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Med Clin N Am 90 (2006) 825–836

Urinary Incontinence: Selected Current Concepts
Marget-Mary G. Wilson, MD, MRCPa,b,*
Division of Geriatric Medicine, St. Louis University Health Sciences Center, 1402 South Grand Boulevard, Room M238, St. Louis, MO 63104, USA b Geriatric Research, Education, and Clinical Center, Veterans’ Administration Medical Center, Jefferson Barracks Division, 1 Jefferson Barracks Drive, St. Louis, MO 63125, USA

Introduction Urinary incontinence (UI) in older adults is a potentially life-threatening problem. Potential consequences include significant functional decline, impaired quality of life, frailty, institutionalization, and death [1,2]. Reported prevalence for urinary incontinence ranges from 15% among relatively healthy community-dwelling older adults to 65% among frail older adults [3,4]. Available figures most likely underestimate the true prevalence of UI for several reasons, including patient embarrassment, low rates of clinical detection, and lack of awareness of effective treatment options [5]. Health care costs for UI exceed $20 billion annually [6]. Additionally, the lifetime medical cost of treating an older adult who has urinary incontinence approaches $60,000 [7]. Added costs arising from complications of UI, such as loss of wages, poor quality of life, depression, and loss of self-esteem, increase the financial burden of UI even further [6].

Pathophysiology of urinary incontinence in older adults Age-related changes in bladder function set the stage for UI (Fig. 1). These include an increased frequency of uninhibited detrusor contractions, impaired bladder contractility, abnormal detrusor relaxation patterns, and reduced bladder capacity. There is also an age-related increase in the volume of nocturnal urine production. In men, prostatic size increases, whereas

* Division of Geriatric Medicine, St. Louis University Health Sciences Center, 1402 South Grand Boulevard, Room M238, St. Louis, MO 63104. E-mail address: 0025-7125/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2006.06.005

Gender Anatomic Cultural Environmental Neurologic disease Childbirth Tissue disruption Pelvic surgery


Constipation Occupation Obesity Surgery Advanced age Disease Dementia Drugs Debility Disease Environment Medications

Urinary Incontinence

Fig. 1. UI in the older adult: risk and predisposing factors.

urethral shortening and urethral sphincter weakening occur in women [8–11]. Aside from advancing age, other risk factors for UI include coexisting morbidity, cognitive dysfunction, functional impairment, gait abnormality, diuretic therapy, and obesity [3,12]. Female gender is an irreversible predisposing factor and mandates routine screening for UI in all women regardless of age. Anatomic genital abnormalities such as hypospadias, epispadias, and ambiguous genitalia may compromise continence. Coexisting illness, such as cerebrovascular disease, radical pelvic surgery, or autonomic neuropathy, may increase the risk for UI further [13,14]. Available data indicate that the occurrence of cerebrovascular disease doubles the risk for UI in the older woman. Obesity, frailty, and diabetes are strong predictors of the occurrence of UI Additionally, older adults are more likely to become incontinent following the onset of UI-promoting factors, such as constipation, obesity, and polyuria from uncontrolled hyperglycemia, hypercalcemia, or diuretic therapy [3,15,16]. Mechanistic classification of urinary incontinence UI can be categorized into five major groups: overactive bladder (OAB), stress incontinence, overflow incontinence, and functional incontinence; combinations of these categories constitute the fifth category, which is referred to as mixed incontinence. Symptoms of bladder hyperactivity and impaired contractility may coexist in patients who have diabetes mellitus. Likewise, benign prostatic enlargement can present with symptoms of bladder overactivity and urinary retention [17–19]. OAB occurs in one in four adults over the age of 65 years and accounts for 40% to 70% of all cases of UI in this cohort. Symptoms of OAB arise



from involuntary contractions of the detrusor muscle at unusually low volumes of urine, resulting in a strong urge to pass urine. Clinically, OAB manifests with urgency, frequency, and nocturia, with or without urge incontinence [20]. People who have urge incontinence present with involuntary urine loss preceded by an urgent and compelling desire to void. Several physiologic mechanisms underlie detrusor muscle contraction. The major mechanism is cholinergic and is mediated through the effect of acetylcholine (Ach) on muscarinic bladder receptors. A second mechanism (purinergic) involves adenosine triphosphate- (ATP) mediated bladder contraction. A third non-neuronal mechanism probably exists, involving local uroepithelial Ach production and subsequent paracrine action on local muscarinic bladder. Available data indicate age-related compromise in cholinergic and purinergic bladder transmission. Purinergic transmission seems to play a greater role in bladder contraction with aging, suggesting disproportionate age-related compromise in cholinergic function. Available data also suggest an age-related compromise of non-neuronal uroepithelial Ach production [10,21]. Twenty-five percent of women who have UI present with symptoms of stress incontinence usually arising from anatomic or pathologic disruption of the angle between the bladder neck and the urethra. Causes of stress incontinence include vaginal childbirth and pelvic surgery, such as hysterectomy in women or prostate surgery in men. Generally, stress incontinence presents with involuntary urine loss associated with increases in intraabdominal pressure in the presence of a relatively incompetent urethral sphincter mechanism. In such patients, involuntary urine loss characteristically occurs when the patient laughs, coughs, or sneezes. In severe cases, UI may occur with a change in posture from supine or sitting to standing [22–24]. Overflow incontinence arises from bladder outlet obstruction that results in progressive bladder distension with a gradual increase in intravesical pressure until the mechanical outlet obstruction is overcome by sheer pressure. People who have overflow incontinence may complain of persistent trickling of urine in the presence of suprapubic distension or discomfort. In men, prostatic enlargement is the most common cause of overflow incontinence. Pelvic masses, such as uterine fibroids or cystoceles, may cause similar obstructive symptoms in women [25–27]. Functional incontinence refers to involuntary urine loss resulting from inability to gain prompt access to toileting facilities for reasons such as limited mobility, impaired cognition, lack of motivation, environmental barriers, or restricted access. This problem occurs commonly in frail elders who have dementia, cerebrovascular disease, Parkinson disease, or delirium. Altered mental status from narcotics, sedatives, or neuroleptic agents also may lead to functional UI [28,29]. Inappropriate use of physical or chemical restraints, poor vision, depression, reduced exercise tolerance, gait abnormality, or fear of falling are other causes of functional incontinence.



Complications and consequences of urinary incontinence in elders Older adults who have urinary incontinence often experience embarrassment, loss of self-confidence, and poor self-esteem. Sixty percent develop depressive symptoms. Unpredictable episodes of UI may lead to withdrawal and social isolation. Limitation of physical activity in affected elders may compromise functional status and hasten progression to frailty. Intimate relationships may be avoided because of the fear of involuntary urine loss during sexual intercourse. Studies have shown an independent association between sexual dysfunction and urinary incontinence in older men [1,30–32]. Financially, UI can become burdensome. Protective garments and bedding often are not covered by insurance plans and are relatively expensive. Productivity of older adults in the workforce may be negatively affected by the threat of frequent and unpredictable episodes of incontinence. Likewise, the productivity of caregivers of patients who have UI may be compromised by their inability to cope with the demands of a relative who has urinary incontinence. Available data highlight UI as the most common cause of institutionalization of elders. Similarly, in long-term care facilities the resident who has urinary incontinence imposes an additional annual financial burden of approximately $5000 to total health care costs. [1,33]. In women aged over 65 years who have incontinence the incidence of falls and consequent fractures increases significantly. Approximately 20% to 40% of women who have UI will fall within 12 months and of these falls about 10% will result in fractures, usually of the hip. Available data show a strong association between UI, acute hospitalization, institutionalization, and death [34,35]. Thirty percent of women who have UI over the age of 65 years are likely to be hospitalized within 12 months. Older men are twice as likely to be hospitalized over a 12-month period. Of the myriad complications associated with UI, the most alarming is the independent association between UI and increased mortality [35].

Clinical assessment of the older adult who has urinary incontinence Health care providers should screen all older adults at risk for UI because few patients volunteer this information as a presenting complaint. Delayed presentation is not unusual and patients may not complain until symptoms become severe [36,37]. Providers should ask about the volume of urine lost, strength of urinary stream, body posture in which urine loss is most likely to occur, number of pads used, and associated fecal incontinence. Quality of life and caregiver burden should also be assessed. Additional information should be sought regarding risk factors and predisposing factors. Patients should be asked about a coexisting history of diabetes mellitus, hypercalcemia, impaired cognition, functional disability, or impaired sensory perception. Medication history is critical because diuretics or hyperosmolar



infusions may contribute to polyuria and precipitate UI. Additionally, anticholinergic medications can cause obstruction and consequent overflow incontinence. Narcotics, sedatives, and hypnotics may impair cognition or cloud consciousness, thereby precipitating functional incontinence. An accurate voiding diary facilitates quantification, classification, and characterization of UI. Short voiding diaries (48 or 72 hours) have been shown to be just as reliable and valid as traditional 7-day diaries and are perceived as less burdensome by patients [38,39]. Physical examination must include a complete neurologic, abdominal, urogenital, pelvic, and rectal examination. Both the anal and bulbocavernosus reflexes should be assessed. Urethral sphincteric response to the cough reflex should be evaluated during pelvic examination to enable exclusion of stress incontinence. People who have stress incontinence may lose urine during coughing, whereas patients who have intact perineal reflexes exhibit tightening of the anal sphincter during coughing. Bedside measurement of postvoid residual volumes is helpful in the clinical diagnosis of overflow incontinence attributable to bladder outlet obstruction. Postvoid bladder residual volumes greater than 150 mL in the older adult suggest inadequate bladder emptying. Postvoid residual volumes greater than 200 mL indicate urinary retention. Where available, noninvasive bladder ultrasound measurements of postvoid residual volumes are preferred over direct measurement using a urethral catheter to minimize the risk for complicating urinary tract infection [40,41].

Practical management strategies Comprehensive physical examination should yield preliminary information relating to postvoid residual volumes and urethral sphincter competence. Providers should be aware of specific indications that prompt referral for specialist urologic evaluation. These include urinary retention attributable to obstructive uropathy, hematuria, prostate disease, recent pelvic surgery, recurrent urinary tract infections, and stress incontinence. Most older patients who have functional UI or urge incontinence associated with overactive bladder can be managed effectively by geriatric or primary care providers. Although urodynamic studies are frequently requested, available data indicate that results of these tests are unlikely to alter management in a significant proportion of older adults. Urodynamic studies are likely to be most helpful in older patients being considered for surgical intervention or in whom the diagnosis remains unclear after a thorough history and physical examination [42,43]. Guidelines issued by the Agency for Health care Policy and Research recommend limitation of initial diagnostic workup to urinalysis and measurement of postvoid residual volumes. The American Medical Director Association’s (AMDA) guidelines for the management of UI are



even more conservative, recommending urinalysis only in patients who have suspected urinary tract infection and new or worsening UI. AMDA guidelines recommend postvoid residual measurements only in men and in female patients at risk for retention because of coexistent neurologic disorders or diabetes mellitus [44,45]. Bedside cystometric studies are no longer recommended for evaluation of UI because of poor correlation with results of urodynamic studies. In addition, bedside cystometry results usually do not alter management initiated based exclusively on clinical criteria [46,47]. The increased risk for urinary tract infection associated with urethral catheterization is an additional disadvantage of bedside cystometry [48]. Nonpharmacologic management should be the first line of therapy in all cases. In the subset of patients who fail to respond, the addition of pharmacologic agents is a viable option [49,50]. The increased risk for adverse drug effects and interactions in older adults, however, mandates due caution with drug selection and dosing. Invasive procedures or definitive surgical intervention occasionally are warranted in older adults who can tolerate such procedures. Nonpharmacologic treatment Nonpharmacologic intervention strategies vary with the type of UI. In patients who have OAB the mainstay of nonpharmacologic management is behavior modification tailored to suit the individual patient. Mentally competent, functionally intact, and highly motivated people are good candidates for patient-dependent intervention, such as biofeedback therapy. Caregiver-dependent toileting protocols are more appropriate in dependent or cognitively impaired patients. Prompted voiding is a caregiver-dependent strategy that offers the patient a regular opportunity to toilet. The designated caregiver offers toileting assistance at scheduled intervals, usually starting with a short period of about 2 hours. Prompted voiding has the added advantage of providing the patient an opportunity for social interaction and positive reinforcement. Habit training is a more complex variant of this method in which people who have UI are encouraged to link voiding to specific activities, such as meals, drinks, or just before outings. Eventually, regular toileting becomes a habit and involuntary urine loss is preempted. In older adults who have severe cognitive impairment and are unable to respond to communication a simple timed toileting schedule may be more helpful. In such cases the caregiver toilets the patient consistently at predetermined intervals. Prompted voiding and habit training also are helpful in the management of older adults who have functional incontinence. Environmental assessment, and modification if indicated, is critical to the effective management of functional UI. Adaptive equipment and assistive appliances may help facilitate efficient toileting and reduce incontinent episodes. Rehabilitative exercises focusing on pelvic muscles and biofeedback therapy can be helpful in patients who have stress incontinence or mixed



incontinence. In patients who have mixed incontinence a combination of pelvic floor exercises and bladder sphincter biofeedback therapy has been shown to result in a reduction in episodes of involuntary loss [51]. Pharmacologic therapy Detrusor muscle contraction depends on the action of Ach on bladder muscarinic receptors. Antimuscarinic drugs therefore are effective in the treatment of overactive bladder. Side effects, such as delirium, cognitive impairment, orthostatic hypotension, falls, and cardiac arrhythmias, mandate caution in the use of these agents in older adults. Data suggest that the newer, selective antimuscarinic agents may provide a safer alternative, although in older patients the occurrence of delirium, dry mouth, urinary retention, constipation, and blurring of vision are still troubling concerns. Five muscarinic receptor subtypes have been cloned (Fig. 2). M1, M4, and M5 receptor subtypes predominate in the nervous system, whereas M2 and M3 receptors predominate in smooth muscle. M2 and M3 receptors are the major cholinergic receptors in the bladder. M3 receptors mediate direct detrusor muscle contraction, whereas M2 receptors seem to play a role in inhibition of bladder relaxation and modulation of bladder contraction in pathologic conditions, such as denervation injury or spinal cord disease. Differences in receptor subtype distribution are particularly important when considering adverse events associated with antimuscarinic agents in older adults. Oxybutynin and tolterodine are the two most commonly used antimuscarinic agents in the treatment of OAB. Oxybutynin is a relatively nonselective antimuscarinic agent and acts primarily on M1, M2, and M3 receptor

M1: CNS, salivary glands, stomach M4: CNS, basal ganglia, striatum M5: CNS: substantia nigra, eye

M2: Bladder, heart, smooth muscle M3: Bladder, salivary glands, brain, bowel, smooth muscle

Fig. 2. Distribution of human muscarinic receptor subtypes.



subtypes. Although oxybutynin has been shown to reduce episodes of UI by almost 50% in 60% to 80% of patients, there is a relatively high incidence of anticholinergic side effects, such as dry mouth, constipation, and blurred vision. Additionally, neurologic side effects, such as dizziness, cognitive dysfunction, and delirium, have been reported in several studies, rendering oxybutynin a poor choice for the geriatric patient. Tolterodine is a more selective antimuscarinic agent that affects predominantly M2 and M3 receptor subtypes. Although the efficacy of tolterodine is comparable to oxybutynin, the incidence of peripheral anticholinergic side effects, such as dry mouth, is much lower. Additionally, cognitive dysfunction related to tolterodine use occurs only rarely. Available data favor use of the extended-release formulations of tolterodine over the immediate release because of greater efficacy, higher tolerability, and higher adherence rates [52]. M3 selective inhibitors, darifenacin and solifenacin, are another effective pharmacologic treatment option for OAB. Adverse effects, such as constipation and blurred vision, in conjunction with the notable paucity of safety and tolerability data in older adults, preclude objective comment regarding prescription of these agents in geriatric practice [53,54]. Trospium has been in use in Europe over the past three decades but has only been approved recently by the Federal Drug Administration for the treatment of OAB. Unlike the M2 and M3 selective agents, which are lipophilic tertiary amines, trospium is a hydrophilic quaternary amine rendering the blood–brain barrier relatively impermeable to trospium, thereby reducing the risk for unwanted central nervous system side effects. Trospium is not metabolized by the cytochrome p450 system and therefore may be less prone to drug interactions. Limited data are available regarding the safety of these agents in the frail elder. Further studies in this area are needed [55–57]. Invasive procedures and surgical management Periurethral sphincter collagen injections and vaginal pessaries are reasonably effective options for older adults unable to tolerate surgery. Sacral neuromodulation involves surgical implantation of a ‘‘bladder pacemaker’’ in the patient’s hip attached to a lead wire that is threaded to a site within the sacral canal at the base of the spine. External programming results in delivery of a painless electrical stimulus to the sacral nerves, which regulate bladder function. This process allows patients to control urine storage and expulsion. For some patients who have stress or overflow incontinence, surgery may be the only effective treatment. Older men who have overflow incontinence because of obstructive uropathy from prostatic hypertrophy may respond to prostatectomy. Several operations have been developed for the treatment of stress incontinence. Prolene suburethral sling insertion is a relatively new technique, with a documented cure rate of greater than 80%. Surgical complications of this procedure include retropubic hematoma, urinary tract infections and fibrosis, pubic osteomyelitis, urinary fistula, and



transient postoperative urinary retention. Late complications include dysuria, urinary retention, detrusor instability, genital prolapse, sexual disorders, chronic pain, chronic urinary tract infections, and complications related to the use of biomaterials, including screws, synthetic tape, and artificial urinary sphincter. Nevertheless, quality-of-life studies after surgery for stress incontinence in younger patients show consistent improvement. Data in older adults are lacking. Tension-free vaginal tape surgery is a highly effective and minimally invasive alternative for treating patients who have stress urinary incontinence. Surgical complications include bladder perforation, urinary retention, pelvic hematoma, suprapubic wound infection, persistent suprapubic discomfort, and intravaginal tape erosion [58–60].

Summary UI is highly prevalent in older adults and associated with excess comorbidity and increased mortality. Intensive screening and comprehensive clinical examination of all elders enables prompt detection, accurate classification, and appropriate treatment. OAB is the most common cause of persistent incontinence in the older adult. As with other types of UI, behavior modification is first-line treatment of OAB. Although antimuscarinic agents have been shown to be highly effective in the treatment of OAB, limited data are available regarding the safety and tolerability of these agents in older adults. Patients who fail to respond to noninvasive treatment or those in whom surgery may be appropriate should be referred to the urologist for evaluation and further management.

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