Urinary incontinence is any involuntary loss of urine. Voiding dysfunction also includes urinary retention (inability to empty the bladder) and neurogenic bladder (bladder control disrupted by nervous system disease). Incontinence is common, especially in older women, but it is never a normal part of aging and is often treatable.

Normal continence needs a bladder that stores urine at low pressure, a competent urethral sphincter and pelvic floor, intact nerve pathways, and the ability to reach a toilet.

Transient (reversible) causes — look for these first: delirium, infection (UTI), atrophic vaginitis, drugs (diuretics, sedatives, anticholinergics, alpha blockers in women), excess urine output (hyperglycemia, heart failure), restricted mobility, and stool impaction.

Neurogenic bladder

• Upper motor neuron (spastic) bladder — lesion above the sacral cord: small capacity, reflex emptying, detrusor-sphincter dyssynergia (high pressures can damage kidneys)
• Lower motor neuron (flaccid) bladder — sacral lesion or peripheral neuropathy: large, poorly contracting bladder → retention and overflow

• Voiding history: onset, triggers (cough, urge, position), frequency, nocturia, volume leaked, pad use, fluid and caffeine intake, bowel habits
• Bladder diary (usually 3 days): times and volumes of voiding, leakage episodes, fluid intake
• Impact on quality of life — embarrassment, social withdrawal, fear of going out, sleep disruption, depression, sexual concerns
• Mobility, dexterity, cognition, toilet access
• Medication review
• Abdomen: distended bladder (retention); perineal skin for incontinence-associated dermatitis
• Pelvic exam (prolapse, atrophic vaginitis); digital rectal exam (impaction, prostate, sphincter tone)
• In a client with constipation plus episodes of liquid stool leakage, check for fecal impaction first — it causes overflow fecal incontinence and can cause urinary retention

• Urinalysis (± culture) — rule out infection and hematuria; glucose for diabetes
• Post-void residual (PVR) by bladder scanner (ultrasound) or catheterization, measured soon after voiding
  • Less than about 50 mL: normal emptying
  • More than about 100–150 mL: incomplete emptying that needs further evaluation; very high volumes (e.g., > 300 mL) suggest retention
  • PVR reflects bladder emptying, not kidney function
• Cough stress test — leakage with cough confirms stress incontinence
• Urodynamic studies (bladder pressure-volume testing) — for complex, mixed, or neurogenic cases or before surgery; not needed before first-line conservative therapy
• Creatinine and renal ultrasound in chronic retention or neurogenic bladder

First-line for all types — behavioral therapy

• Pelvic floor muscle training (Kegel exercises) — first-line for stress and helpful for urge and mixed incontinence
• Bladder training for urge incontinence — the goal is to gradually lengthen the interval between voids (often by 15–30 minutes at a time) and increase functional bladder capacity, using urge-suppression techniques
• Prompted or timed (scheduled) voiding for functional incontinence and cognitive impairment
• Weight loss, smoking cessation, limit caffeine and alcohol, treat constipation, manage fluid timing (not severe restriction)

Medications for urge incontinence / OAB

• Vaginal estrogen for postmenopausal genitourinary atrophy
• Overflow from BPH: alpha blockers (see Topic 55)

Procedures for stress incontinence

• Midurethral sling (most common surgery); Burch colposuspension; periurethral bulking agents (injection — minimally invasive, may need repeat treatment); artificial urinary sphincter (men after prostatectomy)
• Pessaries for prolapse or activity-related leakage

Retention and neurogenic bladder

• Clean intermittent self-catheterization (CIC) — preferred over indwelling catheters for long-term management
• Indwelling or suprapubic catheter only when other methods fail

Listed in priority order.

1. Relieve acute retention and prevent bladder overdistension — scan the bladder; catheterize as prescribed; in spinal cord injury at T6 or above, a full bladder can trigger autonomic dysreflexia (sudden severe hypertension, pounding headache, bradycardia, flushing above the injury) — sit the client up, loosen tight clothing, check any catheter for kinks first, and empty the bladder immediately (lidocaine jelly for catheterization); monitor BP every 2–5 minutes
2. Identify and treat reversible causes — infection, impaction, drugs, hyperglycemia, delirium
3. Protect the skin
   • Change wet or soiled pads immediately; cleanse gently with a pH-balanced no-rinse cleanser (avoid harsh soap and rubbing)
   • Apply moisturizer and a barrier product (zinc oxide, dimethicone, or petrolatum)
   • Choose properly fitting absorbent products — never fasten them tightly (friction, pressure, and trapped moisture damage skin); allow periods off the pad when possible
4. Toileting program — scheduled or prompted voiding; easy access to toilet, bedside commode, or urinal; call light within reach; clothing easy to remove; night lighting
5. Intermittent catheterization — typically every 4–6 hours, timed so that each catheterization drains no more than about 400–500 mL; clean technique at home, sterile technique in hospital per policy
6. Therapeutic communication — acknowledge feelings of embarrassment, explore how incontinence affects daily life, avoid dismissing it as normal aging, and avoid giving advice before understanding the concern
7. Avoid indwelling catheters for incontinence management alone (CAUTI risk)

Pelvic floor muscle training

• Identify the right muscles (the ones used to stop gas or urine flow — but do not routinely practice by stopping urine midstream)
• Tighten and hold for about 3–10 seconds, relax for an equal time; about 10 repetitions, 3 times a day, in lying, sitting, and standing positions
• Do not tighten abdomen, thighs, or buttocks or hold breath
• Improvement usually takes several weeks to 3 months of daily practice; "the knack" — tighten before a cough or lift

Bladder training

• Void on a schedule rather than at every urge; when urgency comes, stop, stay still, do quick pelvic floor contractions, breathe, and wait for the urge to pass, then walk calmly to the toilet
• Lengthen intervals gradually toward every 3–4 hours

Lifestyle

• Do not severely restrict fluids — concentrated urine irritates the bladder and raises UTI risk; drink about 1.5–2 L/day unless restricted; reduce fluids 2–3 hours before bed
• Limit caffeine, alcohol, carbonated drinks, and artificial sweeteners
• Prevent constipation (fiber, fluids, activity); manage weight

Medications

• Antimuscarinics: sugar-free gum or candy for dry mouth, fiber for constipation, avoid overheating; report difficulty voiding or confusion
• Mirabegron: check BP regularly

Intermittent self-catheterization

• Wash hands, use clean technique, and catheterize on schedule, not only when the bladder feels full
• Continue catheterizing if UTI symptoms develop and contact the provider — stopping risks retention and kidney damage
• Record volumes; report cloudy foul urine, fever, blood, or difficulty passing the catheter

After stress incontinence procedures

• Sling surgery: avoid heavy lifting, straining, and strenuous exercise for about 4–6 weeks; report inability to void or fever
• Bulking injection: recovery is quick; short-term dysuria or mild retention can occur — report inability to void

• Acute urinary retention — painful distended bladder, inability to void
• Autonomic dysreflexia in spinal cord injury — hypertensive emergency
• UTI and urosepsis from retention or catheters
• Hydronephrosis and kidney damage from chronic high-pressure retention
• Incontinence-associated dermatitis, pressure injury
• Falls (rushing to the toilet at night), social isolation, depression
• Antimuscarinic toxicity in older adults — confusion, retention

• Stress = leakage with cough, laugh, sneeze → first-line pelvic floor (Kegel) exercises
• Urge / OAB = sudden urgency → bladder training (gradually lengthen voiding intervals to increase capacity), limit caffeine and alcohol, drugs
• Overflow = incomplete emptying (BPH, impaction, neuropathy) with dribbling and high PVR
• Functional = cannot reach toilet → prompted/timed voiding, environment
• PVR < about 50 mL normal; > about 100–150 mL = incomplete emptying
• Antimuscarinics (oxybutynin): dry mouth, constipation, retention, confusion in older adults; avoid in narrow-angle glaucoma; mirabegron → hypertension
• Constipation with leakage → check for fecal impaction (digital rectal exam) first
• CIC: every 4–6 h, keep volumes ≤ 400–500 mL; clean technique at home; keep catheterizing if UTI develops and call the provider
• Do not restrict fluids severely; never fasten pads tightly; change wet pads immediately; barrier cream
• Acknowledge embarrassment — incontinence is not a normal part of aging
• SCI T6 and above: full bladder → autonomic dysreflexia