1148

SECTION 9 Problems of Urinary Function

TABLE 46-18

TYPES OF URINARY INCONTINENCE

TYPE AND DESCRIPTION

Stress Incontinence*

CAUSES

TREATMENT

Sudden increase in intraabdominal pressure

causes involuntary passage of urine.
Can occur during coughing, laughing,
sneezing, or physical activities such as
heavy lifting, exercising.
Leakage usually in small amounts and may
not be daily.

Found most commonly in women with relaxed

pelvic floor musculature (from delivery, use
of instrumentation during vaginal delivery, or
multiple pregnancies).
Structures of the female urethra atrophy when
estrogen decreases.
Prostate surgery for BPH or prostate cancer.

Pelvic floor muscle exercises (e.g., Kegel exercises),

weight loss if patient is obese, cessation of
smoking, topical estrogen products, external
condom catheters or penile clamp in men, surgery
Urethral inserts, patches, or bladder neck support
devices (e.g., incontinence pessary) to correct
underlying problem

Condition is caused by uncontrolled contraction

or overactivity of detrusor muscle.
Bladder escapes central inhibition and contracts
reflexively.
Conditions include central nervous system
disorders (e.g., cerebrovascular disease,
Alzheimers disease, brain tumor, Parkinsons
disease), bladder disorders (e.g., carcinoma
in situ, radiation effects, interstitial cystitis),
interference with spinal inhibitory pathways
(e.g., malignant growth in spinal cord,
spondylosis), and bladder outlet obstruction,
conditions of unknown etiology.

Treatment of underlying cause

Biobehavioral interventions including bladder
retraining with urge suppression, decrease in
dietary irritants, bowel regularity, and pelvic floor
muscle exercises
Anticholinergic drugs (e.g., oxybutynin [Ditropan XL,
Oxytrol], tolterodine [Detrol, Detrol LA], trospium
chloride [Sanctura], solifenacin [VESIcare], and
darifenacin [Enablex]); imipramine (Tofranil) at
bedtime; calcium channel blockers
Containment devices (e.g., external condom
catheters)
Vaginal estrogen creams
Absorbent products

Disorder is caused by bladder or urethral outlet

obstruction (bladder neck obstruction, urethral
stricture, pelvic organ prolapse) or by underactive detrusor muscle caused by myogenic
or neurogenic factors (e.g., herniated disk,
diabetic neuropathy).
May also occur after anesthesia and surgery
(especially procedures such as hemorrhoidectomy, herniorrhaphy, cystoscopy).
Neurogenic bladder (flaccid type).

Urinary catheterization to decompress bladder

Implementation of Cred or Valsalva maneuver
-adrenergic blocker (doxazosin [Cardura], terazosin
[Hytrin], tamsulosin [Flomax], alfuzosin [Uroxatral])
5-reductase inhibitors (e.g., finasteride [Proscar]) to
decrease outlet resistance
bethanechol (Urecholine) to enhance bladder
contractions
Intravaginal device such as a pessary to support
prolapse
Intermittent catheterization
Surgery to correct underlying problem

Spinal cord lesion above S2 interferes with

central nervous system inhibition.
Disorder results in detrusor hyperreflexia and
interferes with pathways coordinating detrusor
contraction and sphincter relaxation.

Treatment of underlying cause

Bladder decompression to prevent ureteral reflux
and hydronephrosis
Intermittent self-catheterization
diazepam (Valium) or baclofen (Lioresal) to relax
external sphincter
Prophylactic antibiotics
Surgical sphincterotomy

Fistulas may occur during pregnancy, after

delivery of baby, as a result of hysterectomy
or invasive cancer of cervix, or after radiation
therapy.
Incontinence is found as postoperative
complication after transurethral, perineal,
or retropubic prostatectomy.

Surgery to correct fistula

Urinary diversion surgery to bypass urethra and
bladder
External condom catheter
Penile clamp
Placement of artificial implantable sphincter

Elderly often have problems that affect balance

and mobility.

Modifications of environment or care plan that facilitate regular, easy access to toilet and promote
patient safety (e.g., better lighting, ambulatory
assistance equipment, clothing alterations, timed
voiding, different toileting equipment)

Urge Incontinence*
Condition occurs randomly when involuntary
urination is preceded by urinary urgency.
Seen with overactive bladder symptoms of
urgency and frequency.
Leakage is periodic but frequent and usually
in large amounts.
Nocturnal frequency and incontinence are
common.

Overflow Incontinence
Condition occurs when the pressure of
urine in overfull bladder overcomes
sphincter control.
Leakage of small amounts of urine is
frequent throughout the day and night.
Urination may also occur frequently in
small amounts.
Bladder remains distended and is usually
palpable.

Reflex Incontinence
Condition occurs when no warning or stress
precedes periodic involuntary urination.
Urination is frequent, is moderate in volume,
and occurs equally during the day and
night.

Incontinence After Trauma or Surgery

Vesicovaginal or urethrovaginal fistula may
occur in women.
Alteration in continence control in men
involves proximal urethral sphincter
(bladder neck and prostatic urethra) and
distal urethral sphincter (external striated
muscle).

Functional Incontinence
Loss of urine resulting from cognitive,
functional, or environmental factors.

BPH, Benign prostatic hyperplasia.

*Patients can have a combination of stress and urge incontinence referred to as mixed incontinence.