Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 4-04: Management of Common Geriatric Problems + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Involuntary loss of urine Stress incontinence: leakage of urine upon coughing, sneezing, or standing Urge incontinence: urgency and inability to delay urination Overflow incontinence: variable presentation +++ General Considerations +++ Transient causes (the mnemonic “DIAPPERS”) ++ Delirium (a common cause in hospitalized patients) Infection (symptomatic urinary tract infection) Atrophic urethritis and vaginitis Pharmaceuticals Potent diuretics Anticholinergics Psychotropics Opioid analgesics α-Blockers (in women) α-Agonists (in men) Calcium channel blockers Psychological factors (severe depression with psychomotor retardation) Excess urinary output caused by Diuretics Excess fluid intake Metabolic abnormalities (eg, hyperglycemia, hypercalcemia, diabetes insipidus) Peripheral edema and its associated nocturia Restricted mobility (see Immobility in Elderly) Stool impaction +++ Established causes ++ Detrusor overactivity (urge incontinence) Uninhibited bladder contractions that cause leakage Most common cause of established geriatric incontinence, accounting for two-thirds of cases; usually idiopathic Detrusor hyperactivity with incomplete contractions is a subtype of urge incontinence that can present with urgency with incomplete bladder emptying Urethral incompetence (stress incontinence) Urethral obstruction Common in older men but rare in older women May be due to prostatic enlargement, urethral stricture, bladder neck contracture, or prostatic cancer in men Cystoceles or other anatomic problems can be causes in women Detrusor underactivity (overflow incontinence) Least common cause of incontinence May be idiopathic or due to sacral lower motor nerve dysfunction + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Atrophic urethritis and vaginitis Vaginal mucosal friability Erosions Telangiectasia Petechiae Erythema Detrusor overactivity (urge incontinence) Complaint of urinary leakage after the onset of an intense urge to urinate that cannot be forestalled A standing full bladder stress test (asking the patient to cough while standing) may result in a few second delay in release of urine Urethral incompetence (stress incontinence) Urinary loss occurs with laughing, coughing, or lifting heavy objects Most commonly seen in women but can be seen following prostatectomy in men A standing full bladder stress test (asking the patient to cough while standing) should result in immediate release of urine Urethral obstruction Common symptoms include dribbling, urge incontinence, and overflow incontinence Detrusor overactivity (which coexists in two-thirds of cases) may cause symptoms of urgency Detrusor underactivity (overflow incontinence) Urinary frequency, nocturia, and frequent leakage of small amounts An elevated postvoid residual (generally over 450 mL) distinguishes detrusor underactivity from detrusor overactivity and stress incontinence, but only urodynamic testing differentiates it from urethral obstruction in men + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Review medications Check urinalysis, urine culture for infection Consider tests for hyperglycemia (diabetes mellitus), hypercalcemia, hyponatremia (diabetes insipidus) +++ Imaging Studies ++ Ultrasonography can determine postvoid residual In older men for whom surgery is planned, urodynamic confirmation of obstruction is strongly advised +++ Diagnostic Procedures ++ To test for stress incontinence, have the patient with a full bladder relax her perineum and cough vigorously (a single cough) while standing Instantaneous leakage indicates stress incontinence if urinary retention has been excluded by postvoid residual determination using ultrasound A delay of several seconds or persistent leakage indicates an uninhibited bladder contraction induced by the cough Because detrusor overactivity may be due to bladder stones or tumor, the abrupt onset of otherwise unexplained urge incontinence—especially if accompanied by perineal or suprapubic discomfort or sterile hematuria—should be investigated by cystoscopy and cytologic examination of the urine + Treatment Download Section PDF Listen +++ +++ Nonpharmacologic Approaches ++ Detrusor overactivity The cornerstone of treatment is bladder training Patients start by voiding on a schedule based on the shortest interval recorded on a bladder record They then gradually lengthen the interval between voids by 30 minutes each week using relaxation techniques to postpone the urge to void For cognitively impaired patients who are unable to manage on their own, timed voiding initiated by caregivers is an alternative Lifestyle modifications, including weight loss and caffeine reduction, may also improve symptoms Pelvic floor muscle ("Kegel") exercises, with or without biofeedback, can reduce the frequency of incontinence episodes Urethral incompetence (stress incontinence) Lifestyle modifications, including limiting caffeine and fluid intake, may be helpful for some women, particularly women with mixed stress/urge incontinence; strong evidence supports weight loss in obese women Pelvic floor muscle exercises are effective for mild to moderate stress incontinence; they can be combined with biofeedback, or electrical stimulation Urethral obstruction and detrusor underactivity For the nonoperative candidate, use an intermittent or indwelling catheter Augmented voiding techniques (eg, double voiding, suprapubic pressure) Intermittent or indwelling catheterization +++ Medications +++ Transient causes ++ Discontinue all anticholinergic agents or substitute less anticholinergic agents Other aggravating medications might include Loop diuretics Sedative-hypnotics Calcium channel blockers α-Blockers (which may exacerbate stress) α-Agonists (which may precipitate retention with benign prostatic hyperplasia) Alcohol and caffeine may exacerbate urge incontinence +++ Established causes ++ Detrusor overactivity Oxybutynin (2.5–5.0 mg orally three or four times daily), long-acting oxybutynin (5–15 mg orally once daily), or tolterodine (1–2 mg orally twice daily) Fesoterodine (4–8 mg orally once daily), trospium chloride (20 mg orally once or twice daily), long-acting trospium chloride (60 mg orally daily), darifenacin (7.5–15 mg orally daily), and solifenacin (5–10 mg orally daily) All appear to have similar efficacy Only fesoterodine has been demonstrated to have tolerability in medically complex older adults that is comparable to younger adults Watch for delirium, dry mouth, or urinary retention Mirabegron, 25–50 mg orally daily The first of a novel class of drugs (β3-agonists) approved for overactive bladder symptoms, which includes urge urinary incontinence Efficacy and safety profiles have been comparable with less dry mouth reported in patients who received mirabegron Its role in treating frail older patients with hypertension or cardiac conditions remains undetermined because of its potential cardiac effects Injection of onabotulinum toxin A into the detrusor muscle An alternative to oral agents Patients had higher rates of complete resolution of incontinence and lower rates of dry mouth However, urinary retention and urinary tract infections were more likely Urethral incompetence (stress incontinence) Topical estrogens may be helpful if atrophic vaginitis with urethral irritation is present Duloxetine may reduce episodes in women It is approved for this indication in some countries but not the United States Urethral obstruction For prostatic obstruction without retention, treatment with α-blocking agents (eg, terazosin, 1–10 mg orally once daily; prazosin, 1–5 mg orally twice daily; tamsulosin, 0.4–0.8 mg orally once daily taken 30 minutes after same meal) Finasteride, 5 mg orally daily, can provide additional benefit to an α-blocking agent in men with an enlarged prostate Detrusor underactivity Antibiotics (only for symptomatic upper urinary tract infection or as prophylaxis against recurrent symptomatic infections with intermittent catheterization) +++ Surgery ++ Although a last resort, surgery is the most effective treatment for stress incontinence; cure rates as high as 96% can result even in older women Surgical decompression is the most effective treatment for urethral obstruction, especially in the setting of urinary retention + Outcome Download Section PDF Listen +++ +++ Complications ++ The most important complication is restriction of social activity In immobile patients, incontinence increases the risk for pressure injuries (formerly pressure ulcers) +++ Prognosis ++ Some incontinence resolves spontaneously In most patients, treatment of exacerbating factors, and pharmacologic and nonpharmacologic treatments can substantially reduce its severity +++ When to Refer ++ Men with urinary obstruction who do not respond to medical therapy should be referred to a urologist Women who do not respond to medical and behavioral therapy should be referred to a urogynecologist or urologist + References Download Section PDF Listen +++ + +Al-Shaikh G et al. Pessary use in stress urinary incontinence: a review of advantages, complications, patient satisfaction, and quality of life. Int J Womens Health. 2018 Apr 17;10:195–201. [PubMed: 29713205] + +Baessler K et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2018 Aug 19;8:CD013108. [PubMed: 30121956] + +Bientinesi R et al. Managing urinary incontinence in women - a review of new and emerging pharmacotherapy. Expert Opin Pharmacother. 2018 Dec;19(18):1989–97. [PubMed: 30304645] + +Culbertson S et al. Nonsurgical management of urinary incontinence in women. JAMA. 2017 Jan 3;317(1):79–80. [PubMed: 28030686] + +Dwyer PL et al. Surgical management of urinary stress incontinence - where are we now? Best Pract Res Clin Obstet Gynaecol. 2019 Jan;54:31–40. [PubMed: 30503362] + +Lukacz ES et al. Urinary incontinence in women: a review. JAMA. 2017 Oct 24;318(16):1592–604. [PubMed: 29067433] + +Qaseem A et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Sep 16;161(6):429–40. [PubMed: 25222388] + +Serati M et al. The role of urodynamics in the management of female stress urinary incontinence. Neurourol Urodyn. 2019 May 2. [Epub ahead of print] [PubMed: 31045271]