ENURESIS = AGING?
"A 70-year-old woman developed intermittant enuresis. She is not taking any medications, has no ther urinary symptoms and a urine culture is negative," explains MARY COMERTON, MD, of Ottawa, Ont. She would like to know, "What further investigations are appropriate?"
With normal aging there is a postural diuresis at night such that normal patterns include up to two voids per night, especially with conditions such as peripheral edema, congestive heart failure, diabetes or lipid diuretics. Residual volumes are increased, capacity is decreased, and there may be less ability to inhibit spontaneous detruser activity. Despite these normal aging changes, intermittant bedwetting in this patient cannot be considered to be normal. I would make certain that the patient is not taking any over-the-counter medications such as decongestants with anticholinergic properties, and I would exclude the possibility of significant alcohol intake, which can inhibit the call to void. Make certain that the patient is not taking inordinate amounts of fluids after dinner: fluids should be restricted after dinner and the patient should void before going to bed. The weight of a large, full bladder at night associated with a degree of sphincter incompetence may predispose the patient to nocturnal stress incontinence, so this possibility should be ruled out. Also, the possibility of urinary retention with overflow incontinence should be ruled out by confirming confirming that a post-void in and out catheterization is less than 50 to 75 cc. In addition I would exclude the possibility of unsuspected dementia associated with detrusor instability by performing formalizing mental status tests such as the Folstein Mini- Mental State examination. Make sure that the patient is truly waking up wet, as opposed to waking up and having incontinence before she can get out of bed, the latter suggestive of detrusor instability. Finally, I would rule out the common causes of transient transient incontinence using mnemonic "diappers": delirium, infection, atrophic vaginitis, psychiatric causes, pharmaceuticals, endocrine, restricted mobility, and stool impaction. The physical exam should focus on neurological, gynecological, musculoskeletal and rectal examination. If no obvious cause is found and the problem persists, I would refer her to urology for further testing, including voiding cystometry. WD