner's fingers during a vaginal examination (without doing a Valsalva maneuver, which is the opposite of the intended effect). A randomized trial has documented that many young-old women (mean age in the mid to upper sixties) can be taught these exercises during an office exam and derive significant reductions in incontinence (Burgio et al., 2002).

Many women, however, especially those older than age 75, require biofeedback to help them identify the muscles and practice the exercises. One exercise

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is a 10-second squeeze and a 10-second relaxation. Most older women will have to build endurance gradually to this level. Once learned, the exercises should be practiced many times throughout the day (up to 40 exercises per day) and, importantly, should be used in everyday life during situations (e.g., coughing, standing up, hearing running water) that might precipitate incontinence. Vaginal cones (weights) may be useful adjuncts to pelvic muscle exercises in some patients. Electrical stimulation may also be used to help identify and train pelvic muscles. This technique (using a different frequency of stimulation) may also be useful in suppressing the involuntary bladder contractions associated with urge incontinence. Many older patients are reluctant to purchase the devices for a therapeutic trial.

Biofeedback generally involves the use of vaginal (or rectal) pressure or electromyography (EMG) and abdominal muscle EMG recordings to train patients to contract pelvic floor muscles and relax the abdomen. Studies show that these techniques can be very effective for managing both stress and urge incontinence in the geriatric population Numerous software packages are now available to assist with biofeedback training.

Other forms of patient-dependent interventions include bladder training and bladder retraining. Bladder training involves education, pelvic muscle exercises (with or without biofeedback), strategies to manage urgency, and the regular use of bladder records (see Fig. 8-8). Bladder training is highly effective in selected community-dwelling patients, especially.

Table 8-14 provides an example of a bladder retraining protocol. This protocol is applicable to patients who have had indwelling catheterization for monitoring of urinary output during a period of acute illness or for treatment of urinary retention with overflow incontinence. Such catheters should always be removed as soon as possible, and this type of bladder retraining protocol should enable most indwelling catheters to be removed from patients in acute care hospitals as well as some in long-term care settings. A patient who continues to have difficulty voiding after 1 to 2 weeks of bladder retraining should be examined for other potentially reversible causes of voiding difficulties, such as those mentioned in the preceding discussion of acute incontinence. When difficulties persist, a urological referral should be considered in order to rule out correctable lower genitourinary pathology.

TABLE 8-14 EXAMPLE OF A BLADDER RETRAINING PROTOCOL

Objective: To restore a normal pattern of voiding and continence after the removal of an indwelling catheter
Remove the indwelling catheter (clamping the catheter before removal is not necessary). Treat urinary tract infection if present. Initiate a toileting schedule. Begin by toileting the patient: Upon awakening Every 2 h during the day and evening Before getting into bed Every 4 h at night Monitor the patient's voiding and continence pattern with a record that allows for the recording of: Frequency, timing, and amount of continent voids Frequency, timing, and amount of incontinence episodes Fluid intake pattern Postvoid catheter volume If the patient is having difficulty voiding (complete urinary retention or very low urine outputs, e.g., <240 mL in an 8-h period while fluid intake is adequate): Perform in-and-out catheterization, recording volume obtained, every 6 to 8 h until residual values are <200 mL Instruct the patient on techniques to trigger voiding (e.g., running water, stroking inner thigh, suprapubic tapping) and to help completely empty bladder (e.g., bending forward, suprapubic pressure, double voiding) If the patient continues to have high residual volumes after 1 2 weeks, consider urodynamic evaluation If the patient is voiding frequently (i.e., more often than every 2 h): Perform postvoid residual determination to ensure the patient is completely emptying the bladder Encourage the patient to delay voiding as long as possible and instruct him or her to use techniques to help completely empty bladder If the patient continues to have frequency and nocturia with or without urgency and incontinence: Rule out other reversible causes (e.g., urinary tract infection medication effects, hyperglycemia, and congestive heart failure) Consider urodynamic evaluation to rule out bladder instability (unstable bladder, detrusor hyperreflexia)

The goal of caregiver-dependent interventions is to prevent incontinence episodes rather than to restore normal patterns of voiding and complete continence. Such procedures are effective in reducing incontinence in selected nursing home residents (Ouslander et al., 1995b). In its simplest form, scheduled toileting involves toileting the patient at regular intervals, usually every 2 h during the day and every 4 h during the evening and night. Habit training involves a schedule of toiletings or prompted voidings that is modified according to the patient's pattern of continent voids and incontinence episodes as demonstrated by a monitoring record such as that shown in Fig. 8-9. Adjunctive techniques to prompt

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voiding (e.g., running tap water, stroking the inner thigh, or suprapubic tapping) and to facilitate complete emptying of the bladder (e.g., bending forward after completion of voiding) may be helpful in some patients. Prompted voiding has been the best-studied of these procedures. Table 8-15 provides an example of a prompted voiding protocol. Up to 40% of incontinent nursing home residents may become essentially dry during the day with a consistent prompted voiding program (Ouslander et al., 1995b). The success of these interventions is largely dependent on the knowledge and motivation of the caregivers who are implementing them, rather than on the physical functional and mental status of the incontinent patient. Targeting of prompted voiding to selected patients after a 3-day trial (see Table 8-15) may enhance its cost-effectiveness. Quality assurance methods, based on principles of industrial statistical quality control, have been shown to be helpful in maintaining the effectiveness of prompted voiding in nursing homes (Schnelle et al., 1995). However, unless adequate staffing, training, and administrative support for the program persist, the effectiveness of prompted voiding will not be maintained.

TABLE 8-15 EXAMPLE OF A PROMPTED VOIDING PROTOCOL FOR A NURSING HOME

Assessment period (3 5 days)

Contact resident every hour from 7 a.m. to 7 p.m. for 2 3 days, then every 2 h for 2 3 days
Focus attention on voiding by asking them whether he or she is wet or dry
Check residents for wetness, record on bladder record, and give feedback on whether response was correct or incorrect
Whether wet or dry, ask residents if they would like to use the toilet or urinal. If they say yes:
- Offer assistance
- Record results on bladder record
- Give positive reinforcement by spending extra time talking with them
  If they say no:
- Repeat the question once or twice
- Inform them that you will be back in 1 h and request that they try to delay voiding until then
- If there has been no attempt to void in the last 2 3 h, repeat the request to use the toilet at least twice more before leaving
Offer fluids
Targeting

Prompted voiding is more effective in some residents than others
The best candidates are residents who show the following characteristics during the assessment period:
- Void in the toilet, commode, or urinal (as opposed to being incontinent in a pad or garment) more than two-thirds of the time
- Wet on 20% of checks
- Show substantial reduction in incontinence frequency on 2-h prompts
Residents who do not show any of these characteristics may be candidates for either:
- Further evaluation to determine the specific type of incontinence if they attempt to toilet but remain frequently wet
- Palliative management by containment devices and a checking-and-changing protocol if they do not cooperate with prompting
Prompted voiding (ongoing protocol)

Contact the resident every 2 h from 7 a.m. to 7 p.m.
Use same procedures as for the assessment period
For nighttime management, use either modified prompted voiding schedule or containment device, depending on resident's sleep pattern
If a resident who has been responding well has an increase in incontinence frequency despite adequate staff implementation of the protocol, the resident should be evaluated for reversible factors

Drug Treatment

Table 8-16 lists the drugs used to treat various types of incontinence.

TABLE 8-16 DRUGS USED TO TREAT URINARY INCONTINENCE

DRUGS	DOSAGES	MECHANISMS OF ACTION	TYPE OF INCONTINENCE	POTENTIAL ADVERSE EFFECTS
Anticholinergic and antispasmodic agents
Hyoscamine (Levsin, others)	0.125 mg tid	Increase bladder capacity Diminish involuntary bladder contractions	Urge or mixed with urge predominant	Dry mouth, blurry vision, elevated intraocular pressure, delirium, constipation
Imipramine (Tofranil)*	25 50 mg tid
Oxybutynin
Short-acting	2.5 5.0 mg tid
Long-acting (Ditropan XL)	5 30 mg qd
Transdermal (Oxytrol)	3.9 mg patch every 4 days
Tolterodine (Detrol LA)	4 mg qd		Stress
-Adrenergic agonists
Pseudoephedrine (Sudafed)	30 60 mg tid			Headache, tachycardia, elevation of blood pressure
Topical estrogens
Topical estradiol cream	0.5 1.0 g/application	Strengthen periurethral tissues Increase periurethral blood flow	Urge associated with atrophic vaginitis Stress	Local irritation
Vaginal estradiol ring (Estring)	One ring every 3 months
Cholinergic agonists
Bethanechol (Urecholine)	10 30 mg tid	Stimulate bladder contraction	Overflow incontinence with atonic bladder	Bradycardia, hypotension, bronchoconstriction, gastric acid secretion
Alpha-adrenergic antagonists
Doxazosin (Cardura)	1 4 mg qhs	Relax smooth muscle of urethra and prostatic capsule	Urge incontinence and related irritative symptoms associated with benign prostatic enlargement	Postural hypotension
Tamsulosin (Flowmax)	0.4 0.8 mg/d
Terazosin (Hytrin)	1 5 mg qhs
* Imipramine may also cause postural hypotension and cardiac conduction disturbances.
Most effective if used after acute bladder overdistention in conjunction with bladder retraining (see Table 8-14).

The efficacy of drug treatment has not been as well studied in the geriatric population as it has in younger populations. However, for many patients, especially those with urge or stress incontinence, drug treatment may be very effective. Drug treatment can be prescribed in conjunction with various behavioral interventions. There are few data on the relative efficacy of drug versus behavioral versus combination treatment (Burgio et al., 1998). Treatment decisions should be individualized and will depend in large part on the characteristics and preferences of the patient and the preference of the health care professional.

For urge incontinence, drugs with anticholinergic and relaxant effects on the bladder smooth muscle are used. All of them can have bothersome systemic anticholinergic side effects, especially dry mouth, and they can precipitate urinary retention in some patients.

Men with some degree of outflow obstruction, diabetics, and patients with impaired bladder contractility are at the highest risk for developing urinary retention and should be followed carefully when these drugs are prescribed. Patients with Alzheimer's disease must be followed for the development of drug-induced delirium, which is, however, unusual. The newest bladder relaxant, tolterodine, appears to have an efficacy similar to that of other anticholinergics (Appell, 1997). Tolterodine and oxybutynin are both available in long-acting preparations. Tolterodine has proven efficacy in the geriatric population (Malone-Lee et al., 2001). Some functionally impaired patients may respond to these drugs when they are prescribed in conjunction with prompted voiding (Ouslander et al., 1995c).

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The goal of treatment in these patients may not be to cure the incontinence but to reduce its severity and prevent discomfort and complications.

For stress incontinence, drug treatment involves a combination of an alpha agonist and estrogen. Drug treatment is appropriate for motivated patients who have mild to moderate degrees of stress incontinence, do not have a major anatomic abnormality (e.g., grade 3 cystocele or intrinsic sphincter deficiency), and do not have any contraindications to these drugs. These patients may also respond to concomitant behavioral interventions, as described above. For stress incontinence, estrogen alone is not as effective as it is in combination with an alpha agonist (Fantl, Bump, et al., 1996). Estrogen is also used for the treatment of irritative voiding symptoms and urge incontinence in women with atrophic vaginitis and urethritis. Oral estrogen is probably not as effective as topical estrogen for these symptoms. Vaginal estrogen can be prescribed 5 nights per week for 1 to 2 months initially and then reduced to a maintenance dose of one to three times per week. A vaginal ring that slowly releases estradiol is also available.

Drug treatment for chronic overflow incontinence using a cholinergic agonist or an -adrenergic antagonist is rarely efficacious.

Bethanechol may be helpful when given for a brief period subcutaneously in patients with persistent bladder contractility problems after an overdistension injury, but it is seldom effective when given over the long term orally. -adrenergic blockers may be helpful in relieving symptoms associated with outflow obstruction in some patients but are probably not efficacious for long-term treatment of overflow incontinence. These drugs are, however, effective in treating irritative voiding symptoms associated with urge incontinence in men with benign prostatic enlargement (Lepor et al., 1996).

Surgery

Surgery should be considered for older women with stress incontinence that continues to be bothersome after attempts at nonsurgical treatment and in women with a significant degree of pelvic prolapse or ISD. As with many other surgical procedures, patient selection and the experience of the surgeon are critical to success. All women being considered for surgical therapy should have a thorough evaluation, including urodynamic tests, before undergoing the procedure.

Women with mixed stress incontinence and detrusor motor instability may also benefit from surgery, especially if the clinical history and urodynamic findings suggest that stress incontinence is the predominant problem. Many modified techniques of bladder neck suspension can be done with minimal risk and are highly successful in achieving continence over about a 5-year period. Urinary retention can occur after surgery, but it is usually transient and can be managed by a brief period of suprapubic catheterization. Periurethral injection of collagen

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and other materials is now available and may offer patients with ISD an alternative to surgery. Surgical intervention for patients with ISD involves a perivaginal sling procedure rather than bladder neck suspension.

Surgery may be indicated in men in whom incontinence is associated with anatomically and/or urodynamically documented outflow obstruction. Men who have experienced an episode of complete urinary retention are likely to have another episode within a short period of time and should have a prostatic resection, as should men with incontinence associated with a sufficient amount of residual urine to be causing recurrent symptomatic infections or hydronephrosis. The decision about surgery in men who do not meet these criteria must be an individual one, weighing carefully the degree to which the symptoms bother the patient, the potential benefits of surgery (obstructive symptoms often respond better than irritative symptoms), and the risks of surgery, which may be minimal with newer prostate resection techniques. A small number of older patients, especially men who have stress incontinence related to sphincter damage due to previous transurethral surgery, may benefit from the surgical implantation of an artificial urinary sphincter.

Catheters and Catheter Care

Three basic types of catheters and catheterization procedures are used for the management of urinary incontinence: external catheters, intermittent straight catheterization, and chronic indwelling catheterization.

External catheters generally consist of some type of condom connected to a drainage system. Improvements in design and observance of proper procedure and skin care when applying the catheter will decrease the risk of skin irritation as well as the frequency with which the catheter falls off. Patients with external catheters are at increased risk of developing symptomatic infection. External catheters should be used only to manage intractable incontinence in male patients who do not have urinary retention and who are extremely physically dependent. As with incontinence undergarments and padding, these devices should not be used as a matter of convenience, since they may foster dependency.

Intermittent catheterization can help in the management of patients with urinary retention and overflow incontinence because of an acontractile bladder or DHIC. The procedure can be carried out by either the patient or a caregiver and involves straight catheterization two to four times daily, depending on catheter urine volumes and patient tolerance. In general, bladder volume should be kept to less than 400 mL. In the home setting, the catheter should be kept clean (but not necessarily sterile).

Intermittent catheterization may be useful for certain patients in acute care hospitals and nursing homes, for example following removal of an indwelling catheter in a bladder retraining protocol (see Table 8-14). Nursing home residents,

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however, may be difficult to catheterize, and the anatomic abnormalities commonly found in older patients' lower urinary tracts may increase the risk of infection as a consequence of repeated straight catheterizations. In addition, using this technique in an institutional setting (which may have an abundance of organisms that are relatively resistant to many commonly used antimicrobial agents) may yield an unacceptable risk of nosocomial infections, and using sterile catheter trays for these procedures would be very expensive; thus, it may be extremely difficult to implement such a program in a typical nursing home setting.

Chronic indwelling catheterization is overused in some settings and increases the incidence of a number of complications, including chronic bacteriuria, bladder stones, periurethral abscesses, and even bladder cancer. Nursing home residents, especially men, managed by this technique are at relatively high risk of developing symptomatic infections. Given these risks, it seems appropriate to recommend that the use of chronic indwelling catheters be limited to certain specific situations (Table 8-17). When indwelling catheterization is used, certain principles of catheter care should be observed in order to attempt to minimize complications (Table 8-18).

TABLE 8-17 INDICATIONS FOR CHRONIC INDWELLING CATHETER USE

Urinary retention that
   Is causing persistent overflow incontinence, symptomatic infections, or renal dysfunction
   Cannot be corrected surgically or medically
   Cannot be managed practically with intermittent catheterization
Skin wounds, pressure sores, or irritations that are being contaminated by incontinent urine
Care of terminally ill or severely impaired patients for whom bed and clothing changes are uncomfortable or disruptive
Preference of patient when toileting or changing cause excessive discomfort

TABLE 8-18 KEY PRINCIPLES OF CHRONIC INDWELLING CATHETER CARE

Maintain sterile, closed gravity-drainage system.
Avoid breaking the closed system.
Use clean techniques in emptying and changing the drainage system; wash hands between patients in institutionalized setting.
Secure the catheter to the upper thigh or lower abdomen to avoid perineal contamination and urethral irritation due to movement of the catheter.
Avoid frequent and vigorous cleaning of the catheter entry site; washing with soapy water once per day is sufficient.
Do not routinely irrigate.
If bypassing occurs in the absence of obstruction, consider the possibility of a bladder spasm, which can be treated with a bladder relaxant.
If catheter obstruction occurs frequently, increase the patient's fluid intake and acidify the urine with dilute acetic acid irrigations.
Do not routinely use prophylactic or suppressive urinary antiseptics or antimicrobials.
Do not do surveillance cultures to guide management of individual patients because all chronically catheterized patients have bacteriuria (which is often polymicrobial) and the organisms change frequently.
Do not treat infection unless the patient develops symptoms; symptoms may be nonspecific and other possible sources of infection should be carefully excluded before attributing symptoms to the urinary tract.
If a patient develops frequent symptomatic urinary tract infections, a genitourinary evaluation should be considered to rule out pathology such as stones, periurethral or prostatic abscesses, and chronic pyelonephritis.

FECAL INCONTINENCE

Fecal incontinence is less common than urinary incontinence. Its occurrence is relatively unusual in older patients who are continent with regard to urine; however, a large proportion (30 to 50 percent) of geriatric patients with frequent urinary incontinence also have episodes of fecal incontinence. This coexistence suggests common pathophysiological mechanisms.

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Defecation, like urination, is a physiological process that involves smooth and striated muscles, central and peripheral innervation, coordination of reflex responses, mental awareness, and physical ability to get to a toilet. Disruption of any of these factors can lead to fecal incontinence. The most common causes of fecal incontinence are problems with constipation and laxative use, neurological disorders, and colorectal disorders (Table 8-19). Constipation is extremely common in the geriatric population and, when chronic, can lead to fecal impaction and incontinence. The hard stool (or scybalum) of fecal impaction irritates the rectum and results in the production of mucus and fluid. This fluid leaks around the mass of impacted stool and precipitates incontinence. Constipation is difficult to define; technically it indicates less than three bowel movements per week, although many patients use the term to describe difficult passage of hard stools or a feeling of incomplete evacuation. Poor

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dietary and toilet habits, immobility, and chronic laxative abuse are the most common causes of constipation in geriatric patients (Table 8-20).

TABLE 8-19 CAUSES OF FECAL INCONTINENCE

Fecal impaction
Laxative overuse or abuse
Neurological disorders
   Dementia
   Stroke
   Spinal cord disease/injury
Colorectal disorders
   Diarrheal illness
   Diabetic autonomic neuropathy
   Rectal sphincter damage

TABLE 8-20 CAUSES OF CONSTIPATION

Diet low in bulk and fluid
Poor toilet habits
Immobility
Laxative abuse
Colorectal disorders
   Colonic tumor, stricture, volvulus
   Painful anal and rectal conditions (hemorrhoids, fissures)
Depression
Drugs
   Anticholinergic
   Narcotic
Diabetic autonomic neuropathy
Endocrine or metabolic
   Hypothyroidism
   Hypercalcemia
   Hypokalemia

Appropriate management of constipation will prevent fecal impaction and resultant fecal incontinence. The first step in managing constipation is the identification of all possible contributory factors. If the constipation is a new complaint and represents a recent change in bowel habit, then colonic disease, endocrine or metabolic disorders, depression, or drug side effects should be considered (see Table 8-19).

Proper diet, including adequate fluid intake and bulk, is important in preventing constipation. Crude fiber in amounts of 4 to 6 g (equivalent to 3 or 4 tablespoons of bran) a day is generally recommended. Improving mobility, body positioning during toileting, and the timing and setting of toileting are all important in managing constipation.

Defecation should optimally take place in a private, unrushed atmosphere and should take advantage of the gastrocolic reflex, which occurs a few minutes after eating. These factors are often overlooked, especially in nursing home settings.

A variety of drugs can be used to treat constipation (Table 8-21). These drugs are often overused; in fact, their overuse may cause an atonic colon and contribute to chronic constipation ( cathartic colon ).

TABLE 8-21 DRUGS USED TO TREAT CONSTIPATION

TYPE	EXAMPLES	MECHANISM OF ACTION
Stool softeners and lubricants	Dioctyl sodium succinate Mineral oil	Soften and lubricate fecal mass
Bulk-forming agents	Bran Psyllium mucilloid	Increase fecal bulk and retain fluid in bowel lumen
Osmotic cathartics	Milk of magnesia Magnesium sulfate/citrate Lactulose Sorbitol	Poorly absorbed and retain fluid in bowel lumen; increase net secretions of fluid in small intestine
Stimulants and irritants	Cascara Senna Bisacodyl Phyenolphthalein	Alter intestinal mucosal permeability; stimulate muscle activity and fluid secretions
Enemas	Tap water Saline Sodium phosphate Oil	Induce reflex evacuations
Suppositories	Glycerin Bisacodyl	Cause mucosal irritation

Laxative drugs can also contribute to fecal incontinence. Rational use of these drugs necessitates knowing the nature of the constipation and quality of the stool. For example, stool softeners will not help a patient with a large mass of already soft stool in the rectum. These patients would benefit from a glycerin or irritant suppositories.

The use of osmotic and irritant laxatives should be limited to no more than three or four times a week.

Fecal incontinence from neurological disorders is sometimes amenable to biofeedback therapy, although most severely demented patients are unable to

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cooperate. For those patients with end-stage dementia who fail to respond to a regular toileting program and suppositories, a program of alternating constipating agents (if necessary) and laxatives on a routine schedule (such as giving laxatives or enemas three times a week) is often effective in controlling defecation.

Experience suggests that these measures should permit management of even severely demented patients. As a last resort, specially designed incontinence undergarments are sometimes helpful in managing fecal incontinence and preventing complications. Frequent changing is essential, because fecal material, especially in the presence of incontinent urine, can cause skin irritation and predispose to pressure ulcers.

References

American Medical Directors Association: Urinary Incontinence: Clinical Practice Guideline. Columbia, MD, AMDA, 1996.

Appell RA: Clinical efficacy and safety of tolterodine in the treatment of overactive bladder: a pooled analysis. Urology 50(Suppl 6A):90 96, 1997.

Burgio KL, Locher JL, Goode PS, et al: Behavioral vs. drug treatment for urge urinary incontinence in older women. JAMA 280(23):1995 2000, 1998.

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