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.2002-2004.139-148

Risk Factors for UI
 Impaired mobility
 Depression
 Stroke
 Diabetes
 Parkinson’s 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 Delirium
 I Infection
 A Atrophic Vulvovaginitis
 P Psychological
 P Pharmacologic agents
 E Endocrine, excessive UO
 R Restricted Mobility
 S Stool impaction
Source: Resnick NM. Urinary incontinence in the elderly.
Med Grand Rounds. 1984;3:281-290.
Pharmacologic Causes
 Opioids
 Calcium channel  Depress detrusor
blockers activity & produce
 Anti-Parkinsons urinary retention
drugs and overflow
 Anti-cholinergics incontinence
 Prostaglandin
inhibitors
Pharmacologic Causes
 sedatives   awareness, detrusor
activity Func & O UI

 loop diuretics  Diuresis overwhelms

bladder capacity Urge
& O UI
 alcohol
 Polyuria,  awareness 
Urge & Functional UI
 caffeine
 Polyuria,  detrusor
activity  Urge
 cholinergics
(donepezil)   detrusor activity 
Urge
Culligan PJ Urinary Incontinence in
women Evaluation and Management AFP
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
ADL’s.

 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

 100—400 Monitor until consistently less than

200cc.

 > 400cc—Insert 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 once—if
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 residual”—the 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: Obstruction—Treat
cause; -antagonists. Detrusor
Underactivity—Review meds, double
voiding, intermittent self-
catheterization, Crede’s.
“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
APPROACH TO REMAINING CAUSES
Symptoms: URGE (REFLEX STRESS OVERFLOW
or NEUROGENIC)
leakage variable volumes small volume small volume
pattern of urine loss unpredictable with intrabd. pressure almost continuous
(cough, sneeze, laugh)
delay voiding? unable able except with able, (at times)
intrabd. pressure
voiding volumes variable normal small
(normally)

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
doesn’t work
***** ALL these drugs suppress the detrusor contractility and MAY CAUSE
URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO
PRESCRIBING!!!
Overflow UI
 Obstruction—Treat cause;
-antagonists; finasteride
 Detrusor Underactivity—Review meds,
double voiding, intermittent self-
catheterization, Crede’s.
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. Women’s Complete
Healthbook, 1995. The Philip Lief
Group, Inc. and the American Medical
Women’s 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