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
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15-30% of community dwelling
persons 65 years and older.
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F>M until age 80 years, then M=F
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Up to 50% in LTC
GU Age-Related Changes
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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
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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
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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
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Transient UI (Acute)
Established UI (Chronic)
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Urge UI
Stress UI
Mixed UI
Overflow UI
“Functional” UI
Transient Incontinence
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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
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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
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Opioids
Calcium channel
blockers
Anti-Parkinsons
drugs
Anti-cholinergics
Prostaglandin
inhibitors
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Depress detrusor
activity & produce
urinary retention
and overflow
incontinence
Pharmacologic Causes
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sedatives
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loop diuretics
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alcohol
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caffeine
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cholinergics
(donepezil)
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 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
Pharmacologic Causes,
Continued

alpha-agonists
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urethral
sphincter tone 
retention and
Overflow

alpha-antagonists
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 urethral
sphincter tone 
Stress
Mrs. R
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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
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Ask sensitively worded questions
Detailed History
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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
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UA, C&S
Creatinine, BUN, Glucose, Calcium,
?PSA
Post-void residual
Clinical urinary stress test
Voiding record
Post-Void Residual (PVR)
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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
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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
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URGE
STRESS
Mixed type (both urge and stress)
OVERFLOW (increased PVR)
“Functional” incontinence
Urge Incontinence
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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
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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
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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
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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
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Management: Obstruction—Treat
cause; -antagonists. Detrusor
Underactivity—Review meds, double
voiding, intermittent selfcatheterization, Crede’s.
“Functional” Incontinence
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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
or NEUROGENIC)
leakage
variable volumes
pattern of urine loss unpredictable
delay voiding?
unable
voiding volumes
variable
STRESS
OVERFLOW
small volume
with intrabd. pressure
(cough, sneeze, laugh)
able except with
intrabd. pressure
normal
small volume
almost continuous
able, (at times)
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
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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
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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
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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
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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
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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
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Urge control exercises
Scheduled toileting
Prompted toileting
Pelvic Muscle Rehabilitation
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Detailed instruction of pelvic muscle
exercises
Biofeedback techniques
Electrical stimulation
Anticholinergic Drugs
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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
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Obstruction—Treat cause;
-antagonists; finasteride
Detrusor Underactivity—Review meds,
double voiding, intermittent selfcatheterization, Crede’s.
Further Urological Evaluation
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PVR > 400 cc
Poor response to treatment
Cystometry, cystoscopy, urodynamic
studies
Evidence of GU tract pathology
UI Summary
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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
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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
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Wendy Adams, MD MPH who also
contributed slides
DuBeau CE. Urinary Incontinence.
Geriatric Review Syllabus, Fifth Edition
2002-2004. 139-148