Urinary incontinence

Urinary and/or fecal incontinence is quite common among elderly people. Urinary incontinence is most common
in elderly people.This pathology is heterogeneous in nature and can be manifested by episodes of involuntary
discharge of small amounts of urine or constant uncontrollable urination.

This extreme form of urinary incontinence is often accompanied by involuntary defecation. Patients with this
pathology may not have any mental disorder and may not follow a strict bed rest regime. According to statistics,
urinary incontinence affects about 30% of elderly women and 15-20% of men.

Unfortunately, most medical professionals believe that urinary or fecal incontinence in the elderly is not
treatable. This opinion is not correct, because not infrequently proper treatment is quite effective. Even if it is
not possible to achieve the desired result, appropriate care and creation of conditions significantly alleviates the
condition of such patients.

When talking, elderly patients often deliberately avoid answering questions related to incontinence or deny such
events altogether. Therefore, it is very important for the doctor to show meticulous tact and skill in detecting this
condition. The patient can be asked such questions as: "Have you been having trouble with your bladder lately?"
or "Have you been urinating involuntarily?
 The normal process of urination
• Controlled retention of urine requires adequate and coordinated functioning of the lower urinary tract, psyche, factors regulating the
urination process, proper motivation and appropriate conditions. During urination, afferent impulses (via somatic and autonomic nerve
fibers) from the overflowing bladder are transmitted to the appropriate center in the spinal cord. Sympathetic impulses cause contraction
of the neck of the bladder and relaxation of its base against the background of inhibition of parasympathetic tone. Through somatic
innervation, the tone of the small pelvic muscles, including the periurethral muscles, is also maintained.

• During urination, the sympathetic and somatic tone decreases, and the parasympathetic cholinergic impulse increases, which causes the
bladder to contract and its neck to relax. The process described in the norm is subject to the corresponding control centers of the brain
stem, cortex and cortex. It is established that the cortex of the brain mainly has an inhibitory effect, and the brain stem has a stimulating
effect on the urination process. Accordingly, when the inhibitory action of the cerebral cortex weakens (for example, during dementia,
stroke, Parkinson's disease), urinary incontinence may develop.

• Normal urination Normal urination is a dynamic process, the realization of which requires the coordinated action of a number of
physiological factors. When the bladder is full, the intravesical pressure remains low (<115 Hg). The urge to urinate usually occurs when
the amount of urine in the bladder reaches 150-300 m

• At the beginning of urination, the tone of the bladder emptying muscle (detrusor) increases, the resistance of the urethra decreases, and
the urination process continues until the pressure developed by the detrusor exceeds the tone of the urethral sphincter. If at any point in
the bladder filling process the intra-bladder pressure exceeds the tone of the urethral sphincter, urine begins to leak prematurely. One of
the reasons for this condition can be a cough against the background of a relaxed urethral sphincter. The bladder can also contract
spontaneously, which is also manifested by urinary incontinence (in the case of detrusor instability - the so-called detrusor hyperreflexia).
Causes of urinary incontinence in the elderly

Neurological Diseases
Urological Diseases

functional/Psychological
iatrogenic/
factors
environmental
factors
The main causes and types of urinary incontinence

• Reversible urinary incontinence

• Hard urinary incontinence
 Conditions that cause reversible urinary incontinence
Conditions treatment
lower urinary tract pathology
infection Antibacterial therapy

Atrophic vaginitis/urethritis Estrogen orally or topically

Constipation Constipation

passing large amounts of urine (polyuria)

Disruption of metabolism (hyperglycemia, hypercalcemia) Treatment of the underlying disease (correction of diabetes,
hypercalcemia)

Polydipsia Limiting intake of diuresis-stimulating (eg, caffeinated) beverages

Hypervolemia
Venous insufficiency Elevating feet, limiting sodium intake, special treatment

heart failure Pathogenic treatment

Medicines causing urinary incontinence

medication the result of his action

diuretics Polyuria, Polakiuria

Anticholinergic drugs Urine retention

Tricyclic antidepressants Anticholinergic action, sedation

Sedatives and sleep aids Sedation, delirium, restriction of movement, muscle relaxation

Narcotic analgesics Urinary retention, constipation, sedation, delirium

Angiotensin converting enzyme inhibitors (first generation) A cough that promotes urinary incontinence

beta-blockers Urine retention

Calcium channel blockers Urine retention

alcohol Polyuria, sedation, delirium, restriction of movement

caffeine Polyuria, irritation of the bladder

Hard urinary incontinence

stressful urinationDriven by
insatiable desire

Due to overflow
dysfunctional
 The main types of hard urinary incontinence and their causes
Type of incontinence
stressful
Due to insatiable urge to urinate
Due to bladder overflow
dysfunctional
definition
Involuntary release of urine as a result of
increased intra-abdominal pressure.
Involuntary release of urine due to inability to
voluntarily stop this process
Involuntary urination occurs due to bladder
atony and/or urethral obstruction
Inability to use the toilet due to physical and/or
mental condition
the main reason
 relaxation of small pelvic muscles, urethral hypermobility;
 Decreased tone of the bladder neck or urethral sphincter
 detrusor hyperactivity, isolated or associated;
 with diseases of the urogenital organs (cancer, stones, diverticula,
urinary tract obstruction);
 Central nervous system diseases (stroke, dementia, parkinsonism,
spinal cord injury)
 anatomical obstruction (prostatic hyperplasia, stricture, cystocele);
 Bladder atony (diabetes mellitus, spinal cord injury);
 Neurogenic (detrusor/sphincter asynergy), associated with multiple
sclerosis or suprasacral spinal cord injury
 marked dementia;
 restriction of movement.
Stress urinary incontinence is particularly common in older women and is usually due to increased intra-
abdominal pressure and/or urethral sphincter relaxation.

Episodes of involuntary urination are relatively rare, and urine is excreted in small volumes. Urinary stress
incontinence usually does not require special treatment.

In some cases, they resort to surgical correction. The main causes of this type of incontinence are a
decrease in the tone of the muscles of the small pelvis (as a result of which hypermobility of the bladder
neck and urethra develops), estrogen deficiency, frequent pregnancies, surgical operations on the small
pelvic organs.

After vaginal plastic surgery, relaxation of the urethra (the so-called primary deficiency of the urethral
sphincter - Intrinsic sphincter deficiency - ISD) may develop, which is characterized by urinary incontinence
during any physical exertion (for example, during coughing).

In men, stress urinary incontinence develops very rarely - for example, in case of damage to the urethral
sphincter during transurethral surgery or radiation therapy for tumors of the lower urinary tract.
Urinary incontinence due to bladder overflow develops due to urethral
obstruction and/or detrusor atony.

The most frequent causes of this type of incontinence are prostatic hyperplasia,
diabetic neuropathic bladder, urethral stricture.

Relatively less often, urinary incontinence is caused by damage to the lower

segments of the spinal cord, anatomical obstruction of the urethra (in women)
and some medication.

Cases have been described when detrusor/sphincter asynergy developed when

the suprasacral region of the spinal cord was damaged (for example, in multiple
sclerosis), which, in turn, led to urinary retention and eventually urinary
incontinence.

A sphincterotomy is recommended to treat this condition.

In dysfunctional incontinence, the patient is unable (due to physical or
mental condition) to use the toilet.

Dysfunctional incontinence is often combined with other types of incontinence

(so-called mixed incontinence), which makes it more difficult to distinguish
between them.
 Basic components of the diagnosis of reversible urinary incontinence

routine examination • Functional tests of kidneys

• Anamnesis • Ultrasound examination of the kidneys
• physical examination
• Gynecological examination
• Urine analysis
• Urological examination
• Residual urine volume
• Cystourethroscopy
Special examination • Study of urodynamics
• Laboratory examination • Routine examination of bladder function
• Bacteriological study of urine
• Cytological study of urine Complex examination of the bladder
• Determination of blood glucose and calcium levels • Fluorometry of urine
• Cystography
Evaluation of the urination process
• Urethral pressure profilometry
• Determining the provoking role of cough • Electromyography of the urethral sphincter
• Simple cystometry • Video urodynamics
 Basic anamnesis data in reversible urinary incontinence
Co-existing pathology

• Neurological disorders, diabetes, chronic heart failure, varicose veins.

• prescribed medications

• Mode of fluid intake other symptoms

• Fluid intake and its volume, especially before going to bed.
• Neurological (information indicating stroke, parkinsonism,
hydrocephalus, spinal cord compression, multiple sclerosis)
The state of the genitourinary system
• psychological (depression)
• Frequency of childbirth, undergone surgical operations, past episodes of urinary retention,
urinary tract infection.
• Stomach activity
• swelling
Symptoms of incontinence

• onset and duration

• Type of incontinence environmental factors

• Frequency
• Possibility to use the toilet
• Dysuric events
• Use of toilet substitutes (urine collection system, diapers,
• Nocturia
"Pampers")
• Peculiarities of urine flow (fast, slow, intermittent, etc.)
Diagnosis in Reversible Urinary Incontinence

Examination
• Anamnesis
• P.E
• Urine Analysis
• Residual Urine Volume
• Functional tests of kidney 
• USG
• Cystourethroscopy
• Bacteriological study
The main components of the examination in irreversible urinary incontinence

Assessment of movement ability Rectal examination

Assessment of mental state • Perianal pain
• Sphincter tone
Assessment of neurological status
• Prostate size
• Local symptoms (especially in the lower limbs)
• Symptoms of Parkinson's disease
• Assessment of lumbar reflexes
Examination of the small pelvis
Examination of abdominal organs • pelvic muscle Hypersensitivity
• Degree of bladder filling • Detection of atrophic vaginitis
• Pain in the pubic area
• Constipation and fecal retention • Presence of cystocele or rectocele
 The main methods of treatment of urinary incontinence

Non-specific methods of treatment Periurethral infections

• Educational work with patients
• Changing fluid and medication regimens
surgical treatment
• Use of toilet substitutes when necessary
• Bladder neck fixation
Bladder training • Obstruction fixation
• “Biofeedback” method
• electrical stimulation mechanical means
• Pelvic muscle training • Artificial sphincter

Medical treatment
Catheterization
• Diuretic muscle relaxants
• temporary
• Agonists of alpha-adrenoreceptors
• Alpha-adrenoceptor antagonists • permanent
• Estrogen
 The main methods of treatment of urinary incontinence

• Pelvic muscle training (Kegel method) is one of the important components of urinary incontinence
treatment. This exercise involves inducing repeated, controlled contraction and relaxation of the
pelvic muscles. The patient is suggested to try to control the process of urination (for example,
temporarily withhold urination, and then continue again). This exercise should be repeated quite
often (about 40 times) during the day.

• Electrical stimulation is also used to train pelvic muscles. This method, which involves stimulation of
the urinary bladder with impulses of different frequencies, is quite effective in suppressing
spontaneous contractions of the urinary bladder.

• the so-called The "biofeedback" method is based on the determination of vaginal or rectal pressure
or electromyography, as well as electrography of the abdominal muscles, which helps the patient to
control the contraction of the pelvic muscles and the relaxation of the abdominal muscles
Diagnosis in Irreversible Urinary
Incontinence
• Mental state
• Movement
• Rectal examination
• Perianal pain
• Sphincter tone
• Prostate
• Check for Parkinson's symptoms
• Examine small pelvis
• Pelvic muscle hypersensitivity
• Cystocele
• Rectocele
Treatment
• Pelvic Floor Management
• Bladder Management 
• Medical Management
• Surgical Management
Pelvic Floor Management
• Kegel Method is one of the most important methods that is used for
training pelvic muscles.
• Kegel exercise is also known as pelvic-floor exercise, involves
repeatedly contracting and relaxing the muscles that form part of the
pelvic floor.
• Patient is advised to withhold the process of urination for some time
and then continued. This is to be repeated often.
• Electrical stimulation method is also used. Urinary bladder is
stimulated with impulses that are of varying frequencies. Mostly used
for suppressing spontaneous contractions of the bladder.
Pelvic Floor Muscle Exercises
(Kegels)

“Squeeze like you’re trying to hold back gas”

Bladder Management
• Bladder management includes micturition and toilet training as well
as pelvic floor exercises.
• Toilet training and pelvic floor training are of particular importance in
incontinence in the elderly.
• These therapeutic measures need to be individually tailored, however,
taking into account patients’ mobility, motivation, and cognitive
competence.
 Medical treatment
medicine dose mechanism of action Type of incontinence Side effects

Anticholinergic spasmolitic
and

Oxybutynin (Ditrophan) 25-50 mg 3 times a day Suppression of spontaneous bladder Urinary incontinence due to an insatiable Dry mouth, impaired vision,
contractions urge to urinate or mixed type. increased intraocular pressure,
delirium, constipation

Imipramine (Tofranil) 25-50 mg 3 times a day Suppression of spontaneous bladder Urinary incontinence due to an insatiable Dry mouth, impaired vision,
contractions urge to urinate or mixed type. increased intraocular pressure,
delirium, constipation

Conjugated estrogen

vaginal (esstring) once in 3 months Improvement of blood supply of periurethral Stress incontinence
tissues

Oral (Premarin) 0.625 mg/d Strengthens the tone of periurethral tissues Urinary incontinence associated with Endometriosis, arterial hypertension,
atrophic vaginitis occurrence of gallstones.

Cholinergic agonists

bethanechol (urecholin) 1-4 mg 1 time per day relaxation of the urethra and prostate capsule. Insatiable urge to urinate, prostatic positional (postural) hypotension).
hyperplasia.

alpha-adrenergic receptor antagonists

Tamsulosin (Flomax) 0.4-0.8 mg 1 time a day relaxation of the urethra and prostate capsule Insatiable urge to urinate, prostatic positional (postural) hypotension).
hyperplasia.
surgical treatment

• Surgical treatment is primarily indicated for elderly women who are resistant to medical treatment,
suffering from stress-type urinary incontinence, as well as for prolapse of the pelvic organs or
weakness of the urethral sphincter.

• Surgical intervention can be effective in case of mixed type of urinary incontinence and in the case of
motor instability of the sphincter muscle. The goal of the operation is to fix the neck of the bladder,
which not infrequently gives a rather long (about 5 years) remission. Currently, periurethral collagen
injection is increasingly used to treat sphincter dysfunction, which is considered an alternative to
surgical treatment.

• In men, surgical treatment is indicated when urinary incontinence is caused by an anatomic defect
(for example, resection of a hyperplastic prostate). Artificial sphincter implantation is carried out in
case of significant relaxation of the sphincter recently.