Urinary Incontinence in Individuals With Diabetes Mellitus 23/05/19 10.

58

Diabetes Spectrum
Volume 11 Number 4, 1998, Pages 241-247

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Urinary Incontinence in Individuals With Diabetes

Mellitus

Adeline M.Yerkes, BSN, MPH

In Brief
Urinary incontinence, a common and costly symptom, is a
problem many health care providers will encounter among
their caseload of people with diabetes.

Dysfunctions of urination have long been known as a problem associated with

diabetes, although the literature on the subject is limited. The neurogenic bladder is
more commonly discussed in the literature as an issue related to such chronic
conditions and diseases as spinal cord lesions, muscular dystrophy, and multiple
sclerosis.

Also called cystopathy, the neurogenic bladder is considered a form of autonomic

neuropathy. It begins with selective damage to autonomic afferent nerves, leaving
motor function intact but impairing the sensation of bladder fullness and, therefore,
resulting in decreased urinary frequency. As this neuropathy progresses, autonomic
efferent nerves become involved, leading to incomplete bladder emptying, urinary
dribbling, and overflow incontinence. This article will focus on the diagnosis and
management of urinary incontinence.

Although less than 1% of all neuropathies are related to the neurogenic bladder,1 due
to the prevalence of diabetes, the prevalence of obesity (a risk factor for urinary
incontinence) among patients with type 2 diabetes, and the overall prevalence of
urinary incontinence (especially among women), most health care practitioners are
likely to encounter patients with urinary incontinence.

URINARY CONTINENCE AND MICTURITION

Urinary continence is the storage of urine, and micturition is the discharge of urine.
These processes require an intact nervous system and a functional lower urinary
tract.

Anatomy
The lower urinary tract of importance to urinary continence and micturition includes
the detrusor muscle and the urethral sphincter, which act together as a coordinated

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unit to control the storage and expulsion of urine.2-4 Relaxation of the detrusor
muscle, together with closing of the urethral sphincter, allows for the storage of
urine, whereas detrusor contraction and sphincter relaxation result in voiding.

The storage and periodic elimination of urine depends on a complex neural control
system that coordinates autonomic and somatic nerve activity to various distal sites,
including the detrusor muscle, regions of the bladder, the urethra and urethral
sphincter, and the striated muscles of the pelvic floor. The detrusor muscle is
innervated primarily by the parasympathetic nervous system,5 which increases the
contractility of the muscle and responses to cholinergic activity. The bladder and the
urethra are innervated by the sympathetic nervous system, which causes the local
receptors to stimulate contractions at the bladder base and proximal urethra.5,6 The
urethral sphincter is controlled by the somatic nervous system.

There are four nervous-system loops for control of micturition, including the cerebral
hemispheres, the spinal cord, and the local nervous system.5 Disruption at any of the
loops can cause urinary dysfunction.

Physiology
The act of micturition can be both a reflex and a voluntary activity.5 As the bladder
fills with urine and distends, signals of fullness are sent to the brain, which in turn
sends a message of urgency to the urethral sphincter, telling it to relax and allow the
flow of urine. In infants, micturition is a reflex only, but as the central nervous
system matures and by the age of 4–5 years, children learn to control the reflex by
contracting the appropriate muscles. In adults, the muscles of the abdomen and
pelvic floor can be made to contract and relax voluntarily.

If one wishes to urinate, one relaxes these muscles. This learned behavior allows an
increase in intra-abdominal pressure and voluntary relaxation of the pelvic floor and
perineal muscles. The result is a decrease in the urethral closure pressure, descent of
the pelvic floor and bladder base, and initiation of a reflex detrusor muscle
contraction, which allow the urine to flow through the urethral outlet.

Changes With Aging

The aging process contributes to the inability to postpone voiding, a relaxed urethra,
and decreased urinary flow rates.3,4 For women, the urethral closure pressure and
urethral length decline, and post-voiding residual (PVR) volume and uninhibited
bladder contractions both appear and increase. In young people, most urine is
excreted during the day, whereas older adults excrete most of their urine during the
night.

URINARY INCONTINENCE
Definition
In simple terms, urinary incontinence is defined as urinating at the wrong time and in
the wrong place. It is not a disease, but rather is a symptom of underlying
dysfunction of the urinary bladder or urethra. Urinary incontinence can be transient
or chronic.

Impact
Urinary incontinence is a common and costly problem in the U.S. population. More

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than 13 million Americans are affected by this condition, which results in an

economic burden of $20 billion annually. Recent community-based studies of
noninstitutionalized individuals have reported urinary incontinence to occur in 1.5–
5% of men versus 10–30% of women aged 15–64 years. For those over 60 years of
age, the rate is 15–35%, with twice as many women than men experiencing the
condition.7-9 Although prevalence increases with increasing age, the aging process
should not be considered a normal cause of urinary incontinence.

Not only a physical problem, urinary incontinence also affects an individual’s

psychological state and quality of life. It is a major factor underlying the placement
of individuals in personal care institutions. More than 50% of all nursing home
residents are incontinent.10

Table 1. Risk Factors Associated

With Urinary Incontinence
immobility low fluid intake
impaired cognition high-impact physical activities
various medications, such as diuretics diabetes mellitus
smoking stroke
fecal impaction estrogen depletion
morbid obesity pelvic muscle weakness
childhood nocturnal enuresis multiple pregnancies delivered vaginally

Source: Agency for Health Care Policy and Research: Urinary Incontinence in
Adults: Acute and Chronic Management. Clinical Practice Guideline. Washington,
D.C., U.S. Public Health Service, Department of Health and Human Services,
AHCPR, 7:19–71, 1996

Risk Factors
Obesity and diabetes are included among the risk factors associated with urinary
incontinence.11 Other risk factors are presented in Table 1.

Types
There are four basic types of chronic urinary incontinence. Classification depends on
whether the bladder empties completely and is of normal size, or whether it retains
urine and becomes over-distended. When the bladder empties completely and is of
normal size, the cause is detrusor muscle overactivity and/or sphincter outlet
incompetence.3,11 When the bladder retains urine and becomes over-distended, the
cause is detrusor muscle inactivity or outlet obstruction.

Urge incontinence. Urge incontinence is due to detrusor muscle over-activity. Here,

the bladder empties completely and is of normal size, but the person cannot
voluntarily retain urine, because the detrusor muscle contracts when it should not.

The primary symptom associated with urge incontinence is involuntary loss of urine
associated with a strong desire to void (i.e., urgency).11 Although urge incontinence
may be associated with neurological disorders, it is also found in individuals with

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normal neurological systems. A common neurological disorder associated with urge

incontinence is stroke. People with urge incontinence and neurological deficits may
have increased PVR volumes, symptoms of obstruction, and stress or overflow
incontinence.9

Stress incontinence. Stress incontinence is incontinence due to inability of the

urethral sphincter to generate enough resistance to retain urine (i.e., it is open when it
should be closed). This urethral incompetence can be caused by displacement of the
urethra and/or bladder neck or by hypermobility of the urethra.11 As with urge
incontinence, the bladder empties completely and is of normal size.

The primary symptom of stress incontinence is involuntary loss of urine during

coughing, sneezing, laughing, or other physical activities that cause increased intra-
abdominal pressure. Stress incontinence can be caused by trauma, congenital
anomalies, or sacral spinal cord lesions.12 People with stress incontinence tend to
have continuous leakage.

Overflow incontinence. Overflow incontinence is due to over-distention of the

bladder.11 This over-distention is related to the retention of urine secondary to an
underactive or noncontracting detrusor muscle or to obstruction of the urethra or
bladder outlet. These abnormalities can be caused by drug therapy, neurological
conditions (such as diabetic neuropathy), low spinal cord injuries, or radical pelvic
surgeries. In men, overflow incontinence is generally associated with prostatic
hyperplasia obstruction. In women, outlet obstruction is rare but can occur with
severe uterine or other pelvic organ prolapse, multiple sclerosis, or spinal cord
injuries.

The symptoms of overflow incontinence appear in a variety of manifestations:

frequent dribbling, constant dribbling, and symptoms of urge or stress incontinence.

Overflow incontinence is associated with the neurogenic bladder.

Mixed incontinence. The fourth type of incontinence is mixed incontinence. This is

a combination of one or more of the above types.

Table 2. Primary Symptoms of the Neurogenic Bladder

impaired sensation of bladder fullness
weak urine stream
periodic or constant dribbling, or unexplained sudden urination
need to strain to void
sensation of incomplete bladder emptying
urinary retention or a post-void
residual volume of 90–500 ml of urine
urinary tract infections

NEUROGENIC BLADDER AND URINARY INCONTINENCE IN

INDIVIDUALS WITH DIABETES MELLITUS
Definition
The neurogenic bladder progresses from mild loss of sensation of bladder fullness to

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bladder paralysis. Due to decreased recognition of the need to void, the interval
between micturitions gradually increases, such that voiding only occurs once or
twice a day. Frequently, the person must strain to void, has a weak stream, dribbles,
and usually feels a sensation of incomplete bladder emptying.13,14 Table 2 presents
other symptoms of the neurogenic bladder.

Prevalence
Only a small number of people with diabetes experience preferential autonomic
nervous system involvement, the cause of the neurogenic bladder.1,15,16 Of all the
neuropathies, <1% are related to the neurogenic bladder.1 Neurogenic bladder is seen
as a comorbidity with gastroparesis, abnormal sweating, or orthostatic
hypertension.13 (Several large, community-based studies have demonstrated that
diabetes and some form of urinary incontinence co-exist in 6.5% of all women with
urinary incontinence.17)

Diagnosis
Due to the fact that individuals often do not report urinary incontinence and delay
seeking help for the condition, it is imperative that physicians question their patients
about the condition. To stimulate conversation related to the problem, questions on
the health history form can cue the physician to problems.18

The basic evaluation should include a history, physical examination, measurement of

PVR volume, and urinalysis.11,19,20 This basic evaluation performed by the primary
care physician can provide an accurate diagnosis of either transient or chronic
urinary incontinence. Patients with urge, stress, or mixed stress and urge
incontinence, normal PVR volumes, and no other complicating features should not
be referred for further urodynamic testing. Patients with overflow incontinence
should be referred for further urodynamic testing.

Table 3. Critical Health History Factors

duration of urinary incontinence (both in length of years and frequency of
incontinence)
frequency, timing, and approximate number of both continent voids and
incontinent episodes
precipitants of incontinence (cough, sneezing, types of exercise, activity,
surgeries, pregnancies, new medications, new illness/disease, injuries)
lower urinary tract symptoms, such as hematuria, nocturia, dysuria,
hesitancy, poor or interrupted stream, straining or needing to press down on
the abdominal area to void, perineal pain
fluid intake, including caffeine-containing or artificially sweetened drinks
alterations of bowel or sexual habits
previous treatment of urinary incontinence or genitourinary surgeries
amount and type of pads, diapers, briefs, or homemade garments used
mental status
mobility, and ability to perform activities of daily living
living environment (number of bathrooms in home, distance to bathroom,
operating toilet)
social factors (living arrangements, isolation, social contacts, caregiver

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involvement)

Health history. To aid in the diagnosis of urinary incontinence, the health history
should contain questions to identify risk factors and symptoms.11 For patients with
known urinary incontinence, the health history should contain a 7-day voiding
schedule that identifies time of voidings, time of incontinent accidents, changing of
pads/barrier protection, and activity at time of accident.

A careful health history must be taken to determine whether the incontinence is

transient or chronic. Table 3 includes critical factors for inclusion in the health
history.

The examination should include:11

general physical examination to determine edema, mobility and manual

dexterity, skin integrity and hydration, or neurological abnormalities;
abdominal examination to check for peritonitis, fluid collection,
organomegaly, or masses;
rectal examination to check for fecal impactions, sphincter tone, perineal
sensation, or rectal masses, and to conduct a prostate exam for men;
genital examination in males to examine the structures and perineal skin and
in females to assess perineal skin condition, genital atrophy, pelvic organ
prolapse, pelvic masses, pelvic muscle tone (have the woman attempt to
tighten pelvic muscles around inserted gloved finger during a vaginal
examination); and
direct observation of urine loss by conducting a cough stress test (have the
patient cough vigorously, and observe for urine loss from the urethra).

Urological testing. Urological testing for overflow incontinence associated with

diabetes should include conducting an estimate of PVR volume and urinalysis, as
well as performing urodynamic tests such as multichannel or voiding
cystometrogram with electromyography, uroflowmetry, and
cystourethroscopy.11,19,20 Patients should be referred to a urologist for urodynamic
tests.

PVR volume. The PVR volume can be determined by catheterization or pelvic

ultrasound. The person should void just a few minutes before either the
catheterization or the ultrasound. Amounts of 50 ml or less of urine retained are
considered normal. The PVR volume should be determined a minimum of two times
in order to adequately estimate PVR volumes.

Urinalysis. Increases in PVR volume, or incomplete bladder emptying, places the

patient at increased risk for bladder infections. Urinalysis is utilized to detect
hematuria, pyuria, and bacteuria.

Multichannel cystometrogram. The multichannel cystometrogram measures intra-

abdominal, total bladder, and true detrusor pressures simultaneously and can
determine involuntary detrusor contractions and bladder incompetence. This test is
utilized primarily to determine detrusor muscle integrity. When conducted with

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electromyography of the striated muscle of the urethral sphincter, this test measures
the integrity and function of the nerves and evaluates the detrusor muscle
innervation. For people with diabetes and cystopathy, the tests generally reflect
impaired sensation of the nerves that innervate the bladder and may show
hyperreflexia of the detrusor muscle.

Voiding cystometrogram. The voiding cystometrogram, or pressure flow study, rules

out urodynamic obstruction and measures detrusor contractions.

Uroflowmetry. Uroflowmetry measures urine flow visually and is useful in

identifying abnormal voiding patterns or difficulty in emptying the bladder. People
with diabetes and cystopathy generally have a low peak and long duration flow
associated with residual urine. Voiding entails straining marked with short,
interrupted spurts of urine.

MANAGEMENT OF URINARY INCONTINENCE AND CYSTOPATHY

There are three general categories of management: behavioral, pharmacological, and
surgical. Because so many women with diabetes suffer co-existing urge, stress, or
mixed incontinence, this area will be discussed, as well as measures to treat
cystopathy. As men age, prostatic hypertrophy or prostatic cancer may be the cause
of stress or overflow urinary incontinence.

The goals of management are to lessen the episodes of incontinence, use the least
invasive treatment with the fewest adverse effects, and meet the goals and
expectations of the person with the condition.11 Behavioral techniques will be
discussed first, followed by pharmacological approaches and then surgical
techniques. First, however, educational strategies for health care professionals will be
addressed.

Educational Strategies for Health Care Professionals

Behavioral outcomes for people with urinary incontinence include improved
knowledge of the anatomy, physiology, and pathophysiology of the lower urinary
tract, improved tone of the pelvic muscles, improved toileting schedule, and
improved fluid intake. A few simple strategies, detailed below, can assist patients in
reaching their goals. These strategies assume that the patient and health care
professionals have established that the patient is the team leader and that the health
care professionals involved are the coaches or resource network to aid in meeting the
goals.

Education regarding normal voiding schedule. One educational strategy is to teach

these individuals about the normal voiding schedule.11,21,22 Most adults urinate
about every 2–3 hours. The average person urinates 6–8 times a day. People over the
age of 50 years frequently have at least one episode of nocturia, which is normal with
the aging process.

People with urinary incontinence will often urinate every 15–30 minutes to
compensate for and manage incontinence during the waking hours. This frequent
urination lessens bladder capacity and detrusor tone. By using a toileting schedule,
health care professionals can assist patients with timing of voids, better design their
medication regimens, and help them to increase fluid intake.

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Instruction in the use of a voiding/fluid diary. Another strategy to teach patients with
urinary incontinence is the use of a voiding/fluid diary. In this tool, the patient
records (by time of day) how much fluid was drunk, when urine was passed, whether
it was passed purposefully or by accident, what caused any accidents, and when
bladder training exercises were performed. This should be kept for 1–8 weeks,
depending on the other treatment modalities. The diary can increase a person’s
knowledge about urinary incontinence and the causes and frequency of incontinent
episodes.11,21,23

The diary is a learning tool for both people with urinary incontinence and for the
health care professionals who coach them. Health care professionals and people with
urinary incontinence can identify critical points in behavioral management, such as
timing of medications, fluid intake, and anticipated continence and incontinence.
With the diary, anticipatory guidance can be given to reinforce positive behaviors.
The diary can graphically show people with incontinence their personal progress
over time. Individuals must keep the diary for at least 6 weeks to show some type of
sustained progress.

Education regarding fluid intake. A third educational strategy is instructing the

person about fluid intake.11,21,24 Frequently, people with incontinence will limit their
fluid intake. This results in concentrated urine, which can cause irritation and
detrusor or sphincter irritability.

Discuss the benefits of drinking water, the amount of water our bodies need in the
day, and the stimulating effects of caffeine and artificial sweeteners. Caffeine and
artificial sweeteners act as natural stimulants and cause fluid flushes within 15–20
minutes after consumption. For some people, acidic beverages or foods will have the
same stimulating effect. Counsel individuals to decrease their intake of caffeine
products and increase water consumption.

Instruction regarding the urge wave. A fourth educational strategy is to counsel

people with urinary incontinence on the urge wave.24 The urge wave is the normal
urge feelings that come in waves. First, a person feels a little urge, which grows and
peaks, and then finally subsides.

People with urge incontinence have trained themselves to urinate at the height of the
urge. Assisting people with understanding the urge wave, focal point relaxation, or
breathing relaxation techniques can promote conscious activity used to deter
urination at the most urgent moment.

Behavioral Techniques
Behavioral techniques lessen the number of episodes of urinary incontinence in most
individuals. There are no potential side effects if the techniques are taught and
monitored by a knowledgeable professional. Behavioral techniques do not limit other
treatment options.11,21

The behavioral techniques discussed in this paper require active participation and
education of patients with the problem. Successful management rests with well-
taught, motivated patients. Unfortunately, there are usually other physical or
functional impairments that make compliance and self-care management difficult.

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Bladder retraining (including relaxation techniques), pelvic muscle exercises,

biofeedback, and intermittent catheterization will be discussed as the behavioral
techniques.

Bladder training. Although varying levels of bladder inactivity or sensation may be

present, bladder training may be helpful in some people. It is strongly recommended
for the treatment of both men and women with urge and mixed incontinence.11,21,23-
26 Bladder training also assists with managing stress incontinence. Bladder training
has three components: education, scheduled voiding with gradual systematic delay of
voiding, and breathing or focal point relaxation skills.

The educational aspect of bladder training combines written, visual, and verbal
coaching. Individuals are taught about the physiology and pathophysiology related to
the lower urinary tract and the urge wave. Using simple drawings of the body, pelvic
sling, and urinary system can help individuals visualize what occurs with the bladder,
detrusor muscle, and the urethral sphincter. Graphic display of the urge wave is also
helpful.24-26

In bladder training, individuals must resist or inhibit the sensation of urgency,

postpone voiding, and urinate according to a timetable. Professionals and patients use
two tools: a voiding diary to review previous voiding habits and accidents, and a
toileting schedule to record progress in delayed voiding.

The initial goal for delayed voiding is a time interval of 15 minutes. The delay time
should be gradually increased so that intervals between voiding reach 2–3 hours.
Starting with only a few minutes of delay gives individuals control. Positive
reinforcement comes from being able to delay or postpone voiding.

Establish with patients the times during the day when they can manage the voiding
schedule and delay voiding. The literature reflects that 75% of cognitive participants
will decrease incontinence episodes by 50% and that this behavior can be sustained
for 6 months or more.27

Breathing relaxation techniques or focal point visioning (distraction technique) are

used to help inhibit the urge wave. A relaxation and distraction technique to teach
patients can be as follows:

When the urge sensation strikes, sit down or stand quietly.

Squeeze the muscles around where you urinate "together and in." You can
squeeze those muscles often in quick repetition.
Relax the rest of your body and your mind. Concentrate on your breathing,
either slow relaxing breaths or short shallow ones.
You may want to try to think about something else pleasurable while you are
waiting for the urge to subside.
After the urge sensation goes away, wait a few minutes and then go to the
bathroom. Try to urinate regardless of whether you feel the urge.

In some people, a "triggering methodology" may be helpful for initiating bladder

contractions. For example, a person may tap the suprapubic abdominal wall until
voiding starts. Others use the Valsalva or Credé maneuvers to assist in voiding. The
Credé maneuver is the most common and is performed by applying pressure
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suprapubically and directly over the bladder until it empties.

Pelvic muscle exercises. Pelvic muscle exercises are strongly recommended to

prevent or decrease the incidence of urinary incontinence. These exercises are
strongly recommended as a management strategy for stress incontinence, are
recommended as treatment for urge incontinence, and may benefit men who develop
urinary incontinence following prostatectomy.

Pelvic muscle exercises are also called Kegel exercises.11,24-26,28 Individuals are
taught to "draw in" or "lift up" the perivaginal muscles and the anal sphincter as if to
control urination or defecation with minimal contraction of abdominal, buttock, or
inner thigh muscles. Individuals should attempt to hold the "draw in" for at least 5
seconds (preferably 10 seconds) with an equal time of relaxation.

The exercises, a total of 75–80 repetitions, should be conducted as 15–20 repetitions

at different intervals several times daily for a minimum of 8 weeks. Ideally, they
should be maintained for a lifetime. A minimum of 8 weeks should show progress in
controlling the stream of urine. Studies reflect that pelvic muscle exercises, as a
behavioral management strategy, can reduce incontinent episodes by 50–60%.27-31

Biofeedback. For individuals who continue to have difficulty controlling urination,

biofeedback can be tried.26 The aim of biofeedback is to improve bladder
dysfunction. Biofeedback therapy uses electronic or mechanical instruments to relay
information to a person about his or her physiological activity, the responses that
mediate bladder control. The use of biofeedback for urinary incontinence involves
simultaneous measurement of the pelvis and detrusor muscle activity. Biofeedback
must be taught by a trained professional. Biofeedback verifies accurate muscle use,
gives immediate feedback, and provides a visual cue for patients.

Intermittent catheterization. Incomplete bladder emptying may lead to urinary tract

infections, which can be compounded with vaginal infections in women. Persistent
residual urines of 400 ml or greater may lead to renal damage. If a person has a
residual urine of 400 ml, and the bladder normally holds 500 ml, this leaves room for
only 100 ml of new urine to enter the bladder, causing a storage problem and
prompting frequent voiding. This same person may suffer from uninhibited detrusor
contractions, causing incontinence after voiding.

Intermittent catheterization stimulates normal physiology by allowing for periodic

filling and emptying of the bladder. It also prevents bladder over-stretching or
shrinkage and minimizes the risk of infection.

Individuals should be taught to perform the procedure utilizing a clean (not sterile)
technique while seated on the toilet. Sitting on the toilet allows the lowering of the
pelvic floor, a normal process that precedes voiding. This position is better than lying
down, but patients may first have to learn the technique while lying down so that
they can view the procedure through a mirror.

With the introduction of a catheter, the sphincter may undergo spasms that may only
allow small amounts of urine to be expelled, or urine may be discharged as dribbles
or spurts. In this case, use of an anticholinergic drug may be necessary.

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Minimizing urinary tract infections is key to successful intermittent catheterization.

Individuals should be taught to seek medical assistance whenever they suspect an
infection.

Intermittent catheterization is recommended for overflow incontinence caused by

spinal cord lesions or chronic urinary retention secondary to underactive bladder or
cystopathy.11,20,25

Pharmacological Approach
When using a pharmacological approach, the risk-to-benefit ratio must be a part of
management decisions.

In the pharmacological treatment of urge incontinence, the best candidates are those
patients with demonstrated detrusor overactivity who do not have reduced bladder
capacity and impaired emptying.11,32

For urge incontinence, anticholinergic agents such as oxbutynin, dicyclomine

hydrochloride, and propantheline are recommended as first-line therapy. These drugs
block the contraction of normal and overactive bladders. Use of these drugs is
contraindicated in people who are diagnosed with narrow-angle glaucoma.

For stress incontinence, the first-line therapy is phenylpropanolamine or

pseudoephedrine. These drugs can be administered with the co-morbidity of
hypertension. To manage stress incontinence, drugs that increase bladder outlet
resistance are the choice. In the treatment of stress incontinence or mixed
incontinence in postmenopausal women, estrogen therapy can be an adjunct.
Estrogen therapy has been shown to result in continence in at least 10% of patients,
while 50% experience fewer episodes of incontinence.33 Estrogen therapy can be
administered either orally or vaginally.

Surgical Treatment
Surgical treatment should be performed after other treatments are unsuccessful or in
the presence of outlet obstruction.

The goal of surgical management is to correct, compensate, or circumvent the

underlying pathology causing urine loss.11 Surgical intervention to improve stress
incontinence is aimed at increasing sphincter outlet resistance. Techniques include
retropubic suspension, needle bladder neck suspension, or anterior vaginal repair.
Surgeries that manage sphincter deficiency include sling procedures or placement of
an artificial sphincter. Overflow incontinence due to bladder neck obstruction can be
addressed by surgical procedures to relieve the obstruction.

SUMMARY
Of the neuropathies, the neurogenic bladder, or cystopathy, is one of the least
common. The outcome of the neurogenic bladder is urinary incontinence, overflow
type.

Urinary incontinence overall is a very common and costly problem. As society ages,
the prevalence of both diabetes and urinary incontinence increase. As medical
technology provides for the extension of life for people with diabetes, co-morbidities
increase.
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Careful and thorough health histories and physical examinations should be conducted
periodically to assess for urinary incontinence and the neurogenic bladder. If a person
is diagnosed with urinary incontinence, an individualized management program
should be developed to decrease incontinent episodes.

Clean-technique intermittent catheterization is the current choice for treating the

atonic bladder and should be carefully taught and monitored by a health care
professional. Reducing the risk for urinary tract infections would be the cornerstone
of management.

References
1Frimodt-Mæller CA: Diabetic cystopathy: epidemiology and related disorders. Ann
Intern Med 92:318-21, 1980.

2Herzog A, Diokno AC, Fultz N: Urinary incontinence: medical and psychosocial

aspects. In Geriatric Health Issues. Herzog A, Ed. New York, Andrus Foundation,
1990, p. 74-118.
3Resnick N: Initial evaluation of the incontinent patient. JAGS 38:311-16, 1990.

4Resnick N: Urinary incontinence in older adults. Hosp Pract 27:139-84, 1992.

5DeGroat W, Booth A: Physiology of the urinary bladder and urethra. Ann Intern
Med 92:312-15, 1980.

6Thon W, Altwein J: Voiding dysfunctions. Urology 23:323-30, 1984.

7Burgio KL, Matthews KA, Engel BT: Prevalence, incidence and correlates of
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8Diokno AS, Brock BM, Brown HB, Herzog AG: Prevalence of urinary incontinence
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Adeline M. Yerkes, BSN, MPH, is chief of the Chronic Disease Service and Women’s
Health coordinator at the Oklahoma State Health Department in Oklahoma City.

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