Urinary incontinence is a relatively common problem seen in patients at the end of life, but the exact prevalence is not clear. Studies of symptom prevalence at the end of life often do not mention urinary incontinence at all, yet most patients who receive palliative care are also elderly, and this population is often affected by urinary incontinence. In fact, urinary incontinence affects 15% to 35% of community-dwelling older adults and more than 50% of nursing home residents. There is a general reluctance for patients and families to discuss urinary incontinence. It may be that care providers assume that urinary incontinence is not a symptom in the ordinary sense, but rather a common, although less serious, problem at the end of life.
Urinary incontinence can have a significant impact on quality of life. In its various forms, urinary incontinence may limit patients’ mobility and social interactions. Elderly patients with urinary incontinence are more likely to be placed in a nursing home. Those with limited economic resources struggle to cope with the costs of investigations and treatment. Urinary incontinence may also lead to depression. The impact of urinary incontinence on the place of care or on other aspects palliative care is not reported. If not properly managed, however, urinary incontinence may add to the suffering of these patients. Neglected urinary incontinence may lead to systemic infections, skin problems, and skin wounds, thus introducing other significant physical morbidity to patients who are already dealing with numerous symptoms at the end of life.
One study showed that men are more likely than women to develop sexual dysfunction in association with urinary incontinence. Another study indicated that, among heterosexual couples, urinary incontinence correlates with interference of sexual satisfaction.
Cultural attitudes toward urinary incontinence vary significantly. In North American culture, urinary incontinence is gaining recognition as a medical illness and is discussed more openly, even in television commercials. In other societies, however, urinary incontinence is still traditionally viewed as evidence of self-neglect, being unclean, having poor self-discipline, or being socially incompetent. Patients with urinary incontinence who live in such societies may manage their symptoms in isolation and secrecy. The onset of urinary incontinence may adversely affect self-esteem.
Physiology and Pathophysiology
Micturition, the process of voiding urine from the bladder, is a complex process that involves the interplay of involuntary smooth muscle, voluntary striated muscle, the autonomic and somatic nervous systems, and the brain, as well as a cognitive aspect.
The components of the system include the following :
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The bladder wall is composed of a mesh of smooth muscle fibers.
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An internal, involuntary sphincter is composed of layers of smooth muscle at the bladder neck that surrounds the urethral orifice, known as the detrusor muscle.
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The outer layer of this smooth muscle continues in a circular fashion along the full length of the urethra in girls and women and to the distal prostate in boys and men, forming the involuntary urethral sphincter.
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An external, voluntary sphincter made up of striated muscle interdigitating with smooth muscle is located between the layers of the urogenital diaphragm. In boys and men, these fibers are concentrated at the distal aspect of the prostate; in girls and women, they are found mainly in relation to the middle third of the urethra.
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The innervation of the system is complex. The bladder receives its principal nerve supply from one paired somatic and two paired autonomic nerves. The hypogastric nerves (arising from lumbar spinal segments L1 and L2) mediate sympathetic activity, whereas the pelvic nerves (derived from S2–S4) contain parasympathetic fibers. The pudendal nerves (S2–S4) are primarily somatic fibers innervating the striated, voluntary sphincter. With distention of the bladder wall, stretch receptors trigger parasympathetic pelvic nerve fibers that, unless inhibited by higher centers, lead to a parasympathetic motor response and bladder contraction. In micturition, the detrusor muscle contracts, thus drawing the bladder downward, and the external sphincter, under voluntary control, relaxes. Micturition is inhibited by sympathetic nervous system stimulation. All are coordinated by higher centers to initiate or inhibit bladder emptying. Therefore, problems can arise at one or more levels: the physical structure of the bladder, the enervation of the bladder and urethra, and the cognitive function of the patient. Each may result in or may be a factor in urinary incontinence.
Other factors may be involved in producing urinary incontinence. Estrogens may be associated with increased prevalence of urinary incontinence. Benzodiazepines and selective serotonin reuptake inhibitors are also associated with an increase in the frequency of urinary incontinence. Another factor in urinary incontinence needs to be mentioned here: Urinary incontinence may result from failure by the care provider to manage reversible causes, such as urinary tract infections.
Types of Urinary Incontinence
Overactive Bladder Syndrome
Overactive bladder (OAB) is characterized by urgency, a sudden compelling desire to pass urine that is difficult to defer. It is usually accompanied by frequency and nocturia, and it may occur with urge urinary incontinence. The exact cause of OAB is not entirely known, but it is both myogenic and neurogenic. OAB affects about 16% of the adult population, and the prevalence increases with age. OAB can have a negative impact on health, ability to function, and quality of life. Elderly patients with urge urinary incontinence are also more likely to be admitted to nursing homes. Patients, families, and physicians may treat OAB as a normal consequence of aging, an attitude that results in underdiagnosis and undertreatment of this condition. In the typical population requiring palliative care—namely, elderly patients—preexisting OAB can lead to urinary incontinence. As palliative care patients become weaker or have significant pain, it is more difficult for them to reach the washroom in time, and the result is urgency urinary incontinence.
Other Forms of Urgency Incontinence
Inflammation of the bladder, tumors at or near the internal urethral orifice, urinary infections, inflammation secondary to radiation, and some neurologic disorders may also result in an urgency type of urinary incontinence.
Stress Incontinence
Stress urinary incontinence consists of involuntary urethral loss of urine associated with increased intra-abdominal pressure from coughing, sneezing, jumping, laughing, or, in severe cases, even walking. It is associated with faulty urethral support that results in abnormal sphincter function and an inability to resist increased bladder pressure. It is more common in women, but it can be present in men, especially those who have had prostate or bladder neck surgery. In female patients, parity, pelvic surgery, obesity, menopause, and smoking are also cofactors in the development of stress urinary incontinence. In palliative care, preexisting stress urinary incontinence may be made worse by symptoms such as poorly controlled coughing or nausea. New stress urinary incontinence may be caused by surgery to the bladder neck, radiation-induced inflammation and fibrosis, tumors external to the bladder that cause increased intravesical pressure, and spinal cord damage.
Overflow Incontinence
The continuous urinary leakage seen with overflow urinary incontinence is mostly the result of overflow with chronic urinary retention secondary to urethral stricture or blockage. The bladder remains palpable and percussible, considerable residual urine is present, and the condition is nonpainful. Benign or malignant prostatic disease, spinal nerve damage, and urethral obstruction from tumors are common causes of this problem in palliative care patients.
Incontinence Secondary to Neurologic Dysfunction
Spinal cord damage from any cause, sacral tumors, pelvic surgery, and pelvic tumors that invade the nerve supply to the bladder may result in partial or total urinary incontinence.
Incontinence Associated with Cognitive Failure
Patients who suffer from significant dementia or delirium are almost always incontinent.
Assessment
An initial evaluation should include the following:
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A good history. Ask about the following:
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Urinary frequency
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Presence of the sensation of urgency
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Leakage
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Influence of activities that increase intra-abdominal pressure
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Pattern of urinary incontinence (occasional, continual)
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Neurogenic symptoms such as paresthesia, dysesthesia, anesthesia, motor weakness, or lack of sensation of bladder fullness or of bladder emptying
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Pain
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Presence of hematuria or dysuria
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How often does the patient void during the day and night and how long can she or he wait comfortably between urinations?
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Why does voiding occur as often as it does (urgency, convenience, attempt to prevent incontinence)?
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How severe is incontinence (e.g., a few drops, saturate outer clothing)?
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Are protective pads worn?
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A review of the patient’s disease process and treatments.
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A review of previous imaging to look for sources of neurogenic urinary incontinence and pelvic masses . New imaging may be required, depending on the stage of the patient’s illness and whether this will change management.
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Patient, caregiver, or care provider monitoring for at least 2 days. Ask for a voiding diary, which should record urinary frequency, urgency, volume of urine, relation to other symptoms (if any), and the presence of pain on urination.
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A targeted physical examination. Ask for the following:
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Abdominal examination to exclude a distended bladder
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Neurologic assessment of the perineum and lower extremities
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Pelvic examination in women, if warranted
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Genital and prostate examination in men, if warranted
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Rectal examination to assess for pelvic masses and anal sphincter tone
The rectal examination may include a bulbocavernosus reflex. Both are tests of nerve function to the area.
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Urinalysis. Reagent strip testing of urine is a sensitive and inexpensive screening method that can be supplemented with urine microscopy and culture.
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Further testing as needed. Depending on the patient’s illness stage, further investigations such as residual urine determination, urodynamic studies, and cystoscopy may be indicated if they can help with the management of urinary incontinence. Consultation with a urologist can be very helpful.
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