A history of urine leakage (generally small amounts) during periods of increased abdominal pressure (laughing, sneezing, coughing, lifting, high-impact physical activity) suggests a diagnosis of stress UI (SUI). SUI is related to urethral-sphincter changes that result in impaired support and/or closure, as well as pelvic-floor weakness. SUI is generally more common in younger women than in older women.
Sudden overwhelming feelings of urgency or the inability to prevent urine leakage before arriving at the bathroom is generally considered urge UI (UUI). UUI occurs most commonly in women over the age 65 years and is associated with detrusor overactivity (DO) or uninhibited bladder contractions. With aging, there is thought to be some impairment in central nervous system activity along with DO. The neuronal control of the LUT is complex, and disruption of the pathways can lead to UI.13
Mixed UI (MUI) is a combination of symptoms related to both urge and stress UI. In most cases, MUI can be identified while gathering the patient history. Generally, a cluster of symptoms will occur more frequently with each individual patient. MUI is the second most common type of UI in older women.
Although less common in older adults, a history of continual dampness or frequent dribbling, with or without a sensation of fullness, may indicate a diagnosis of overflow UI. The loss of urine in this manner is associated with bladder distension related to inefficient bladder emptying or outflow obstruction.13,14
Functional UI (FUI) has more to do with issues outside the GU tract, as many individuals presenting with this type of leakage have intact voiding systems. No clear-cut symptoms identify UI as functional, other than the older woman’s self-report of specific difficulties, which may include inability to reach the bathroom independently, limited access or lack of caregiver assistance.
After other types of incontinence are ruled out, FUI becomes a diagnosis of exclusion given cognitive and functional status. Individuals presenting with these symptoms generally have positive outcomes if the cause is identified and altered. FUI can be associated with transient or potentially reversible causes of UI.
Potential barriers to diagnosis
The literature is filled with explanations of why UI continues to be underdiagnosed and undertreated. Older women have attributes or issues that contribute to the problem, such as considering the topic to be taboo, being powerless over the condition, or believing that UI is inevitable with aging or not a serious medical condition requiring treatment.15,16 Lack of knowledge, inaccurate information and misperceptions on the part of the patient can delay appropriate diagnosis and treatment of UI. Individuals who are actively engaged in the control of their health experience have been found to have a better QOL.17,18 An improved QOL leads to a happier and healthier woman. Clinicians can empower women to gain control over their UI.
Clinicians have been generally reluctant to incorporate evidence-based UI guidelines into their practice.19 The literature indicates that older women are not asked about urine leakage, and fewer than 50% of women experiencing leakage report the problem to their provider.20 The current education of health-care providers is insufficient to improve detection and treatment of UI.20,21 UI is a complicated disorder, and many clinicians feel they do not have the time to acquire the subjective and objective data needed to make a diagnosis or develop a treatment plan.
The most important aspect of evaluating and managing UI is to initiate a dialogue by asking, “Do you ever leak urine or have difficulty getting to the toilet in time?” Every older woman should be asked this question routinely. If the answer is yes, an evaluation should follow.
A thorough and age-appropriate history is the single best tool for gathering accurate information about urine leakage. The amount and frequency of the incontinence should not be the determining factor in proceeding with a thorough assessment. If urine leakage is discovered, in any amount, evaluation is warranted.
The purpose of a systematic evaluation is to identify potentially reversible or transient causes of UI, recognize individual patient risk factors, and determine the actual or potential effect of UI on QOL and functional status. A consistent approach to evaluation will enable the clinician to develop a set of interventions that target the risk factors and causes for each older woman. All these data need not be collected in one patient visit, and printed materials can be sent to the patient to complete at home prior to an office visit.
Transient UI (TUI) usually refers to leakage or other symptoms of relatively new onset and is often based on factors outside the GU tract. TUI may be temporary or reversible, acute or chronic (persistent). Determining and treating underlying issues, including depression and cognitive impairment, may lead to leakage resolution.
History. A focused, holistic history related to urine leakage should be obtained. Initially, the history can be brief and targeted to identify UI type.22 In many instances, the type of UI can be diagnosed through history alone. At a second patient visit, a detailed review of the patient’s medical (including obstetrical) and surgical history to identify pre-existing or comorbid conditions can be accomplished.
A review of systems should identify sensory, mobility, or functional problems, as well as cognitive or emotional disorders, and can elicit clues to a change in functional status, weight, eating habits or fluid intake.23 Asking the woman how urine leakage has impacted QOL is imperative.
During the focused history, the woman should be questioned about usual bladder habits; frequency; urgency; hesitancy; leakage with coughing, sneezing, laughing, bending, lifting, or physical activity; difficulty starting and maintaining the urine stream; a feeling of bladder fullness that persists after urination; and straining to complete the voiding process. Asking about UTI history, GU tract procedures and any history of catheterization is crucial.
Nighttime voiding pattern, sleep and rest patterns, usual activity pattern, bowel habits, dysuria and pain on urination are also important aspects of the history-gathering process. Duration and severity of all symptoms should be assessed. Asking about prior UI interventions and outcomes is informative as well.
A basic social history — generally related to lifestyle choices and culture — is also very important. Topics that need to be covered include smoking/tobacco history, alcohol use, hobbies, leisure or recreational interests, exercise pattern and any illicit drug use. Gathering data on level of education, occupation and sexual history can also provide cues for treatment and for establishing patient goals.
If possible, the patient should be asked to complete a 24-hour dietary recall or similar nutrition/fluid diary and bring the document to the next visit. This information helps the clinician to understand dietary habits, favorite foods and drink and alcohol consumption.
Reviewing the data with the patient helps to ensure a better understanding of eating and drinking patterns and consumption of potential bladder irritants. In addition, since many older women engage in socialization at mealtime, this is a logical point at which to ask about social support, relationships and use of available community resources.
Questions about living arrangements and the environment should also be posed. Lighting, steps, rugs and floor coverings, location and number of bathrooms and distance to the bathroom may be important. Understanding the living environment helps the clinician make positive suggestions that may enable the patient to maintain independence with relatively modest environmental changes versus recommending a different living situation.