CASE 16

A 65-year-old woman comes to your geriatric clinic to establish care. About 6 months
ago, she started to have urinary incontinence when she coughed or sneezed. Patient
stopped going to the gym because of leakage of urine during exercise. She is living with
her husband at home and able to walk 2 miles on regular basis. Her husband reports no
memory or cognition problem. The medical history includes allergic rhinitis and GERD.
Her only surgery was a cholecystectomy at age 50. She is taking aspirin (ASA) and
omeprazole daily and drinks 1 cup of tea in the morning. She does not smoke or
consume alcohol. The patient denies dysuria, hematuria, abdominal pain, fever, or
chills. The physical examination reveals no palpable firmness in the abdomen, no
cystocele, no fecal impaction, and no pedal edema. Leakage of urine is observed during
the cough stress test. Her mini mental status examination score is 30/30.

What is most likely the diagnosis?

What is your next diagnostic step?

What is the next step in therapy?

ANSWERS TO CASE 16:

Urinary Incontinence and Urinary Tract Infection
Summary: A 65-year-old woman has urinary incontinence for 6 months when she
coughs or sneezes and on exertion. She lives at home and is active. Medical history
includes allergic rhinitis and GERD. She is taking ASA, loratadine, and omeprazole and
drinks 1 cup of tea in the morning. The patient denies dysuria, hematuria, abdominal
pain, fever, or chill. Her physical examination is normal except for leakage of urine
during the cough stress test. She does not have cognitive impairment.

Most like diagnosis: Stress incontinence.

Next diagnostic step: Urinalysis.
Next step in therapy: Behavior treatment with pelvic floor muscle training and
exercise.

ANALYSIS
Objectives
1. To be able to identify modifiable causes and contributing factors for urinary
incontinence.
2. To recognize the symptoms for different types of urinary incontinence.
 3. To be familiar with available treatment options for various types of urinary
incontinence.
4. To compare and contrast the criteria for diagnosis of asymptomatic bacteriuria
and urinary tract infection in elderly.
Considerations
This patient has urinary incontinence (UI) for the last 6 months. It is important to identify
the type of UI to guide the treatment. Transient UI symptoms can be alleviated by
treating underlying medical factors. Reviewing of medical history and medication list
does not reveal significant medical conditions or drugs that contribute to her UI
symptoms. Her caffeine intake is minimal and only in the morning. She has a good
functional status, and does not have cognitive impairment. She is unlikely to have
functional incontinence. This patient more likely has stress incontinence as urine
leakage occurs with exertion and increased intra-abdominal pressure. Urinalysis is a
routine, inexpensive test to look for hematuria and glycosuria. Hematuria deserves a
prompt referral to specialist. Presence of glycosuria may indicate diabetes. Bacteriuria
or pyuria may indicate urinary tract infection (UTI). Asymptomatic bacteriuria is very
common in elderly. This patient does not have symptoms of UTI and her UI is not of
sudden onset. Hence, it is unlikely that her UI is due to UTI. Treatment of asymptomatic
bacteriuria has not been proven to improve clinical outcomes. Her UI is bothersome
enough that it prevents her from having her routine exercise. Behavior therapy including
bladder diary, pelvic floor muscle training, and these exercises should be initiated. A
bladder diary may be helpful in characterizing patient’s UI and monitor progress of
therapy. Pelvic floor muscle exercise, the hallmark of behavior treatments, prevents
urine leakage by strengthening of pelvis floor muscle. It is effective in decreasing stress,
urge, and mixed incontinence in cognitively intact elderly. Lifestyle changes including
reduced caffeine intake, fluid management, and weight loss can be used together with
behavior therapies. Behavior interventions are all safe but require active, continuing
participation of motivated patients and experienced clinicians.

APPROACH TO:
Urinary Tract Disorders: Part I—Urinary Incontinence

DEFINITIONS
URINARY INCONTINENCE (UI): It is defined as involuntary leakage of urine and
divided into several different types (Table 16–1)

Table 16–1 • TYPES OF URINARY INCONTINENCE

URGE INCONTINENCE: It is the leakage of urine accompanied or immediately
preceded by urgency, a sudden compelling desire to pass urine which is difficult to
defer, associated with inhibited bladder detrusor muscle contractions. This is most
common type in men
STRESS INCONTINENCE: Leakage of urine that occurs during exertion or effort, or on
increasing intra-abdominal pressure such as sneezing, laughing, or coughing
MIXED INCONTINENCE: It is the combination of urge UI and stress UI. It is the most
common type of UI in women
HIGH POSTVOID RESIDUAL OR OVERFLOW INCONTINENCE: This happens when
the bladder is overdistended, resulting in leakage of small amount of urine. It can be
caused by obstruction or neurological conditions
FUNCTIONAL INCONTINENCE: It is incontinence due to cognitive, functional, or
mobility difficulty or lack of access to toilet
OVERACTIVE BLADDER (OA): It is characterized by symptoms of urgency, frequency,
and nocturia without urge incontinence

CLINICAL APPROACH
Etiologies of Incontinence
UI is common in the elderly. It affects 30% to 60% of women and 10% to 35% of men aged ≥65
years. Even though, UI is not a life-threatening illness, it associated with depression, anxiety,
social isolation, increased risk of falls, fracture, and long-term care facilities placement. It is not
a part of the “normal” aging process. Not everyone with predisposing factors has UI.
Multiple age-related changes in the lower urinary tract are associated with UI.
Detrusor contractility decreases, resulting in increased postvoiding residual volumes.
The amount of urine excreted increases later in the day causing nocturia. Also, there is
a decrease in bladder outlet and urethral pressure in women and presence of prostatic
enlargement in men. Urge incontinence occurs as the result of involuntary uninhibited
contraction of the bladder, which is known as detrusor overactivity (DO). Stress
incontinence usually is caused by weakness of pelvic floor supportive structures and
urethral hypermobility, impaired intrinsic sphincter function, or any combination of these.
Detrusor hyperactivity with impaired contractility (DHIC) is urgency UI with detrusor
underactivity and high postvoid residual. Also, there are functional changes associated
with aging which are the contributing factors to UI, including potential decline in
mentation, mobility, motivation, manual dexterity, and sensory input.
Risk factors include high caffeine intake, smoking, consumption of carbonated and
alcoholic beverages, comorbidity, obesity, white female, medications, and functional
impairment. Many medications that can potentially affect continence are diuretics,
anticholinergics, psychotropics, estrogen, narcotics, α-adrenergic blockers and agonists,
calcium channel blockers, alcohol, and caffeine. Medical conditions that can cause or
worsen UI are diabetes, urinary tract infection, constipation, prostatectomy, obesity,
mobility impairment, obstructive sleep apnea, hypercalcemia, vitamin B 12 deficiency,
cardiovascular disease, neurologic conditions, and psychiatric diseases.
Evaluation/Diagnosis of Urinary Incontinence
Even though UI is a common geriatric syndrome, only about 30% to 50% of the affected
elderly report symptoms or seek help, often from embarrassment. Hence, sensitive
probing and evaluation of UI in elderly is important. As a general rule, an inquiry about
UI should be performed every 2 years on all older adults.
The history should consist of onset, duration, volume, frequency, timing, voiding
pattern, type and severity of UI, precipitants, and reversible contributing factors. It is
necessary to review chronic medical conditions, medication, previous history of UI and
treatment, and impact on quality of life of the patient and burden on caregiver. Review
of system should involve questions about bowel habits, dysuria, nocturia, and vaginal
dryness/bulging.
The physical examination entails:

1. General examination: Look for signs of volume overload; abdominal masses,

palpable bladder, suprapubic tenderness; impairment in strength, gait, or balance;
neurological abnormality or deficit, especially lumbosacral innervation.
2. Gynecological examination: Inspection of external genitalia and vagina; stress
test, during which leakage of urine is observed with coughing or Valsalva
maneuver, useful in diagnosing stress incontinence; prolapsed evaluation;
muscular strength testing.
3. Rectal examination: Testing sphincter tone and symmetry with squeezing, looking
for impaction, examining prostate for size, contour, tenderness; perineal skin
inspection.
 4. Cognitive assessment: Investigate the present of delirium, dementia, or
psychological barriers.

In all patients, urinalysis is the only recommended test to examine for hematuria, the
sign of infection, and glucosuria. In selected patients, urine culture, metabolic panel,
thyroid studies, vitamin B12 and D levels, postvoid residual volume, and KUB may be
indicated. In cases of pelvic pain, UI with sudden onset of neurological symptoms,
pelvic mass or severe prolapse, suspected fistula, hematuria, history of pelvic floor
surgeries or radiation, and abnormal finding during prostate examination, further
evaluation, and immediate referral is recommended.
Treatment of Urinary Incontinence
Management should be guided by types of incontinence and advanced in a step-wise
manner. However, in geriatric population, management of UI should be individualized,
emphasizing the patients’, and/or family and caregivers’ goals and preference.
Assessment and treatment of modifiable causes and contributing factors are necessary
to maximize potential for reestablishing continence, as they may ameliorate UI
symptoms.
Behavior intervention should be the initial treatment including pelvic floor muscle
training and exercise, also called Kegel exercise (foundation for behavior interventions);
delayed voiding; bladder training; urge suppression; bladder diary; scheduled and
prompted voiding. Lifestyle changes consist of weight loss, decreased consumption of
caffeinated and alcoholic beverage, fluid intake management, and smoking cessation.
Drug treatment should be used in combination with behavior therapy, started at a low
dose and titrated for efficacy and adverse effects. Antimuscarinic or bladder relaxant
agents (eg, oxybutynin and fesoterodine) are effective in the treatment of urge and
mixed incontinence for both genders. Common side effects are dry mouth and
constipation. Antimuscarinic agents occasionally can cause urinary retention in the
elderly with incomplete bladder emptying, and their use has been associated with
worsening cognition. α-Adrenergic antagonists and 5-α-reductase inhibitor are effective
for urge incontinence associated with BPH. Low-dose vaginal estrogen cream may be
effective in improving symptoms of OA and urge incontinence.
Surgery treatment for stress incontinence include bladder neck suspension, tension-
free vaginal tapes, and periurethral collagen injection in women. Midurethral slings are
available for men and women. Implantation of artificial urinary sphincter is an option for
men with stress incontinence. Recently, there are a few surgical approaches developed
for urge incontinence, including sacral nerve neuromodulation, percutaneous tibial
nerve stimulation, and injection of botulinum toxin A into the bladder (indication not
approved by FDA). Some men may benefit from prostate surgery as treatment for
overflow incontinence.
Pessaries are supportive devices used intravaginally to treat stress incontinence and
pelvic prolapse in women. For men, stress UI can be managed by penile clamps or
condom catheters. Some patients may prefer to use protective undergarments and
absorbent pads.
Urinary Tract Disorders: Part II Urinary Tract Infection

DEFINITIONS
URINARY TRACT INFECTION (UTI) is defined as the presence of significant bacteriuria
(≥105 CFU/mL in a clean-catch specimen and ≥102 CFU/mL in a catheterized specimen) with
associated genitourinary symptoms
ASYMPTOMATIC BACTERIURIA (ASYMPTOMATIC UTI) is diagnosed: (a) When there
are 2 consecutive voided urine specimens with isolation of the same organism in quantitative
counts ≥105 CFU/mL in asymptomatic female. (b) For male, it is the presence of 1 bacterial
species in quantitative counts ≥10 5 CFU/mL from a single, clean-catch voided urine specimen.
(c) For a single catheterized urine specimen in both men and women, bacteriuria is defined when
1 bacterial species in quantitative counts ≥102 CFU/mL
PYURIA is defined as the presence of increased number of white blood cell count on
urinalysis and is an indicator of inflammation in the urinary tract
Etiologies
UTI, including cystitis, pyelonephritis, and catheter-associated infection is the most
common infection in older adults. In elderly, UTI becomes more common because of
different anatomic and functional changes in the urinary tract associated with aging.
Risk factors for UTI are: female gender; decreased functional ability; fecal incontinence;
impaired cognition; any conditions that impair bladder emptying and cause urinary
retention in the bladder including uterovaginal prolapse, or cystocele with obstructive
voiding; neurogenic bladder in patients with spinal cord injuries; diabetes mellitus; and
anticholinergic medications.
Clinical Presentation
Diagnosing UTIs in the geriatric population can be challenging because of the high rate
of asymptomatic bacteriuria, pyuria, and atypical presentation. Common symptoms
include urinary frequency, urgency, dysuria, suprapubic discomfort, fever, chills,
malaise, nausea and vomiting, and flank pain. Change in character of the urine, dysuria,
and change in mental status are more common in long-term care residents.
Diagnosis/Treatment of Urinary Tract Infection
Diagnostic evaluation should include a urinalysis, urine culture, and sensitivity testing.
The most common pathogen frequently seen are Escherichia coli, Enterobacter,
Klebsiella, Proteus, Enterococcus, Pseudomonas spp, and Staphylococcus aureus
(MRSA).
Antimicrobial treatment for symptomatic UTI is similar to that in the general
population, and should be based on antibiotic susceptibility testing. Dosage usually is
adjusted according to renal function. Trimethoprim/sulfamethoxazole (TMP-SMZ) and
nitrofurantoin are first-line oral agents. Other oral alternatives include amoxicillin or
amoxicillin-clavulanate, nitrofurantoin, and oral second- and third-generation
cephalosporins. Third-generation cephalosporins, aztreonam, piperacillin, or an
aminoglycoside can also be used intravenously. Fluoroquinolones are effective, but its
utilization is discouraged because of increasing antimicrobial resistance.
 Uncomplicated UTI should be treated for 3 to 7 days in women and 7 to 14 days in
men. Pyelonephritis should be treated for 14 days. Prostatitis requires antimicrobial
treatment for 6 to 12 weeks.
In the elderly living in community or long-term care facilities, screening for and
treatment of asymptomatic UTI is not recommended, since there is no benefit in treating
asymptomatic bacteriuria. Inappropriate antibiotic use in elderly has been associated
with development of undesirable drug side effects, adverse drug interaction, multidrug
antimicrobial resistance, and excessive costs.
In women, acute, recurrent, lower UTI may be prevented with the use of long-term,
low-dose antibiotics (nitrofurantoin, TMP/SMX, TMP, cephalexin, norfloxacin, or
ciprofloxacin) for a duration of 6 months to 1 year. Use of topical vaginal estrogen
therapy is controversial and should not be prescribed as a continuous, lone agent for
UTI prophylaxis. Even though cranberry juice has not been proven effective in
preventing UTI, its ingestion should not be discouraged. In patients who undergo
invasive genitourinary procedure, prophylactic antibiotic treatment is indicated for
bacteriuria. Catheters should be removed promptly when they are no longer needed.

CLINICAL CASE CORRELATION

See also Case 15 (Clostridium difficile Diarrhea).

COMPREHENSION QUESTIONS

16.1 A 72-year-old woman is brought to outpatient clinic for routine follow-up. She
recently went to a long-term care facility for 3 days for respite care while her
daughter was out of town on a business trip. The patient has no concerns
today. Her past medical history includes hypertension, atrial fibrillation, and
dementia that has been stable for the past 2 years. She is taking
hydrochlorothiazide (HCTZ), warfarin, and donepezil. The daughter is
concerned about the result of urinalysis and urine culture obtained routinely
from the long-term care facility; the urinalysis reveals 20 WBCs, many bacteria,
and is positive for nitrites. The urine culture grew >100,000 CFU/mL of
Enterococcus faecalis which is sensitive to ampicillin and vancomycin.
According to both patient and daughter, there is no dysuria, frequency,
incontinence, fever, chill, abdominal pain, or change in mentation or behavior
lately. Which of the following is the next appropriate step?
A. Start ampicillin.
B. Repeat urinalysis and culture.
C. No antibiotic.
D. Start vancomycin.

16.2 An 89-year-old woman has a history of urinary incontinence for 2 years, but
has been stable. She also has mild-to-moderate dementia, diabetes mellitus,
and hypertension. She is living in a long-term care facility. The patient is able to
 ambulate but has difficulty finding her bathroom most of the time. What is the
most likely best treatment for managing this patient’s UI?
A. Protective undergarment and prompted voiding
B. Midurethral sling procedure
C. Oxybutynin each day
D. Pelvic floor muscle training and exercise.

ANSWERS

16.1 C. This patient does not have symptoms or signs of a UTI. Asymptomatic
bacteriuria is very common in the elderly and does not require treatment.
Unnecessary antibiotic treatment is not beneficial and may cause harm.
Routine urinalysis and urine culture in asymptomatic elderly are not
recommended.

16.2 A. This is an elderly with chronic UI likely associated with dementia. There is
no indication of loss of urine with valsalva or coughing, and likely the patient is
not a good surgical candidate even with stress UI. There is no evidence of
urgency, and anti-cholinergic medications such as oxybutynin can cause
mental status changes, dry mouth, dry eyes, and constipation. Pelvic floor
muscle exercises are unlikely to be effective with this patient’s dementia.

CLINICAL PEARLS

Many elderly patients are embarrassed to report or discuss UI, unaware of available
treatments, or assume that UI is part of “normal” aging. It is vital to ask specific
questions about UI during the initial and periodic assessment.

Bladder training, and especially pelvic floor muscle exercise, is effective in reduction
of stress, urge, and mixed incontinence in cognitively intact patients who can
cooperate with training.

In cognitively impaired elderly patients with urge incontinence, the caregiver’s

involvement is needed and prompted voiding is effective.

Antimuscarinic agents are only indicated for urge UI.

There is no drug treatment approved for stress incontinence in the United States.

Asymptomatic UTI in the elderly individual is common and does not require
treatment.

Treatment of asymptomatic bacteriuria is only recommended before patients

undergo invasive genitourinary procedures.
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