Urinary incontinence, or involuntary loss of urine, plagues more than 30% of community-living individuals older than 60 years of age, 50% of hospitalized older adults, and 60% of residents in long-term care facilities. These estimates may be low because individuals often fail to report symptoms of urinary incontinence, perhaps owing to the attached social stigma. Health care professionals often neglect to elicit such information as well.
Incontinence is an expensive problem. A conservative estimate of cost for direct care of adults with incontinence is more than $15 billion annually.43 Urinary incontinence can have deleterious consequences, such as social isolation and embarrassment, depression and dependency, skin rashes and pressure sores, and financial hardship. Although urinary incontinence is a common disorder, it is not considered a normal aspect of aging. Studies reveal that 60% to 70% of community-dwelling older adults with urinary incontinence can be successfully treated and even cured.
Changes in the micturition cycle that accompany the aging process make the older adult prone to urinary incontinence. Decreases in bladder capacity, in bladder and sphincter tone, and in the ability to inhibit detrusor (i.e., bladder muscle) contractions, combined with the nervous system's increased variability to interpret bladder signals, can cause incontinence (see Chapter 37). Impaired mobility and a slower reaction time also can aggravate incontinence.
The causes of incontinence can be divided into two categories: transient and chronic. Of particular importance is the role of pharmaceuticals as a cause of transient urinary incontinence. Numerous medications, such as long-acting sedatives and hypnotics, psychotropics, and diuretics, can induce incontinence. Treatment of transient urinary incontinence is aimed at ameliorating or relieving the cause on the assumption that the incontinence will resolve.
Chronic, or established, urinary incontinence occurs as a failure of the bladder to store urine or a failure to empty urine. Failure to store urine can occur as a result of detrusor muscle overactivity with inappropriate bladder contractions (i.e., urge incontinence). There is an inability to delay voiding after the sensation of bladder fullness is perceived. Urge incontinence is typically characterized by large-volume leakage episodes occurring at various times of day. Urethral incompetence (i.e., stress incontinence) also causes a bladder storage problem. The bladder pressure overcomes the resistance of the urethra and results in urine leakage. Stress incontinence causes an involuntary loss of small amounts of urine with activities that increase intraabdominal pressure, such as coughing, sneezing, laughing, or exercising.43-45
Failure of the bladder to empty urine can occur because of detrusor hyper-reflexia, resulting in urine retention and overflow incontinence. Also called neurogenic incontinence, this type of incontinence can be seen with neurologic damage from conditions such as diabetes mellitus and spinal cord injury. Outlet obstruction, as with prostate enlargement and urethral stricture, also can cause urinary retention with overflow incontinence. Functional incontinence, or urine leakage due to toileting problems, occurs because cognitive, physical, or environmental barriers impair appropriate use of the toilet.44,45
After a specific diagnosis of urinary incontinence is established, treatment is aimed at correcting or ameliorating the problem. Probably the most effective interventions for older adults with incontinence are behavioral techniques.
These strategies involve educating the individual and providing reinforcement for effort and progress. Techniques include bladder training, timed voiding or habit training, prompted voiding, pelvic floor muscle (i.e., Kegel) exercises, and dietary modifications. Biofeedback, a training technique to teach pelvic floor muscle exercises, uses computerized instruments to relay information to individuals about their physiologic functions. Biofeedback can be helpful when used in conjunction with other behavioral treatment techniques. Use of pads or other absorbent products should be seen as a temporary help measure and not as a cure. Numerous types of products are available to meet many different consumer needs.
Pharmacologic intervention may be helpful for some individuals. Estrogen replacement therapy in postmeno-pausal women, for example, was thought to help relieve stress incontinence. However, it is no longer recommended as a treatment approach, in light of newer information about the cardiovascular side effects and increased cancer risks that estrogen can pose. Drugs with anticholinergic and bladder smooth muscle relaxant properties (e.g., oxy-butynin, tolterodine) may help with urge incontinence. These medications are not without side effects, however, and their use must be carefully weighed against the possible benefits.
Surgical intervention may help to relieve urinary incontinence symptoms in appropriate patients. Bladder neck suspension may assist with stress incontinence unrelieved by other interventions, and prostatectomy is appropriate for men with overflow incontinence due to enlarged prostate. However, older adults may have medical conditions that preclude surgery. Other treatments include intermittent self-catheterization for some types of overflow incontinence.
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