Urinary Incontinence (UI)

Dr. Khaled Alakhali PhD

Learning Outcome
✓ Define the term urinary incontinence.
✓ Describe the epidemiology of urinary incontinence.
✓ Discuss the etiology and pathophysiology of urinary
incontinence.
✓ Discuss the classification of urinary incontinence.
✓ Identify the drugs which may induce urinary incontinence.
✓ Describe the clinical presentation of urinary incontinence
✓ Discuss various treatment of urinary incontinence and its
monitoring.

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Urinary Incontinence (UI)
✓ UI is defined as involuntary urine loss and is a condition that is
not always recognized or reported.

✓ Individuals may be reticent to self-report UI to health

providers due to embarrassment, yet it can negatively impact
dignity and contribute to increased social isolation

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The epidemiology of UI in elderly people
✓ Approximately 30% of older adults within the community and
almost 60% of individuals residing in long term care facilities
are affected by UI.
✓ Prevalence in population over age of 60 years old.
✓ Although the prevalence of UI increases with age, it is not
considered a normal part of aging.
✓ The incidence in men is about one third that of women, but at
the age of 80, men and women have similar rate of UI.
✓ Peak incidence in women occurs around menopause and
increase steadily after the age of 65.
✓ Several studies reported the prevalence rate of UI among
Malaysian elderly in which ranged from 7% to 42%,

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Causes of UI
✓ Delirium and dementia
✓ Infections
✓ Atrophic vaginitis, atrophic urethritis and atonic bladder.
✓ Physiological causes, depression
✓ Pharmacologic agents
✓ Endocrine (diabetes, hypercalcemia, hypothyroidism)
✓ Restricted mobility
✓ Stool impaction
✓ Neurologic impairment, immobility, female gender, and
hysterectomy are independent risk factors for UI.

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Pathophysiology of UI
The urinary tract

✓ The lower urinary tract consist of bladder (with detrusor muscle),

urethra, urinary sphincter, and musculofascial components, including
nerves, connective tissue, and blood vessels.
✓ Urination is controlled by the CNS, the spinal cord, and the
peripheral nerves. The para sympathetic nervous system, the
sympathetic nervous system, and the somatic nervous system all
work together to proceed proper bladder control.
✓ Overall, bladder physiology and micturition are regulated by the
action of various neurotransmitters and nervous system.
✓ Acetylcholine is the major neurotransmitter responsible for bladder
contraction and interacts with muscarinic receptors on the detrusor
muscle.
✓ UI occurs as a result of over-functioning or under-functioning of
urethra sphincter, bladder, or both

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Pathophysiology of UI
✓ Urethral sphincter (innervated by SNS) maintain adequate
closure to resist flow of urine from bladder until micturition
centre located in CNS response to bladder distension or
fullness
✓ Bladder emptying occurs when
✓ Bladder detrusor muscle (innervated by PNS) contraction is
coordinated with
✓ Urethra sphincter relaxation leading to urethra opening
✓ M2 & M3 receptors are in detrusor muscle normally exist in
ratio 3:1, M3 is pathogenic in causing involuntary bladder
contraction, while M2 mediate volitional contraction
✓ M3 receptors are responsible for both
✓ The emptying contraction associated with urination and
✓ Involuntary bladder contractions that lead to UI (due to
overstimulation)

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Aging-related physiological changes within
urinary tract
✓ Reduced detrusor muscle strength leading to decrease bladder
wall elasticity and bladder capacity (300 ml in elderly
comparing to 400ml in young adults)
✓ Decreased muscle strength also lead to incomplete bladder
emptying
✓ Involuntary/spontaneous bladder contractions in 20% of
normal continent elderly
✓ In women:
✓ Weaken urethral closing pressure or resistance in women
(postmenopausal decline in estrogen production)
✓ In men:
✓ Prostate enlargement caused blockage to urine flow
✓ Despite age being an important risk factor, UI is not an
inevitable consequences of aging i.e. it is pathogenic

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Drug induced UI
✓ α1 antagonists (e.g Prazosin) have been associated with female
stress incontinence they have a relaxant effect on smooth
muscle.
Others drugs include:
✓ Diuretics: increases bladder filling, diuresis, polyuria lead to
urge UI
✓ ACEIs: cough lead to stress UI
✓ Narcotic analgesics: bladder relaxation lead to overflow UI
✓ α adrenergic agonists (e.g pseudoephedrine): urethral
constriction, retain urine lead to overflow UI
✓ Sedative hypnotics: delirium lead to Functional UI
✓ Neuroleptics and antipsychotics: bladder relaxation, retention
lead to overflow UI
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Acute incontinence
✓ Acute incontinence is urinary incontinence that is recent or
associated with acute medical problems e.g.,:
✓ Cystitis
✓ Atrophic vaginitis
✓ Urethritis
✓ CHF
✓ DM
✓ Delirium, and Immobility.
✓ First treat reversible conditions.
✓ Women with urethritis and atrophic vaginitis can benefit from
intravaginal estrogen cream administered nightly for 7 days
followed by at least once weekly application thereafter or oral
conjugated estrogen 0.625 mg/day

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Classification of UI
Persistent UI occurs in 4 forms
1. Urge incontinence
✓ Most common form affecting the elderly and occurs when
involuntary voiding is preceded by a warning of a few seconds to
a few minutes.
✓ It is characterized by precipitous (rash or fast) urine leakage.
✓ It is most often associated with involuntary contraction of the
bladder or detrusor motor instability caused by:
✓ Neurological disorder. (Parkinson's Disease, Stroke)
✓ Endocrine: (Diabetes induced polyuria)
✓ Local infection: (Urinary Tract Infection, Cystitis)
✓ Treatment is with:
✓ Anticholinergic (antispasmodic) agent
✓ Oxybutynin, propantheline, flavoxate, dicyclomine, imipramine

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2. Stress incontinence

✓ The involuntary leakage that occurs only when there is an

abrupt increase in intra abdominal pressure (coughing,
sneezing, laughing, lifting) that overcomes urethral resistance.

✓ Primarily occurs in elderly women and is due to weakness and

laxity of the pelvic floor musculature.
✓ Risk factors of stress incontinence: Estrogen deficiency and a
genetic defect in the connective tissue may contribute.
✓ Obesity and aging
✓ Rare in men except when urethra sphincter was surgically
damaged during transurethral resection of prostate (TURP)
✓ Treatment by Phenylpropanolamine, pseudoephedrine,
imipramine, or estrogens.

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3. Overflow incontinence
✓ Occur when the weight of urine in a distended bladder
overcomes outlet resistance.
✓ Typically there is leakage of small amounts throughout the day.
✓ Patients complain of hesitancy, diminished and interrupted
flow.
✓ Patient need to strain to void, and a sense of incomplete
emptying.
✓ It usually results from an anatomical outlet obstruction this
may be due obstructed urinary out flow due to BPH, prostate
cancer, fecal impaction and neurogenic bladder
✓ Treatment is with:
✓ Prazosin (0.5 to 1 mg daily at bedtime) or
✓ Bethanechol 10 mg TID.

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4. Functional incontinence
✓ It occurs when a individual is unable or unwilling to reach
the toilet to urinate.
✓ Patients with cognitive or physical impairments.
✓ Associated with musculoskeletal disorder, muscle
weakness, impaired mental status.
✓ Treatment:
✓ Assisted with commode or bedpan and preferred in weak
elderly to prevent potential falls
✓ Catheterization
✓ Last resort
✓ Risk of UTI

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Treatment
Non pharmacological
1. Intra vagina pessary
✓ As a bulking agent to support area of pelvic in uterus prolapse
lead to improve urethral closure in SUI
✓ Long term use requires monitoring for vaginal infection and
ulcer

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Cont.,
2. Pelvic muscle Rehabilitation and exercises
✓ Pelvic floor muscle exercise (Kegel exercises)
✓ Contract pelvic floor muscle for 5 seconds and relax for 5 seconds
repeated for 5 times each episode at 3 times daily
✓ Strengthen urethral muscle to improve functioning in Stress and
Urge UI
✓ Build bladder capacity to reduce bladder distention and Urge UI

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Cont.,
3. Behavioural therapy
✓ Regular toilet voiding schedule
✓ Every 2 hrs during waking
hours
✓ To minimize the volume of
urine in bladder
✓ Helpful in urge, overflow and
functional UI
4. Catheterization
✓ Foley catheter, a soft, plastic or
rubber tube inserted into the
bladder to drain the urine
✓ Usual resort in overflow or
functional incontinence

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Cont.,
Drug therapy
✓ Drug therapy is aimed at modifying bladder contractility
(anticholinergic agents, since the major neurohormonal
stimulation for bladder muscle contraction is acetylcholine)
and increasing bladder outlet resistance (imipramine,
sympathomimetics, estrogens).
✓ Urge
✓ Oxybutynin 2.5 mg daily TID (anticholinergic)
✓ Flavoxate 100 mg TID-QID (anticholinergic)
✓ Dicyclomine 10-20 mg TID (anticholinergic)
✓ Propantheline 15-30 mg TID (antimuscarinic)
✓ Imipramine 25 mg daily TID (tricyclic agent)

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Cont.,
Stress
✓ Pseudoephedrine 15-30 mg BID-TID (sympathomimetics)
✓ Imipramine 25 mg daily (tricyclic agent)
✓ Conjugated estrogens 0.625 mg daily
✓ Vaginal estrogen cream 0.5-1 gm 2 times/week
Overflow
✓ Prazosin 0.5-1 mg daily (usually at bedtime) (alpha-antagonists)
✓ Bethanechol 10 mg TID (cholinergic)
Functional
✓ None

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Cont.,
Monitoring of UI treatment
✓ Incontinence record
✓ Every 2 hours observation to evaluate improvement in urinary
frequency and urgency
✓ Dryness checks
✓ Quantify use of incontinence pad or shields (diapers)
✓ Side effects of drugs manage xerostomia by dosage
reduction or chew sugarless gum or saliva substitutes
✓ UI related Quality of life
✓ Using survey instruments

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Reference:
✓ Hutchinson LC, Sleeper, RB. Fundamentals of Geriatric
Pharmacotherapy: An Evidence- Based Approach. 2nd ed:
American Society of Health-System Pharmacists; 2015.
✓ DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM.
Pharmacotherapy: A Pathophysiologic Approach. 10th ed:
McGraw-Hill; 2016.
✓ Koda-Kimble MA, Young LY, Caroline S. Zeind, Michael G.
Carvalho. Applied Therapeutics: The Clinical Use of Drugs. 11th
ed: Lippincott Williams & Wilkins; 2018.

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