Information
Editors
MariaNuotio
SeijaAla-Nissilä
Urinary Incontinence in the Elderly
Essentials
- Urinary incontinence in an elderly person has an effect on the patient's and his/her family's quality of life as well as on health care costs. It increases the risk of falls and the need for long-term institutional care.
- The patient is often too embarrassed to seek appropriate help.
- Various treatment options that either cure or at least ease the situation are available to manage urinary incontinence in an elderly person.
Prevalence and types
- More common in women and in those living in round-the-clock care
- Among individuals aged over 70 years, over half of women and about a quarter of men suffer from troublesome urinary incontinence.
- Urge incontinence
- Characterised by a sudden urge to urinate (urgency)
- Part of overactive bladder syndrome, the other symptoms of which include urinary urgency without incontinence, urinary frequency and nocturia
- The most common type in men. The underlying cause is often the increased resistance to urine flow in the outflow tract caused by benign prostatic hyperplasia (BPH).
- Stress incontinence
- Involuntary loss of urine during physical exertion or strain
- Common in women
- Rare in men, mostly seen as a complication of prostate surgery
- Mixed incontinence
- A combination of urge and stress incontinence
- The most common type in women
- Overflow incontinence
- Incontinence caused by either acute or chronic urinary retention
Changes connected with aging
- Women
- Atrophy of urogenital mucous membranes
- Weakening of the pelvic floor supporting structures
- Urethral shortening
- Men
- Men and women
- Detrusor hyperactivity with impaired contractile function
- The functional volume of the bladder decreases leading to an increased volume of residual urine.
- Tthe ability of the kidneys to concentrate urine decreases.
- The volume of urine excreted during the night (nocturnal polyuria) increases in relation to the volume excreted during the day.
Factors associated with urinary incontinence in the elderly
- Neurological diseases
- Memory disturbances
- Cerebrovascular disease and the so-called white matter changes in the deep parts of the brain
- Parkinson's disease
- One component in the triad of symptoms in the normal pressure hydrocephalus (NPH)
- Other chronic diseases
- Type 2 diabetes
- Cardiac insufficiency (fluid retention, diuretics)
- Lung disease (cough)
- Musculoskeletal disease (e.g. spinal stenosis)
- Depression and depressive symptoms
- Intestinal symptoms
- Constipation
- Faecal incontinence
- Reduced mobility and functional capacity
- Frailty syndrome
- Delirium
- Acute urinary tract infection
- Moreover, asymptomatic bacteriuria is very common in an elderly person and requires no management.
- Medication
- Diuretics
- Antipsychotic drugs with anticholinergic properties
- Analgesics acting on the central nervous system
- Hypnotics and sedatives
- Acetylcholinesterase inhibitors used in Alzheimer's disease
Treatment
- Investigations and treatment are decided on according to the cause(s) and type of incontinence.
- In cases where the patient has a memory disease, several comorbidities or a medication consisting of a variety of drugs, the emphasis of management should be on a holistic approach and rehabilitation.
Overactive bladder with associated urge incontinence
Drug therapy
- Antimuscarinic drugs Anticholinergic Drugs and Non-Drug Active Therapies for Urgency Urinary Incontinence or Overactive Bladder Syndrome in Adults
- Darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium chloride
- Adverse effects: dry mouth, constipation, urinary retention, orthostatic hypotension, memory disturbances, confusion
- Possibly associated with the development of cognitive impairment in long-term use.
- Must not be used concomitantly with acetylcholinesterase inhibitors.
- Lowest possible starting and maintenance dose
- Careful observation of treatment response and the emergence of adverse effects
- Sources focusing on pharmatherapy of elderly people may advise against the use of these drugs. See locally available sources and e.g. the Meds 75+ database by the Finnish Medicines Agency (Fimea) http://www.fimea.fi/web/en/databases_and_registeries/medicines_information/database_of_medication_for_older_persons.
- Mirabegronhttp://www.dynamed.com/condition/urinary-incontinence-in-women#B_3_AGONISTS
- Beta-3 adrenergic receptor agonist that does not have the typical adverse effects of antimuscarinics. One should be careful, however, especially when treating persons with cardiovascular diseases, such as hypertension. Cardiac QTc time should also be monitored in risk patients for a possible prolongation of it.
- In the context of any oral drug taken for urinary incontinence, the tolerance to and safety of the medication should be considered because of the general renal insufficiency by utilizing the GFR value Gfr Calculator.
- Drug therapy of benign prostatic hyperplasia
- Injection of botulinum toxin A into the bladder muscle may be considered in severe urge incontinence.
- Topical oestrogen therapy
Surgery
- Transurethral resection of the prostate in benign prostatic hyperplasia after urodynamic studies.
Other therapies
- Scheduled visits to the toilet (timed voiding)
- A programme of timed verbal toileting reminders (prompted voiding) can be implemented in residential care facilities
- Percutaneous tibial nerve stimulation may be beneficial in the treatment of urge incontinence in the elderly. It may also be applied at home.
Nocturia and nocturnal urinary incontinence
- Changing the administration of a diuretic to the afternoon
- Intermittent catheterisation (in-and-out catheterisation) in round-the-clock care before bedtime
- Graduated compression stockings if the patient has lower leg oedema
- Mirabegron (or an antimuscarinic drug) at night
- Desmopressin is contraindicated due to the risk of hyponatraemia.
Stress and mixed urinary incontinence in women
Physical exercise therapy
- The first line treatment option, also in elderly patients
- Pelvic floor exercises Pelvic Floor Muscle Training for Urinary Incontinence in Women as such or in combination with e.g. general muscle strength exercises of the lower extremities, if necessary under the guidance of a physiotherapist. These exercises are also effective in urinary urgency.
- Other illnesses or mild memory disorder do not prevent excercises.
- Encouragement to general physical training (prevents urinary incontinence in the elderly)
Surgery
- Sling procedures performed in local anaesthesia are also suitable for elderly women for the management of difficult stress incontinence Urinary Incontinence in Women.
- In stress urinary incontinence, injection of polyacrylamide hydrogel (Bulkamid® ) around the urethra may be a treatment alternative in elderly women for whom surgery poses a high risk.
- Sling procedures for men performed in local anaesthesia are suitable in mild and moderate stress incontinence also in elderly male patients.
Overflow incontinence
- The volume of residual urine should be measured with ultrasonography or by single catheterisation after urination.
- Any obstruction to urine flow must be excluded; an obstruction may be caused by
- benign prostatic hyperplasia in men
- significant prolapse in women.
- Treatment of constipation, gradual withdrawal of drugs that relax the urinary bladder (anticholinergics in particular)
- The complete emptying of the bladder must be ensured, preferably with intermittent catheterisation carried out at sufficiently frequent intervals
- The use of an indwelling catheter should be avoided in the treatment of chronic urinary retention.
Rehabilitation aspects
- The maintenance and promotion of mobility and functional capacity improve bladder control.
- Speedy and effective rehabilitation should be provided after an acute illness or surgery using appropriate mobility aids.
- An indwelling catheter should be removed as soon as possible in order to preserve bladder control and to avoid catheter-induced infections and other complications.
- It must be ensured that the patient has an obstacle-free and safe route (e.g. adequate lighting etc.) to the toilet or commode both at home and in residential care.
Incontinence protection
- High quality incontinence pads that are changed sufficiently frequently
- Various collection bags are available for men
- It may be more difficult for elderly men to accept the use of incontinence pads, and they should be given particular attention during counselling and education.
Other points of importance
- Listen to the wishes of the patient and his/her family
- Observe the mood of the incontinent patient and prescribe, if necessary, antidepressants.
- Treat constipation Obstipation in the Adult.
- Review all medication.
- In persons with a memory disorder, consider also other possible aetiological factors of urinary incontinence than the memory disorder.
Referral criteria
- Suspicion of urinary obstruction (e.g. a prolapse in women and prostate problems in men)
- Severe symptoms
- No results are achieved with conservative treatment
- Postoperative complications
References
- DuBeau CE, Kuchel GA, Johnson T 2nd et al. Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence. Neurourol Urodyn 2010;29(1):165-78. [PubMed]
- Schröder A, Abrams P, Andersson KE ym. Urinary incontinence in frail/older men and women. Guideline on urinary incontinence: European Association of Urology 2010 http://www.uroweb.org/gls/pockets/english
- Gibson W, Wagg A. New horizons: urinary incontinence in older people. Age Ageing 2014;43(2):157-63. [PubMed]
- Gibson W, Johnson T, Kirschner-Hermanns R et al. Incontinence in frail elderly persons: Report of the 6th International Consultation on Incontinence. Neurourol Urodyn 2021;40(1):38-54. [PubMed]