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) Excessive 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 ++ Urethral incompetence (stress incontinence) Detrusor overactivity (urge incontinence) Uninhibited bladder contractions that cause leakage Most common cause of established incontinence in older adults, accounting for two-thirds of cases Detrusor hyperactivity with incomplete contractions is a subtype of urge incontinence that can present with urgency with incomplete bladder emptying Overflow incontinence 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 is less common but can also cause overflow incontinence May be idiopathic or have an identifiable cause including medications and sacral lower motor nerve dysfunction When it causes incontinence, detrusor underactivity is associated with urinary frequency, nocturia, and frequent leakage of small volumes + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Atrophic urethritis and vaginitis Vaginal mucosal friability Erosions Telangiectasia Petechiae Erythema 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 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 Detrusor underactivity (overflow incontinence) Urinary frequency, nocturia, and frequent leakage of small amounts Although the measurement of postvoid residual volume is not considered standard in the evaluation of urinary incontinence, it should be measured when overflow is suspected No standardized cutoff has been established for postvoid residual volume, but it is generally above 200 mL in overflow incontinence Urethral obstruction Common symptoms include dribbling, urge incontinence, and overflow incontinence Detrusor overactivity coexists in two-thirds of cases + 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 ++ 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 ("Kegel") exercises are effective for mild to moderate stress incontinence; they can be combined with biofeedback, or electrical stimulation Detrusor overactivity (urge incontinence) 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 can reduce the frequency of incontinence episodes Overflow incontinence Most men with overflow incontinence from obstructive uropathy will first undergo bladder decompression with 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 incontinence) α-Agonists (which may precipitate urinary retention with benign prostatic hyperplasia) Alcohol and caffeine may exacerbate urge incontinence +++ Established causes ++ 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 Detrusor overactivity (urge incontinence) 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 Overflow incontinence α-Blocking agents (eg, terazosin, 1–10 mg orally daily; prazosin, 1–5 mg orally twice daily; or tamsulosin, 0.4–0.8 mg orally daily taken 30 minutes after the same meal) may be initiated after bladder decompression Finasteride, 5 mg orally daily, can provide additional benefit to an α-blocking agent in men with an enlarged prostate Antibiotics Should be used only for symptomatic urinary tract infection or as prophylaxis against recurrent symptomatic infections in a patient using intermittent catheterization Should not be used as prophylaxis in a patient with an indwelling catheter +++ 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 overflow incontinence 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 +++ + +Chapple CR et al. Randomized double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron, a β3-adrenoreceptor agonist, in overactive bladder. Eur Urol. 2013 Feb;63(2):296–305. [PubMed: 23195283] + +Culbertson S et al. Nonsurgical management of urinary incontinence in women. JAMA. 2017 Jan 3;317(1):79–80. [PubMed: 28030686] + +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] + +Sung VW et al. Effect of behavioral and pelvic floor muscle therapy combined with surgery vs surgery alone on incontinence symptoms among women with mixed urinary incontinence: the ESTEEM randomized clinical trial. JAMA. 2019 Sep 17;322(11):1066–76. [PubMed: 31529007]