Functional Incontinence

Pathology and Management of Functional Factors Contributing to Incontinence

The condition of functional incontinence is associated with inability to toilet because of impairment of cognitive and/or physical functioning, psychological unwillingness or environmental barriers (Ouslander, 1994, p. 151).

In functional incontinence, the lower urinary tract Opens in new window and bowel produce normal sensations of urge, and the ability to inhibit urge is intact but other factors precipitate the loss of control. As mentioned earlier, functional incontinence is often associated with cognitive impairment and/or loss of the ability to perform behaviors needed for independent toileting. The end result is the inability to respond to bladder or bowel urge, which results in varying degrees of incontinence Opens in new window.

Etiology of Functional Incontinence

To maintain continence, there must be intact sensory and motor function of the urinary tract and bowel as well as the ability and desire to respond appropriately to urge.

The central nervous system must process stimuli effectively so that the individual can recognize the sensation of urge, determine the appropriate response, and carry out the sequence of psychomotor activities necessary for controlled voiding or defecation.

The individual must be motivated to maintain continence and must be able to use a toilet or a toilet alternative such as a urinal or bedpan.

Mobility and coordination must be such that the sequence of gross and fine motor skills required for toileting can be executed. Finally, the environment must provide cues and toileting facilities that support continence.

In summary, an individual is a risk for functional incontinence if s/he has cognitive impairment, diminished motivation, a loss of mobility and/or coordination, and/or environmental barriers to toileting. Box X1 lists patients at risk for functional incontinence.

Frail older adults, adults with multisystem and multidimensional impairments, and adults who are developmentally disabled have a greater risk for the development of functional incontinence resulting from physical and/or cognitive impairments. Some changes in bladder function associated with aging also contribute to increased risk in this population. These changes are highlighted in Table X2; those of greatest significance to the development of functional urinary incontinence (UI) include the following:

1. In the older adult, there is a decrease in bladder size and an increase in postvoid residual urine. These normal changes reduce functional bladder capacity and cause an increase in voiding frequency. In the presence of impaired mobilitiy, increased voiding frequency can increase the risk of incontinence because the individual may not be able to reach the toilet in time.
2. Older adults can also experience increased increased urine production at night (that is, nocturnal polyuria); this is usually a normal finding but can also be symptomatic of disease such as renal failure, hypercalcemia, or diabetes. Frequent nighttime urination contributes to functional UI when an older adult has difficulty getting out of bed or takes excessive time to do so.
3. Older adults can also experience increased frequency of uninhibited bladder contractions, which produce urinary urgency and frequency. When these “normal” changes are compounded by impaired cognition or reduced mobility, the end result is a complex UI that can be difficult to diagnose as well as treat.

1. Cognitive Impairment

Cognitive impairment is a common cause of functional incontinence and has been identified along with immobility as a critical contributing factor in the development of incontinence in nursing home residents. Intact function is crucial to the effective execution of the series of behaviors required for maintenance of continence.

The individual must be able to recognize the sensation of urge, determine the appropriate response, locate a bathroom or socially acceptable substitute, remove clothing, perform personal hygiene, and flush the toilet or empty the waste receptacle. Cognitive impairment can limit the individual’s ability to activate this complex sequence of behaviors.

The origin of cognitive impairment ranges from the acute impairment caused by traumatic brain injury to the gradual steady decline in cognition that characterizes most dementias.

Cognitive skills Opens in new window guide interaction with one’s environment, and when compromised, the individual will experience some degree of loss in the ability to perform self-care and to cope with the environment in a socially acceptable manner. Alzhemer’s disease is the most common form of dementia among people 65 years old and older, with prevalence doubling every 5 years beyond the age of 65.

2. Motivation

Functional incontinence can be caused in total or in part by lack of motivation to maintain continence. As discussed earlier, continence requires a complex series of psychomotor skills Opens in new window that may demand an exceptional exertion of effort.

A diagnosis of depression may result in impaired physical, mental, and social functioning, which can affect the desire and ability to be continent, and studies have shown that incontinence has a negative impact on psychologic health. Thus, a vicious cycle can be created, in which depression causes or contributes to incontinence, which then exacerbates the depression.

Health care providers often underdiagnose and undertreat depression in older adults because the older adult does not manifest typical symptoms such as depressed mood; instead, depression in the elderly may be manifest by symptoms such as social withdrawal, isolation, and decline in activities of daily living, which can include toileting and self care activities.

Fortunately, both incontinence and depression are usually treatable, and studies indicate that treatment of incontinence results in an improved sense of psychologic well-being.

There are situations when incontinence may be a conscious choice because the physical effort required to use the toilet is valued as being too burdensome.

Persons with acute or chronic pain, weakness and fatigue, or debilitating dyspnea may be incontinent until their pain and/or energy levels are manageable enough to permit toileting.

Frail older adults may also forego continence because of the effort required to be continent. Some may fear toileting because of a recent fall or injury and out of this fear will refuse to use the toilet until they feel secure in their ability to transfer to the toilet safely. The clinician must intervene to modify factors that contribute to poor motivation (such as fear or fatigue) while respecting the autonomous wishes of the individual.

3. Compromised Mobility or Manual Dexterity

Functional incontinence can be caused by any factor that interferes with the ability to perform the sequence of fine and gross motor skills required for independent toileting. The culturally mandated response to a full bladder involves moving to an appropriate toileting facility and executing a number or fine motor skills such as clothing removal and personal hygiene.

Any compromise in mobility or manual dexterity can result in the inability to respond to a full bladder or rectum “fast enough” to prevent incontinence Opens in new window.

Musculoskeletal trauma, joint contractures, and deconditioning have the potential to cause incontinence Opens in new window because they affect the mobility and motor skills Opens in new window necessary for independent toileting.

A common example of this type of functional incontinence occurs in the older adult following hip or shoulder fracture. Hip fracture interferes with independent ambulation to a toilet, and a fracture of the shoulder interferes with some of the motor skills needed for clothing management and personal hygiene.

Individuals with preexisting stress UI Opens in new window, urge UI Opens in new window, or fecal urgency may experience a significant increase in their incontinence after musculoskeletal trauma because the ability to quickly reach the bathroom is compromised.

Any condition that interferes with manual dexterity can cause or contribute to functional incontinence. For example, the joint deformities and pain caused by arthritis can interfere with the ability to open bathroom doors, manage clothing, perform hygiene, or flush a toilet.

Individuals with neuromuscular diseases or disorders such as multiple sclerosis, Parkinson’s disease, spinal cord injury, or cerebrovascular accident are all high risk for incontinence, in part because of the neurologic impairment and in part because of motor skill disabilities that compromise their ability to use the toilet independently. Thus, these patients should be carefully assessed for functional as well as neurologic contributors to their incontinence.

4. Environmental Factors

Anything that creates a barrier to reaching a toilet or toilet substitute in a timely manner contributes to functional incontinence. This is especially true in patients with impaired cognition, mobility, or manual dexterity.

Toileting barriers include elements in the physical environment that interfere with toileting and a care environment where continence is dependent on caregivers.

Continence depends on the ability to reach the appropriate place to void or defecate in a timely manner. Easily accessible toilets or toileting substitutes such as commodes or urinals are essential.

Persons who use wheelchairs, crutches, or walkers may have increased difficulty with toilet access because not all bathrooms are “wheelchair or walker accessible.” Poorly lit bathrooms and access hallways can acts as a barrier for the person with decreased visual acuity.

Bathrooms and access hallways may be unsafe because of uneven floors, throw rugs, and wet floors (caused by leaking plumbing or urine); all of these factors can impede independent toileting.

Toilet seats that are too low, the absence of grab bars, or bathrooms that are too small to accommodate wheel chair transfers or walkers can create significant barriers for both independent and dependent toileting.

Bathrooms that are located at a distance from living areas, bathrooms that require climbing or descending stairs, and bathrooms with pathways blocked by furniture, trash, or equipment all increase the time needed to reach the toilet and can all interfere with independent or assisted toileting.

There may also be instances when bathroom accessibility is impeded by crowded conditions and too few toilets for the number of people. This is a well-founded fear of incontinent people when they travel, visit public places, or are in institutions. Individuals who are unable to reach or hold a urinal in a secure manner are also dealing with a barrier to continence. In all these instances, continence is possible if bathrooms and/or equipment are modified to accommodate needs.

An often-overlooked environmental barrier to continence is the inappropriate us of incontinence containment products. Containment products are an essential component of continence management but should not interfere with timely access to toileting.

Products that are difficult to remove such as pads with buttons and belts, adult briefs, or external catheters create incontinent episodes because the product cannot be removed quickly enough to use a toilet, bedpan, or urinal. Individuals with impaired manual dexterity are at higher risk to experience functional incontinence caused by an inability to manage an incontinence containment product independently.

Assessment

The assessment of functional incontinence should include an evaluation of all factors that could influence timely access to a toilet (or toilet substitute) and effective toileting.

When the clinician suspects functional incontinence, either alone or in combination with other types of incontinence, the evaluation should include a careful assessment of cognition, other mental impairments, motivation, fear, mobility and coordination, manual dexterity, the living environment, clothing, use of containment products, devices or equipment that restrain independent movement, and the ability, motivation, and education of caregivers to promote and support continence.

1. Cognitive Assessment

An evaluation of cognition and function is an essential component in the assessment and treatment of the incontinent person who is cognitively impaired.

Numerous mental status exams are available that measure different aspects of cognition including alertness, attention, cooperation, orientation, memory, language, apraxia, logic, and mood.

A frequently used test is the Folstein Mini-Mental Status Exam, which includes questions about the following: the year, season, day, and date; memory and math questions; and language questions that assess the ability to understand and follow spoken and written instructions.

If a standardized tool is not available, the clinician should be sure to evaluate orientation (person, place, time), memory (short-term and long-term), and the ability to read and follow simple directions.

Mental status exams are not perfect measure of memory loss or mental decline. An individual’s level of education, native language, hearing or vision problems, psychiatric problems (such as depression), and many other factors may influence the results of these tests.

2. Motivation Assessment

When addressing issues of motivation, it is important to identify factors that could interfere with the desire to maintain continence. As discussed earlier, depression can play a role in the development of functional incontinence, especially in the older adult.

There are quick and easy tools that can be used in the clinical setting to screen for depression, such as the Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. If depression is strongly suspected to be an influencing factor in the incontinence, a referral for treatment should be made in addition to initiation of a toileting program.

Other factors that influence the willingness to toilet should also be assessed such as pain, fatigue, ambulatory stability, and the fear of falling. Any factors found to interfere with the individual’s motivation to maintain continence must be addressed in the overall management plan; for example, the patient who avoids toileting because of pain should be referred to a pain specialist.

3. Mobility, Coordination, and Manual Dexterity Assessment

Functional incontinence is frequently associated with conditions that limit independent toileting. The best way to identify these factors is to observe all the behaviors associated with independent toileting. Patients should be observed as they walk to the toilet, remove clothing, perform personal hygiene, and prepare to leave the toileting area. This observation needs to be discrete in order, to preserve dignity.

4. Environmental Assessment

Certain factors need to be considered when assessing the environment for barriers to continence.

Anything that increases the time and effort required to carry out toileting should be factored into the environmental assessment. The assessment begins with a survey of the living area, whether in the home, hospital or long-term-care facility. Factors to be assessed include the following:

• What is the location of the toilet in relationship to living areas? Is the toilet close enough to allow timely access?
• Are there stairs to navigate that could create a barrier?
• Is the hallway leading to the bathroom wall lit?
• In long-term care facilities, are there toilets located near nonresidents care areas such as physical therapy rooms, day rooms, or activities areas? Residents in long-term care facilities may not want to participate in activities if no easily accessible toilets are nearby.
• In cramped hospital rooms, are there extra chairs or equipment blocking access to in-room bathrooms?

Assessment of functional incontinence includes an evaluation of bathrooms and toileting equipment. Clinicians should always inspect or focus the health history to include questions about the bathrooms.

Are there any obstacles in the bathroom that could create a barrier? If a wheelchair or walker is needed to access a toilet, is there enough room in the bathroom to accommodate it and allow safe transfer to the toilet? Is the toilet seat at a height that is comfortable? Are there grab bars? In the presence of diminished visual acuity and/or cognitive impairment, is the bathroom clearly lit and marked? How many people use the same bathroom and are there times when a queue forms to use this bathroom? If a bedside commode is used, is it located in a private place and is it sturdy enough to support the weight of the patient? Can the urinal be easily reached and held securely? Often, simple and relatively inexpensive environmental modifications can be made to support continence, such as providing a urinal to individuals with mobility problems or removing throw rugs or small pieces of furniture to facilitate access to the bathroom. Box X2 provides a sample guide for assessment of the home environment.

3. Artificial sphincter

Artificial sphincter placement, described below in the section on ISD in men, has been used for women with ISD. Combined data from 8 studies of 192 women with ISD treated with artificial sphincter placement indicated that 77 percent were dry, and 80 percent were “cured” or improved (Parulkar and Barrett, 1990). Complications included fluid leak, loose cuff, erosion or atrophy of the cuff site, tubing kink, and infection.

Sling procedures are recommended for women who have ISD with coexisting hypermobility or as first-line treatment for ISD. (Strength of Evidence = B.)

Periurethral bulking injections are recommended as first-line treatment for women with ISD who do not have coexisting hypermobility. (Strength of Evidence = B.)

Artificial sphincter is recommended for ISD patients who are unable to perform intermittent catherization and have sever SUI that is unresponsive to other surgical treatments. Because of the high complication rate, this treatment is rarely used as primary therapy. (Strength of Evidence = B.)

Stress Incontinence in Men: Intrinsic Sphincter Deficiency

An underactive outlet in men may result from a congenital defect or from direct or indirect trauma to the anatomy or physiology of the bladder outlet.

Direct trauma due to prostatectomy is the most common cause of sphincter insufficiency. Neurologic dysfunction (e.g., sympathetic innervations to the bladder neck, pelvic nerve to the intrinsic sphincter, pudendal nerve to the external sphincter) may be a primary or contributory etiology.

Devascularization or fibrosis, most commonly following radiation therapy or surgery, may also contribute to decreased closure pressure of the bladder outlet. The high incidence of mixed incontinence requires that an alteration in bladder function be considered and diagnosed before surgical intervention for decreased outlet resistance. Postprostatectomy incontinence is not always due to sphincter insufficiency but sometimes to detrusor dysfunction or both. Patients must be evaluated for other possible causes of incontinence, including obstruction, DI, and poor bladder compliance.

The choices for surgical treatment of male sphincter insufficiency include:

• Periurethral bulking injections.
• Placement of an artificial sphincter.

The preoperative evaluation may require a cystoscopy, and a simple cystometry or complex videouodynamic studies, depending on the suspected etiology. Special care and follow-up are required in neurologically impaired individuals due to a significant incidence of bladder compliance changes following therapy to increase outlet resistance. Before injection or sphincter implantation, it is advisable to wait at least 6 months to a year and to have the patient undergo behavioral and pharmacologic intervention during the intervening months. If an artificial sphincter is being considered, it is important to assess whether the patient has enough manual dexterity and ability to operate the device.

1. Periurethral Bulking Injections

Periurethral bulking injections are recommended as a first-line surgical treatment for men with ISD. (Strength of Evidence = B.)

Periurethral bulking injections can improve urinary loss in men with stress incontinence. The mechanism for improvement after injection therapy is still unclear but may reflect an improvement in urethral coaptation and possibly compression. Periurethral injections are less likely to succeed in male than in female patients and in all patients who have undergone pelvic radiation therapy or who have extensive periurethral scarring. Success is more common in patients who have stress incontinence after transurethral or open prostatectomy than in those after radical prostatectomy. The literature does not support the use of bulking agents in men with severe postprostatectomy incontinence (Appell, 1994).

Experience and follow-up are limited for treatments by injections with collagen and fat, which are absorbed by patients over time. There are no randomized studies comparing the efficacy of different materials or of injection therapy with other forms of treatment.

The analysis included 9 studies of 1,005 men treated with periurethral injection (McGuire and Appell, 1994). Sample sizes ranged from a minimum of 3 to a maximum of 720. The mean age was 69 years, and mean follow-up time was 2.0 years. The “cure” rate was reported in eight studies and ranged from 0 to 66 percent, with a mean of 20 percent. The “cure”–improvement rate was reported in nine studies and ranged from 0 to 81 percent, with a mean of 42 percent.

Complications reported with PTFE included infection, urinary retention, fever, temporary erectile dysfunction, periurethral inflammatory reaction, extrusion of the material into the urine or perineal area, and burning sensation or perineal discomfort. Particles of PTFE have been found in patients’ lungs after periurethral injection of PTFE, but the exact incidence and the clinical significance of this migration are not known.

2. Placement of an Artificial Sphincter

Artificial sphincter may be elected for ISD during the 6 months after prostatectomy. Behavioral intervention should also be tried during this period. (Strength of Evidence = B.)

Before periurethral injection therapy became available, placement of an artificial urinary sphincter was the most commonly used surgical procedure for the treatment of underactive outlet in men. Data on the current rate of comparative utilization of these two techniques are not available. Before implantation, urodynamic evaluation to confirm a stable, compliant, low pressure bladder is critical.

The analysis included 10 studies that presented data on 346 men, with sample sizes ranging from 11 to 96 (Nordling, Holm-Bentzen, and Hald, 1986). The average age of the patients was 61.4 years. The “cure” rate was presented in nine studies and ranged from 33 to 88 percent, with a mean of 66 percent. The “cure” or improvement rate in the 10 studies ranged from 75 to 94.5 percent, with a mean of 85.3 percent.

Initial preoperative complications are mainly associated with urethral or bladder injury during implantation. Delayed complications included mechanical problems such as pump malfunction, fluid leak, or tubing kink; infection; or cuff-related site atrophy, incomplete compression, or erosion. In addition, urethral injury, pump erosion, and herniated reservoir were reported in fewer patients.

The utilization of the artificial urinary sphincter in patients after radiation therapy, cryotherapy, or pelvic fracture with urethroplasty is controversial because of concern about compromising the urethral blood supply. Also controversial is the use of intermittent catherization after sphincter implantation. The experience of the implanting surgeon may be related to the incidence of complications.