**4.2.4 Functional incontinence**

118 Urinary Incontinence

Chronic or established incontinence: it is associated with structural disorders, either in the urinary tract or outside of it, like in the nervous system. Usually the duration of this type of incontinence is over four weeks and some complementary examinations (ultrasounds, urodynamic) will be required to discover its etiology. It is important to emphasize that some transient causes of incontinence may contribute to an established form and that mixed incontinence is more common in the frail elderly population than in other groups of

Mechanisms that are responsible for greater frequency of established incontinence in elderly

Urge incontinence: this is the most common type of established incontinence in the older population. Usually underlies detrusor hyperactivity in relationship with several neurological diseases (brain ischemia, dementias, Parkinson's disease). Clinically, this type of UI presents as urgency, frequency and nocturia, and it has a higher impact on quality of

Stress incontinence: this is most common in frail elderly women and uncommon in men, except when the external urethral sphincter has been damaged during prostatic surgery. The causes are generally related to pelvic floor weakness which produces a urethral hypermobility (multiparity, hypoestrogenism, obesity) or previous pelvic surgery (gynaecological, prostatic resection). The urine leakages will be produced with manoeuvres that cause an increase in intra-abdominal pressure (coughing, laughing, sneezing, Valsalva). Usually the length of the symptoms is long, and the impact on quality of life is lower than

Overflow incontinence: this appears in situations of bladder overdistension. There are two different mechanisms: bladder outlet obstruction (prostatic hyperplasia, urethral stenosis, faecal impaction) and bladder contractile impairment (spinal cord lesions, peripheral and/or autonomic neuropathy, detrusor myopathy, anticholinergic drugs). Within this subgroup of incontinence, a relatively common entity exists, especially in disabled patients, called Detrusor Hyperactivity with Impaired Contractility (DHIC). This term was coined by Resnick in 1987 when he observed a characteristic urodynamic pattern, in an incontinent and disabled elderly group, of uninhibited bladder contractions together with an inability to empty more than 50% of the bladder content (Resnick, 1996). Nowadays, DHIC is considered a subtype of bladder hyperreflexia, but the mechanism that produces bladder contractile impairment is unknown. It is proposed that it may be an evolved phase of bladder hyperreflexia, with the production of muscle failure (Smith PP, 2010). From the clinical point of view, patients may present with both irritative type urinary symptoms

life due to the bothersome and the severity of the symptoms.

**4.2 Chronic or established incontinence** 

patients.

people are:

**4.2.1 Urge incontinence** 

**4.2.2 Stress incontinence** 

urge incontinence.

**4.2.3 Overflow incontinence** 

Functional incontinence: many social and environmental factors, such as lack of carers to assist with toileting, and physical barriers, including bed-restraints, may be responsible for incontinence. However, a diagnosis of functional incontinence should only be accepted by exclusion, once other mechanisms have been ruled out.

### **4.2.5 Mixed incontinence**

Mixed incontinence: many frail older people with chronic incontinence have a combination of different type of incontinence. A combination of urge incontinence and stress is very common. Another type of specific mixed incontinence in the frail elderly is the DHIC as previously has been exposed above.
