Clinical Review: Managing Urinary Incontinence in Older People

CLINICAL REVIEW:
Managing urinary
incontinence in older people
Subashini Thirugnanasothy
INTRODUCTION
• Urinary incontinence is defined by the
International Continence Society as
involuntary urinary leakage
• Urinary incontinence has both physical
and psychological consequences,
including damage to skin, urinary tract
infections, an increased risk of falls,
avoidance of going far from home, and a
feeling of alienation
• Urinary incontinence can also be difficult
for carers to manage, and a cohort study
of about 6000 patients found that urinary
incontinence was second only to
dementia as a reason for admission to
long term care.
INTRODUCTION
A study of individuals living in

community dwellings
reported a prevalence of
21%, with higher prevalence
in women and in individuals
aged over 65 years
INTRODUCTION
• Continence is maintained by bladder
wall stability and an intact pelvic floor
and nerve supply to the bladder
• As people age, physiological changes
in the lower urinary tract can
predispose to urinary incontinence.
Bladder capacity and urethral closure
pressure decrease with age, while the
post-void residual volume and
overactivity of the detrusor muscle
increase
STRESS INCONTINENCE
• Stress incontinence is caused by weakness

of the pelvic floor muscles and bladder neck
and is associated with obesity, pregnancy,
vaginal delivery, and hysterectomy in
women and prostatectomy in men
• Typically patients complain of leaking small
volumes of urine when they exert themselves,
cough, or sneeze
How do patients present?
Stress incontinence is caused by weakness of the pelvic floor muscles and
bladder neck and is associated with obesity, pregnancy, vaginal delivery, and
hysterectomy in women and prostatectomy in men.
How should patients be assessed?
Urinary symptoms
Storage symptoms: frequency, nocturia, urgency
Voiding symptoms: hesitancy, poor urinary stream,
dribbling
Precipitants of urinary leakage (such cough, exertion)
History of haematuria and recurrent urinary tract
infections (may indicate serious underlying disease and
necessitate specialist referral)
Bowel symptoms
Constipation, straining, faecal incontinence
Fluid intake
Specific drinks (such as caffeinated drinks) and volume
How should patients be assessed?
Medical history
Previous surgery such as hysterectomy
and prostatectomy
In women: details of pregnancies, mode
of delivery, birth weight of children
Drug history
Sedatives and hypnotics,
antimuscarinics, diuretics, alcohol
Social history
Access to toilets and aids; mobility
Impact on quality of life
Examination
Assessments of body mass index
How should patients be investigated?
Basic investigations
Urine analysis, measurement of the post-void residual
volume, and completion of bladder diaries are necessary
for all patients presenting with urinary incontinence. Urine
analysis can be used to detect or rule out infection.
Don’t forget to asking the patient to complete a bladder

diary by recording details of fluid intake, voiding times, and
volumes. It can help determine the cause of urinary
incontinence.
Specialist investigation: urodynamic testing
The test replicates the patient’s symptoms by filling the

bladder and observing changes in pressure and urinary
leakage with provocation tests such as jogging on the
spot.
Urodynamic testing is considered in women before surgery

for stress incontinence if (a) overactivity of the detrusor
muscle is suspected, (b) symptoms of incomplete bladder
emptying are present, and (c) the patient has had
previous surgery for stress urinary incontinence or prolapse.
Who can urinary incontinence be treated?
• Palpable bladder on abdominal

examination after voiding
• Suspected mass arising from the pelvis or
urinary tract
• Microscopic or visible haematuria
• Symptomatic vaginal prolapse that is visible
at or below the vaginal introitus.
How can urinary incontinence be treated?
• Weight loss for obes patient

• Modification and reduce fluid intake
• Using absorbent product (pads and
pants)
• Intermitten catheterization
• Suprapubic catheterization
How to treat stress incontinensia?
• Pelvic floor muscle training
Bladder retraining is the first line treatment for men and
women with urge incontinence.15 17 The aim of this
treatment is to re-establish voluntary bladder control and
increase bladder capacity
• Duloxetine
Duloxetine, a serotonin and noradrenaline reuptake
inhibitor, is licensed for moderate to severe stress
incontinence
• Surgical intervention
Surgical intervention to augment urethral closure or support
the bladder neck and urethra can be considered when
conservative treatment has failed
• Injection of bulking agents
Injection of bulking agents, such as silicone, into the
submucosal tissues of the urethra or bladder neck, and
artificial sphincters may also be considered in men and
women with stress incontinence, but the evidence for these
interventions is limited to small controlled trials and case
series.
How to treat urge incontinensia?
• Bladder Retraining
Bladder retraining is the first line treatment for men and women with
urge incontinence.15 17 The aim of this treatment is to re-establish
voluntary bladder control and increase bladder capacity
• Prompted and timed voiding programmes
Prompted and timed voiding programmes can be used for patients
with stress or urge urinary incontinence who are not able to use the
toilet independently
• Antimuscarinic drugs
Antimuscarinic drugs may be used either in combination with
bladder retraining or as monotherapy if bladder retraining is
unsuccessful or impossible. These agents act by blocking muscarinic
receptors in the bladder, which reduces bladder muscle
contractility
• Surgery
Surgery may be considered if conservative treatment is
unsuccessful. Injection of botulinum toxin A into the bl adder wall
can be used in urge incontinence, but the long term efficacy of this
treatment is unknown. Other surgical interventions include sacral
nerve stimulation, augmentation cystoplasty, and urinary diversion
(tra nsposing the ureters to an isolated segment of ileum to create
a permanent cutaneous stoma), but the evidence for efficacy of
these treatments in older people is limited.
THANK YOU

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CLINICAL REVIEW:

A study of individuals living in

• Stress incontinence is caused by weakness

Don’t forget to asking the patient to complete a bladder

The test replicates the patient’s symptoms by filling the

Urodynamic testing is considered in women before surgery

• Palpable bladder on abdominal

• Weight loss for obes patient

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