Defined as involuntary loss of urine.
Causes. Causes of transient incontinence include
delirium, infection, atrophic vaginitis or urethritis, drugs, including
sedatives, hypnotics, diuretics, opiates, calcium-channel blockers,
anticholinergics (antidepressants, antihistamines), decongestants, and others.
Less common causes include depression, excess urine production (diabetes,
diabetes insipidus), restricted mobility (i.e., patient cannot get to the bathroom),
and stool impaction.
Types of Incontinence and Their Specific Causes.
Urge incontinence. Involuntary loss of urine associated with a sudden urge and
desire to void. Associated with detrusor overactivity.
Causes include neurologic disorders (such as stroke, multiple sclerosis),
urinary tract infections, and uroepithelial cancer.
Stress incontinence. Involuntary loss of urine during
coughing, sneezing, laughing, or other increases in intra-abdominal pressure.
Most commonly seen in women after middle age (especially with repeated
pregnancies and vaginal deliveries), stress incontinence is often a result of
weakness of the pelvic floor and poor support of the vesicourethral sphincteric
unit. Another cause is intrinsic urethral sphincter weakness such as that from
myelomeningocele, epispadias, prostatectomy, trauma, radiation, or sacral cord
Overflow incontinence. Involuntary loss of urine associated with overdistension
of the bladder. May have frequent dribbling or present as urge or stress incontinence.
May be attributable to underactive bladder, bladder outlet obstruction (such as
tumor, prostatic hypertrophy), drugs (such as diuretics), fecal impaction,
diabetic neuropathy, or vitamin B12 deficiency.
Functional incontinence. Immobility,
cognitive deficits, paraplegia, or poor bladder compliance.
Evaluation. Confirm urinary incontinence and identify
factors that might contribute:
History, including medications and provoking factors.
Physical, including abdominal exam, pelvic exam, rectal exam, sensation in the
rectal and perineal area, edema, drugs.
Do stress testing. Have patient cough or sneeze.
UA and microscopic examination of urine. Urine
culture, if warranted.
Check postvoid residual; will be increased by outlet obstruction, neurogenic
Follow timing of incontinence. Observe patient urinating and watch for signs of
Cystometry with flow rates, etc., may be needed if cause clinically inapparent.
Treatment. Set goals and scoring system ahead of time.
Most patients will respond to behavioral techniques. Most require structured
input from nursing personnel.
Bladder training. Need education, scheduled voiding,
and rewards. Must inhibit urinating until a set time, and
this set amount of time should be progressively increased. Start at 2 to
3 hours and progress upward. 12% may become entirely continent, and 75% may
have a 50% reduction in incontinent episodes. Works best in urge incontinence
but also may help stress incontinence.
Habit training. Teach patients to void when they
normally would (e.g., morning, before bed, after meals).
Prompted voiding. Especially good in
cognitively impaired individuals. Reduced incontinent
episodes by about 50%.
Pelvic floor exercises (Kegel exercises). Especially useful in stress
incontinence; 16% cure rate and 54% improve.
Intermittent catheterization may also be used.
For urge incontinence, bladder spasms, detrusor instability.
Oxybutynin (Ditropan, Ditropan XL), tolterodine (Detrol) (low
incidence of dry mouth). Tolterodine is expensive and no more
efficacious than is oxybutynin. Second-line drugs include propantheline (may
affect smooth muscle in the small bowel), flavoxate (Urispas), hyoscyamine
sulfate (Levsin, Levsinex), and tricyclic antidepressants.
For stress incontinence. Agents that
increase bladder outlet resistance (e.g., pseudoephedrine).
For men. Treating obstructive prostatic symptoms may
help (see section on BPH).
In women. Estrogen may be useful for stress and urge
incontinence (start with half applicator of estrogen cream every other day and
increase to 1 applicator QHS if needed or used orally as for postmenopausal
use). The efficacy of estrogen has been questioned by double-blind studies. May need surgical repair.
Newer products include Introl bladder neck support prosthesis (similar to
pessary and assists women with incontinence secondary to urethral
hypermobility), Reliance urinary control insert, magnetic
A 55-year-old woman
has had profuse watery diarrhea for 3 months. Laboratory studies of fecal water
show the following:
Sodium: 39 mmol/L
Potassium: 96 mmol/L
Chloride: 15 mmol/L
Bicarbonate: 40 mmol/L
Osmolality: 270 mosmol/kg H2O (serum osmolality: 280 mosmol/kg H2O)
The most likely diagnosis is
A villous adenoma
B lactose intolerance
C laxative abuse
D pancreatic insufficiency
E nontropical sprue
The answer is A
In the case described, the osmolality of fecal water is approximately equal to
serum osmolality. Furthermore, there is no osmotic 'gap' in the fecal
water; the osmolality of the fecal water can be accounted for by the stool
electrolyte composition: = [2 (39 + 96)] = 270. A
villous adenoma of the colon typically produces a secretory diarrhea. Lactose
intolerance, nontropical sprue, and excessive use of milk of magnesia produce
osmotic diarrheas with osmotic 'gaps' caused by lactose,
carbohydrates, and magnesium, respectively. Pancreatic insufficiency causes
steatorrhea, not watery diarrhea.