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Evaluation and Management of Incontinence in Females

Michelle S. Eslami, M.D.

The Scope of the Problem Urinary incontinence (UI) is a common problem affecting over 17 million Americans most of whom are women and the elderly. In 1995, the estimated yearly cost of managing incontinence in the U.S. is $26 billion.1 The prevalence of UI increases with age but it is not a part of normal aging. UI affects 25% of repro- ductive age women, 50% of post-menopausal women, and 50%-75% of women in nursing homes with a strong association with dementia, fecal incontinence, and the inability to walk and transfer independently.2,3 Despite this, UI remains under diagnosed and underre- ported with only 32% of primary care physicians routinely asking all of their patients about UI, and 50%-75% of incontinent community-dwelling patients never describing their symptoms to physicians.3

Risk factors for UI include impaired functional and mobility status, impaired cognition, multiple pregnancies/vaginal delivery/episiotomy, estrogen depletion, hysterectomy, obesity (BMI > 30 kg/m2), smoking, and medications.4,5(Table 1)

Physiology of Micturition The detrusor muscle is innervated by the cholingeric nervous system via the sacral plexus (S2-S4) which when stimulated, contracts the bladder to cause emptying of the bladder. The bladder outlet has two components. The internal urethral sphincter is inner- vated by the alpha-adrenergic nervous system via the hypogastric plexus (T11-L2) which when stimulated, contracts the internal urethral sphincter to cause

Table 1: Medications that May Affect Continence

  • Sedatives, hypnotics - sedation, delirium, immobility

  • Alcohol - polyuria, frequency, urgency

  • Anticholinergics, antipsychotics, antidepressants, antihistamines - urinary retention, overflow incontinence, fecal impaction, delirium

  • Narcotic analgesics - urinary retention, sedation, fecal impaction

  • Alpha-adrenergic antagonist - urethral relaxation, stress UI

  • Alpha-adrenergic agonist - urinary retention

  • Calcium channel blockers, dihydropyridines - urinary retention, nocturnal urination

  • Potent diuretics - polyuria, frequency, urgency

  • ACE inhibitors - drug induced cough

storage of urine. The distal component, the external urethral sphincter, is innervated by the somatic nervous system via the pudendal nerve which also innervates pelvic floor muscles and is under voluntary control. The storage of urine occurs when the detrusor muscle relaxes and the sphincters close. The normal bladder stores between 300 to 600 cc with the first urge to void between 150 to 300 cc. Emptying of the bladder occurs with detrusor contraction and the opening of the sphincters as true detrusor pressure increases and exceeds urethral resistance. The hormonal effects of estrogen also play a role on the urethra and pelvic floor musculature whereby estrogen deficiency can reduce the effectiveness of sphincters and pelvic muscles and may exacerbate "stress" urinary incontinence. Estrogen deficiency can also predispose women to urethritis, atrophic vaginitis, and trigonitis/cystitis, all of which may exacerbate "urge" urinary incontinence.6

Potentially transient causes of UI are usually present for less than eight weeks and can be remem- bered by the DIAPPERS mnemonic.7(Table 2) If incontinence still exists after eliminating these possi- bilities, then the patient may have persistent UI. Urge incontinence (a.k.a. detrusor instability, detrusor hyperreflexia, overactive bladder, and irritable bladder) is a common cause of UI especially in women over 75 years of age.8 Patients complain of loss of urine preceded by strong urge to void (urgency) and frequency that can occur during both

day and include stones,

night. It is bacterial atrophic

usually idiopathic but other causes

cystitis, bladder tumor,



bladder stroke,

Table 2: Reversible Causes of Urinary Incontinence (DIAPPERS)

D- I- A- P-

Delirium Infection Atrophic vaginitis or urethritis Pharmaceuticals: benzodiazepines, alcohol, diuretics, anti-

cholinergic agents, alpha-adrenergic agents, calcium channel blockers P - Psychological disorders E - Endocrine disorders, excessive urine production R - Restricted mobility S - Stool impaction


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