URINARY INCONTINENCE

IN THE AGING PATIENT

September 2007
Deb Mostek

Definition

UI is the involuntary loss of

urine that is objectively
demonstrable and a social or
hygienic problem.
International Continence
Society

Prevalence of UI

15-30% of community dwelling

persons 65 years and older.

F>M until age 80 years, then

M=F

Up to 50% in LTC

GU Age-Related Changes

Detrusor overactivity (20% of healthy

continent)
BPH
PVR , nocturia, UO later in day
Atrophic vagintis & urethritis
ability to postpone voiding, total bladder
capacity, detrusor contractility
urine concentrating ability, flow
DuBeau CE.Urinary Incontinence.Geriatric Review Syllabus Fifth Ed.20022004.139-148

Risk Factors for UI

Impaired mobility
Depression
Stroke
Diabetes
Parkinsons Disease
Dementia (moderate to severe)
1/3 have multiple conditions
FI, Obesity, CHF, Constipation, TIAs,
COPD, Chronic cough, Impaired mobility
& ADLs

Consequences of UI

Cellulitis, Pressure ulcers, UTI

Falls with fractures
Sleep deprivation
Social withdrawal, depression
Embarrassment (50%), interference with
activities
Caregiver burden, contributes to
institutionalization
Costs > $16 billion

Types of Urinary
Incontinence

Transient UI (Acute)
Established UI (Chronic)

Urge UI
Stress UI
Mixed UI
Overflow UI
Functional UI

Transient Incontinence

Lower urinary tract pathology

Precipitated by reversible factor
1/3 Community dwelling
1/2 Hospitalized incontinent aged
patients
Causes: Delirium, UTI, Meds, Psychiatric
disorders, UO, Stool impaction
Restricted mobility

Causes of Transient
(Acute) Incontinence

D
I
A
P
P
E
R
S

Delirium
Infection
Atrophic Vulvovaginitis
Psychological
Pharmacologic agents
Endocrine, excessive UO
Restricted Mobility
Stool impaction

Source: Resnick NM. Urinary incontinence in the elderly.

Med Grand Rounds. 1984;3:281-290.

Pharmacologic Causes

Opioids
Calcium channel
blockers
Anti-Parkinsons
drugs
Anti-cholinergics
Prostaglandin
inhibitors

Depress detrusor
activity & produce
urinary retention
and overflow
incontinence

Pharmacologic Causes

sedatives

loop diuretics

alcohol

caffeine

cholinergics
(donepezil)

awareness, detrusor
activity Func & O UI
Diuresis overwhelms
bladder capacity Urge &
O UI
Polyuria, awareness
Urge & Functional UI
Polyuria, detrusor
activity Urge
detrusor activity Urge
Culligan PJ Urinary Incontinence in women
Evaluation and Management AFP 12-1-01

Pharmacologic Causes,
Continued

alpha-agonists

urethral
sphincter tone
retention and
Overflow

alpha-antagonists

urethral
sphincter tone
Stress

Mrs. R

85 y/o female brought to the emergency

room with new onset urinary incontinence.
Daughter is worried about possible UTI and
inability to care for patient at home if
incontinence persists.
PMH: Dementia, hypertension, advanced
osteoarthritis, gait disturbance.
Meds: ASA 81mg daily, hydrochlorothiazide
12.5 mg daily, calcium with vitamin D tid.

Mrs. R

SH: lives with daughter and grandson.

Dependent on family for assistance with
ADLs.

Physical Exam: BP 138/80 P78 R18 T98

Gen: Alert, cooperative, vague
historian; Chest: Clear; CV: RRR;
Abdomen: Benign; GU: Atrophic
changes; Ext: Trace edema

Screening

Ask sensitively worded questions

Detailed History

Duration, previous
evaluation/treatment?
Volume, how often, what situations?
Urgency, dysuria, straining?

EVALUATION:
THE APPROACH
Focused H & P for:
1) Reversible conditions
2) Conditions that require Urologic
or Gynecologic consult or
Urodynamics early on.
3) Function focused approach to the
remaining cases
4) Contributing factors

Evaluation, continued

UA, C&S
Creatinine, BUN, Glucose, Calcium,
?PSA
Post-void residual
Clinical urinary stress test
Voiding record

Post-Void Residual (PVR)

Measure volume of urine left in bladder

after voiding by catheter or bladder scan

< 50-100 Normal

100400 Monitor until consistently less

than 200cc.

> 400ccInsert Foley catheter

Clinical Stress Test

Bladder should be full. Ask patient to

strain (Valsalva maneuver). If no leakage,
have her perform a half sit-up and cough
look for leakage. If no leakage in supine
position, repeat testing in standing
position. Patient should relax perineum
and cough onceif immediate
leakage=stress UI; if leakage is delayed
several seconds=detrusor overactivity

20 Common Problems in Urology; JM Teichman, Ed. 2001

2003 GAYFP; DB Reuben et al

Established Incontinence

URGE
STRESS
Mixed type (both urge and stress)
OVERFLOW (increased PVR)
Functional incontinence

Urge Incontinence

Most common
Detrusor overactivity with uninhibited
bladder contractions
Unpredictable, abrupt urgency, frequency,
variable volumes lost, PVR usually normal
(Post-void residualthe volume of urine
left in bladder after spontaneous voiding)
Management: bladder retraining,
scheduled toileting, pelvic muscle
exercises (PME), pharmacologic agents

Stress UI

2nd most common cause in aging females

Impaired urethral closure due to
insufficient pelvic support, sphincter
opens during bladder filling
Leakage occurs with intra-abdominal
pressure
Management: pelvic muscle exercises,
biofeedback, electrical stimulation, adrenergic agonists, pessary, surgical
interventions.

Mixed Incontinence

Features of both urge and stress

incontinence.
Common in older women
Management: bladder retraining,
pelvic muscle exercises, other
pelvic muscle rehabilitative options
outlined previously, pharmacologic
agents.

Overflow UI

Detrusor underactivity and/or outlet

obstruction
Continuous small volume leakage
Dribbling, weak stream, hesitancy,
nocturia
Outlet obstruction=2nd most common
cause of UI in Males
Detrusor underactivity Urinary retention
& overflow Incontinence in 12%F; 29%M

Overflow UI

Management: ObstructionTreat
cause; -antagonists. Detrusor
UnderactivityReview meds,
double voiding, intermittent selfcatheterization, Credes.

Functional Incontinence

Unable or unwilling to toilet due to

physical impairment, cognitive
dysfunction, environmental
barriers
No underlying GU dysfunction
Diagnosis of exclusion

3)FUNCTION
FOCUSED
APPROACHURGE
TO
Symptoms:

REMAINING
(REFLEX STRESS CAUSES
OVERFLOW

or NEUROGENIC)

leakage
variable volumes
pattern of urine loss unpredictable
delay voiding?

unable

voiding volumes

variable

(normally)

small volume
with intrabd. pressure
(cough, sneeze, laugh)
able except with
intrabd. pressure
normal

small volume
almost continuous
able, (at times)
small

N o c t u r n a l Yes (pt. is unaware) Rare

Yes (dribbling)
incontinence 1
1.Rovner ES, Wein AJ, The treatment of Operative bladder in the geriatric patient . Clinical
Geriatrics Vol. 10 Number 1 Jan 2002

Mrs. J

Pleasant, thin 86 y/o with c/o urgency,

frequency, with variable UI for past 2-3
years.
PMH: Osteoporosis with old thoracic
vertebral compression fractures,
hypertension
SH: Widowed, lives alone
Meds: Calcium w Vit. D tid; alendronate 70
mg weekly; amlodipine 5 mg daily; MVI daily
ROS: Mild fatigue, sleep disturbance, admits
to depressed ideation. Otherwise negative.

Mrs. J

PE: BP 126/70 sitting; 118/68

standing. Wt. 44kg
Gen: Thin, alert, excellent historian.
CV, Pulm, Abd, Neuro: all neg
GU: Ext genitalia/BSU/Vag Atrophic;
no pelvic relaxation; Bimanual exam:
consistent with previous
hysterecomy, no masses.
RV:Confirmatory

Mrs. J

PVR: 250 ml
Clinical stress test: Some urine loss
after several seconds delay after
cough

DHIC
(Detrusor Hyperactivity with Impaired
Contractility)

Most common cause of UI in frail

and old:
Detrusor hyperactivity plus impaired
bladder
contractility (DHIC).
The clinical picture is:
a story of Urge incontinence with
elevated or borderline PVR
ie PVR= 100-400 cc range.

Management of UI

Treat reversible cause (ie.

Constipation)
Review meds
General measures: Behavioral
interventions before pharmacologic
Rx,. Avoid caffeine & ETOH,
minimize evening intake, pads,
Surgery last.

Pelvic Muscle exercises

Motivated patient, careful instruction

56-95% decrease in UI episodes
dependent on intensity of program
Focus on pelvic muscles (10 ctx 3-10
times/d)avoid buttock, abdomen,
thigh muscle contraction.
Biofeedback may help

Bladder Retraining

Urge control exercises

Scheduled toileting
Prompted toileting

Pelvic Muscle
Rehabilitation

Detailed instruction of pelvic

muscle exercises
Biofeedback techniques
Electrical stimulation

Anticholinergic Drugs

Oxybutynin
Tolterodine
Trospium
Darifenacin
Variety of preparations: Immediate
Release; Extended Release; Transdermal
Outcomes same; Try different agent if
one doesnt work

***** ALL these drugs suppress the detrusor contractility and

MAY CAUSE URINARY RETENTION!!! ALWAYS CHECK PVR
PRIOR TO PRESCRIBING!!!

Overflow UI

ObstructionTreat cause;
-antagonists; finasteride
Detrusor UnderactivityReview
meds, double voiding, intermittent
self-catheterization, Credes.

Further Urological
Evaluation

PVR > 400 cc

Poor response to treatment
Cystometry, cystoscopy,
urodynamic studies
Evidence of GU tract pathology

UI Summary

Look for reversible causes and Rx

Check PVR (>100 cc investigate
further)
Start with behavioral interventions
before meds
Referral and urodynamic studies if no
response to usual measures
Early referral if underlying GU tract
pathology present

Acknowledgments

Ahronheim JC. Aging. In Epps RP,

Stewart SC eds. Womens Complete
Healthbook, 1995. The Philip Lief
Group, Inc. and the American Medical
Womens Association, Inc. Stress
Urinary Incontinence figure 11.2, p156.
Edward Vandenberg, MD who
contributed a number of the slides

Acknowledgments

Wendy Adams, MD MPH who also

contributed slides
DuBeau CE. Urinary Incontinence.
Geriatric Review Syllabus, Fifth
Edition 2002-2004. 139-148