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Thursday, 26 April 2012


Urinary incontinence (UI) in older women is an under addressed problem by patients and clinicians. In general, women's rates of UI are twice that of men and are a problem for 80% of institutionalized elder (e.g. living in nursing homes.) Because women don't bring it up (less than half in some studies) and clinicians don't screen, clinicians miss the more than one out of three women with this condition. A woman's lifetime risk is 30-60% This 'miss' is incredibly expensive. It is expensive in terms of quality of life (women have greater isolation, depression, anxiety, falls/fractures as well as bedsores and admission to long term care facilities) - but it is expensive in care delivery. Excluding cost of long term care facilities, some estimates are up to $20 billion dollars (about 1/3 are for absorbant products alone)

More than one in five young women have IU, for middle aged women the range is about 42-56 percent and in elderly the number is about 75%. With boomers, booming, we will see more and more of IU. Clinicians and patients alike need to be more aware and discuss this.

So, the breakdown of types of IU and urine leakage include functional (mobility or access reasons); stress (pressure overcomes pelvic muscles); urgency (bladder signals urination is needed and releases urine); mixed reasons and overflow (this occurs more in men than women but is often seen in neurological conditions or as a result of medications). Overactive bladders refers to bladder wall hyperreactivity that creates urgency (but leakage does not occur) It is also important to recognize that the urinary incontinence can be associated with rectal or fecal incontinence, so even if not identified by the patient, elements of rectal tone should be included in the evaluation.
Women at higher risk include - ethnicity being Caucasian, being postmenopausal; having multiparity; having a higher BMI, using hormonal therapy; having Diabetes/Sleep Apnea/CHF; having neurologic diseases (Parkinsons, MS) An interesting point I came upon is that women with two or more of the following (DM, HTN, Back Pain, Arthritis, COPD;  hearing/visual deficits; cognitive deficits; parkinsons) are also a higher risk.

The pelvic muscles are an amazing grouping of muscles. It is extremely rare in a human body to have a muscle group simultaneous contract and relax in a coordinated fashion. That's what the pelvic floor does. That is why you can void without deficating and deficate without voiding. It is also why the coordination can get confused - post hysterectomy or birth or trauma.

In older women - more than 50% have mixed UI. So it is important to assess if it is stress or urgency predominant in order to treat.  One item jumps out when reviewing contributing factors of incontinence and that is the functional status and the ability to void.

We have no practice standard to assess functional strength of pelvic muscles (and maybe we should!!) So if pelvic floor muscles are weak, women will have IU. How we hydrate and when we void are another important element.

Many people only urinate when they feel they can't hold any more urine and are very uncomfortable. The 'waiting until your eyes turn yellow' approach is NOT bladder healthy. 

Retraining on intake and urination is important in addressing incontinence and bladder diaries are used to guide this. Some women have to schedule getting up and voiding in their daily calendar to remind them and that is one strategy that can work. Another important piece of information about hydration is that is you are dehydrated, concentrated urine is an irritant and can contribute to the sense of urgency!
A reversible element a clinician must screen for is urinary infection (taking into consideration that asymptomatic bactiuria should not be treated.) Functional status is also important. If gait is unsteady or arthritis is severe and transfers take a long time, incontinence can results. If there are sensory deficits (vision, hearing) o if it takes far longer to get to the toilet than is planned, women can have leakage. Sometimes, soft cognitive deficits (which can be hidden) are the reason why strategies to address incontinence don't work.

Medications also play a role - these include caffeine and alcohol as well as diuretics.
As seen in the chart, multiple medications can have a urinary effect. It is reasonable to consider that if a patient has polypharmacy, she should be screened for incontinence.

CHECK IT OUT - HOT OFF THE PRESSES APRIL 2012!! Info for clinicians and consumers here: 


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