American Journal of Hospice and Palliative

Medicine
http://ajh.sagepub.com/

The management of urinary incontinence

Robert E. Enck
AM J HOSP PALLIAT CARE 1989 6: 9
DOI: 10.1177/104990918900600603

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Current concepts
The management of urinary incontinence
Robert E. Enck, MD
The involuntary loss of urine or uri-
nary incontinence is a clinical problem
that has often been overlooked and
poorly understood. In a study by
Wilkes some 15 years ago,1 incon-
tinence was one of the ten major
symptoms after admission in 296
patients cared for ina small, 25 bedpal-
liative care unit in England. In this
same study, urinary incontinence was
the reason for respite care admission in
11 percent of the cases. Indeed, urinary
incontinence is a major health and so-
cial problem in this country. It is es-
timated that at least 10 million adult
Americans suffer incontinence,includ-
ing 15 to 30 percent of community-
dwelling older people and atleast half
of all nursing home residents. The
monetarycosts ofmanaging urinary in-
continence are estimated at $10.3 bil-
lion annuallyand the psychosocial bur-
den of urinary incontinence is great. Z
As reviewed by the Consensus Con-
ference on Urinary Incontinence in
Adults,2 continence requires a com-
pliant bladder and active sphincteric
mechanisms such that maximum
urethral pressure always exceeds in-
travesical pressure. Normally, voiding
requires sustained and coordinated
relaxation of the sphincters and con-
traction of the urinary bladder. These
functions are regulated by the central
nervous system through both auto-
nomic and somatic nerves. This system
Robert F. Enck, MD is past president of theAs-
sociation of Community Cancer Centers,
Columbus, Ohio.
The American Journal of Hospice Care, November/December 1989
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requires the integration of visceral and
somatic muscle function and involves
control by voluntary mechanisms
originating in the cerebral cortex.
These voluntary mechanisms are
learned and culturally prescribed, that
is, toilet training.
Incontinence can be produced by
any pathological, anatomical, or
physiological factor that disrupts the
pressure gradient between the bladder
and the urethra.
In the general adult population, the
most common clinical forms of urinary
incontinence are stress incontinence,
urge incontinence, overflow incon-
tinence, and a mixed form. In stress in-
continence, dysfunction of the bladder
outlet causes leakage of urine as intra-
abdominal pressure is raised above
urethral resistance while coughing,
bending, or lifting heavy objects. Stress
incontinence has many etiologies in-
cluding direct anatomic damage to the
urethral sphincter.
Urge incontinence occurs when
patients sense the urge to void, but are
unable to inhibit leakage long enough
to reach the toilet. In most cases,
uninhibited bladder contractions con-
tribute to the incontinence. In patients
with advanced cancer, central nervous
system involvement by primary brain
tumors or metastatic lesions maycause
urgency leading to incontinence. Also,
bladdertumors orother cancersinvolv-
ing the bladder may cause local irrita-
tion which often are manifested as
urgency.3
Overflow incontinence occurs
when the bladder is unable to empty
normally and becomes overdistended,
leading to frequent urine loss. Lesions
in the true pelvis involving the per-
pheral pelvic nerves can often cause
overflow incontinence.Any factorthat
causes outflow obstruction, such as
direct invasion of the bladder by acan-
cer, can lead to uncontrolled urine loss
due to overflow. Also, the mechanical
effects of fecal impaction often lead to
overflowing incontinence.4
Many types ofurinary incontinence
fall into the mixed category, displaying
various aspects ofmore than one of the
major subtypes.
The term functional incontinence is
applied to those patients in which the
function of the lower urinary tract is in-
tact, but other factors such as immobi-
lity or severe cognitive impairment
result in urinary incontinence. This
category certainly is highly applicable
to the chronically ill, as is seen in the
hospice setting.
In occasional circumstances, uri-
nary incontinence may be related to
prior cancer therapy. For example,
treatment with cyclophosphamide can
cause bladder wall fibrosis leading to
pronounced contraction of the bladder
and loss of compliance. Radiation
therapy has a similar effect.3
It is clear that urinary incontinence
is caused by multiple and often inter-
acting factors. Of importance are the
identification of the reversible condi-
tions such as infection, delirium and
drugs.
9

Like other symptoms in the dying
patient, clinical evaluation for possible
etiologies of urinary incontinence is of
paramount importance. The patient
should not be relegated to the discom-
fort of an indwelling catheter until cor-
rectable conditions have been
thoroughly ruled out. An extensive
work-up, as suggested by the Consen-
sus Conference,2 is not appropriate for
the hospice patient. A careful history
and physical examination with special
attention to the pre-iliness voiding pat-
tern often produces an accurate diag-
noses.3 Simple laboratory measure-
ments including urinalysis, serum
creatinine or blood urea nitrogen
(BUN) levels, urine cultures and
postvoid residual urine volume maybe
clinically helpful.
The management of urinary incon-
thence generally includes the use of
drugs and protective devices. Although
highly successful in areas such as nurs-
ing homes, behavioral therapy has
limited use in hospice care due to the
time necessary to train patients in these
techniques.
The pharmacologic therapies cur-
rently used in the management of uri-
nary incontinence have not been
studied in well designed clinical trials.2
Nonetheless, it has been suggested that
many agents are beneficial for patients
with urge incontinence due to unin-
hibited bladder outlet muscle contrac-
tions. Since these drugs increase the
bladder capacity, they may precipitate
urinary retention. Bladder relaxants in-
clude the anticholingerics, direct
smooth muscle relaxants, calcium
channel blockers, and imipramine.
Alpha-adrenergic agonists act as
bladder outlet stimulants. These drugs
produce smooth muscle contraction at
the bladder outlet and may improve
stress incontinence.
Protective devices availableinclude
absorbent pads or garments, indwelling
catheters and external collection
devices such as condom catheters. Ab-
sorbent pads or garments are con-
venient temporary devices but are not
suitable for long term use. For men, ex-
ternalcollection devicesmaybe useful,
but, are associated with an increased in-
cidence ofurinary tract infection. Prac-
tical external collection devices for
women are not generally available.
Chronic indwelling catheters, which
are often necessary in the hospice set-
ting, invariably lead to urinary tract and
systemic infections. Of interest, Her-
wig3 feels that self- catheterization,
when possible, is more physiologic and
is better tolerated by the patient.
Like many other areas in hospice
care, there is a need to study the
problem of urinary incontinence in
dying patients. Hopefully now that the
subject ofincontinence hascome out of
the closet,5 these studies will be
forthcoming. Based on this review of
the medical literature, the following
guidelines on the management of this
clinical problem are offered:
• Urinary incontinence is a com-
mon finding in hospice
patients.
• The etiologies of incontinence
are often complex and inter-
twined, but correctable causes
must be sought.
• Current protective devices and
drug therapy are adequate at
best. LI
References
1. Wilkes E: Some problems in cancer manage-
ment. Proc R Soc Med, 1974;67:1001-1005
2. Urinary incontinence in adults. JAMA,
1989;261 :2685-2690. Consensus Conference
3. Herwig KR: Management of urinary incon-
tinence and retention in the patient with ad-
vanced cancer. JAMA, 1980;244:2203-2204
4. Wrenn K: Fecal impaction. N Engl J Mcd,
1989; 321:658-662
5. Ouslander JG: Urinary incontinence: out of
the closet. JAMA, 1989;261:2695-2696
The American Journal of Hospice Care~November/December 1989
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Letters
(continued from page 7)
where wehave provided hospice consultations.
Perhaps care givers need to see it used to ap-
preciate the value of this approach.
Robert Enck’s fine review of dyspnea
prompted me to take up the cause of old-
fashioned techniques again. Here I advocate the
use of a fan as an alternative to oxygen. There
is nothing original in this piece, but it does con-
nect an old-fashioned technique with contem-
porary respiratory physiology. The goal is to
remind care givers that the care of the dying
need not be based on biomedical technology.
The photograph may seem pointless, but I
think thereis nothing like apicture to emphasize
a point. The oxygen issue is a touchy one in
America. This article and photomay provoke a
lively and overdue debate.
Derek Kerr, MD, NA
Laguna Honda Hospital
San Francisco, California
Confusion symptoms among hospice
patients
Dear Editor:
Kenosha Hospice Alliance is an inde-
pendent, community based program with an
average daily census of25. About 95 percent of
the deaths occur at home.
Threemonths following the death, the fami-
ly is sent a satisfaction survey. Included in the
questions are three that pertain to symptom
management. The first question asks the family
to check off all the symptoms that were a
problem for the patient. The second question
asks them to check off the symptoms of the
patient that were considered a problem for the
family. The final question asks which of the
symptoms the family felt were adequatelycon-
trolled.
These surveys were reviewed over a one
yearperiod. Notsurprisingly, the most common
symptom that was a problemfor the family was
the patients lack of appetite.
Patient problems included the expected
symptoms of pain, constipation, weakness,
nausea/vomiting, anorexia and confusion.
In the majority of the questionnaires the
family indicated that all symptoms were ade-
quately controlled by hospice except for con-
fusion. Hospice failed the majority of the time
to reverse this symptom.
The hospice pharmacist consultant sug-
gested we do a study on all patients who were
confused to determine if there were any com-
mon elements in these cases.
We reviewed eight currentcharts of patients
who had the symptoms of confusion.
(continued on page 15)