Acute reversible causes of urinary incontinence in the elderly

What it is

When a patient presents with urinary incontinence, the first move is not to name the chronic type but to assess for transient incontinence. That means to apply the DIAPPERS mnemonic and review the medications. The reversible causes are treated on a line of their own: if the incontinence resolves, no further intervention is needed, and if it does not, the path returns to the chronic arm. The chronic arm also follows straight on from the transient one, and it holds history with the 3 Incontinence Questions questionnaire, the voiding diary, physical examination including a cough stress test if stress incontinence is suspected, PVR urine and laboratory evaluation.

Causes and risk

The DIAPPERS mnemonic holds the transient causes:

• Delirium
• Infection, meaning acute urinary tract infection
• Atrophic vaginitis
• Pharmaceuticals
• Psychological disorder, especially depression
• Excessive urine output, for example hyperglycemia
• Reduced mobility, that is functional incontinence, or reversible urinary retention, for example drug-induced
• Stool impaction

Medications carry their own table. Among the antihypertensives, alpha-adrenergic antagonists decrease sphincter tone, causing stress incontinence; angiotensin-converting enzyme inhibitors may increase coughing, causing stress incontinence; calcium channel blockers relax the bladder, causing retention and overflow incontinence; and diuretics give a high urine flow that leads to bladder contractions, causing urge incontinence. Among the pain relievers, cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs increase fluid retention, causing nocturnal diuresis and functional incontinence; opioids relax the bladder, causing fecal impaction, sedation, retention, and overflow incontinence; and skeletal muscle relaxants inhibit bladder contractions, causing sedation, retention, and overflow incontinence. Among the psychotherapeutics, antidepressants, antiparkinsonian agents and antipsychotics inhibit bladder contractions, causing retention and overflow incontinence; and sedatives and hypnotics lead to sedation and impaired cognition, causing functional or overflow incontinence. The others are alcohol, which leads to diuretic effect and depressed central inhibition, causing urge incontinence, overflow incontinence, or both; antihistamines and anticholinergics, which inhibit bladder contractions, causing sedation, retention, and overflow incontinence; medications for urinary urgency, with the same mechanism and the same result; and thiazolidinediones, which increase fluid retention, causing nocturnal diuresis and functional incontinence.