? Involuntary loss of urine.
? Stress incontinence: leakage of urine upon coughing, sneezing, or standing.
? Urge incontinence: urgency and inability to delay urination.
? Overflow incontinence: may have variable presentation.
? General Considerations
Incontinence in older adults is common, and interventions can improve most patients. Many patients fail to tell their providers about it. A simple question about involuntary leakage of urine is a reasonable screen: “Do you have a problem with urine leaks or accidents?”
Because continence requires adequate mobility, mentation, motivation, and manual dexterity, problems outside the bladder often result in incontinence. In general, the authors of this chapter find it useful to differentiate between “transient” or “potentially reversible” causes of incontinence and more “established” causes.
A. Transient Causes
Use of the mnemonic “DIAPPERS” may be helpful in remembering the categories of transient incontinence.
1. Delirium—A clouded sensorium impedes recognition of both the need to void and the location of the nearest toilet. Delirium is the most common cause of incontinence in hospitalized patients; once it clears, incontinence usually resolves.
2. Infection—Symptomatic urinary tract infection commonly causes or contributes to urgency and incontinence. Asymptomatic bacteriuria does not.
3. Atrophic urethritis or vaginitis—Atrophic urethritis can usually be diagnosed presumptively by the presence of vaginal mucosal telangiectasia, petechiae, erosions, erythema, or friability. Urethral inflammation, if symptomatic, may contribute to incontinence in some women. Some experts suggest a trial of topical estrogen in these cases.
4. Pharmaceuticals—Drugs are one of the most common causes of transient incontinence. Typical offending agents include potent diuretics, anticholinergics, psychotropics, opioid analgesics, a-blockers (in women), a-agonists (in men), and calcium channel blockers.
5. Psychological factors—Severe depression with psychomotor retardation may impede the ability or motivation to reach a toilet.
6. Excess urinary output—Excess urinary output may overwhelm the ability of an older person to reach a toilet in time. In addition to diuretics, common causes include excess
fluid intake; metabolic abnormalities (eg, hyperglycemia, hypercalcemia, diabetes insipidus); and disorders associated with peripheral edema, with its associated heavy nocturia when previously dependent legs assume a horizontal position in bed.