OVERACTIVE BLADDER AND URINARY INCONTINENCE

Treatment of Overactive Bladder

and Incontinence in the Elderly
Darshan Shah, MD, Gopal Badlani, MD
Department of Urology, Long Island Jewish Medical Center, New Hyde Park, NY

The prevalence of urinary incontinence (UI) and overactive bladder rises with
age, and elderly people are the fastest-growing segment of the population.
Many elderly people assume UI is a normal part of the aging process and do
not report it to their doctors, who must therefore make the effort to elicit the
information from them. Coexisting medical problems in older patients and the
multiple medications many of them take make diagnosis and treatment more
complex in this population. Just as the etiology of incontinence is often multi-
factorial, the treatment approach may need to be multipronged, with behavioral,
environmental, and medical components; in any case, it must be targeted to the
individual patient. New, less-invasive surgical techniques and devices make sur-
gery more feasible if other therapy fails. [Rev Urol. 2002;4(suppl 4):S38–S43]

© 2002 MedReviews, LLC

Key words: Geriatrics • Overactive bladder • Urinary incontinence

T
he percentage of the population over age 65 has increased dramatically
over the past 100 years and is expected to continue to increase well into
the 21st century. Furthermore, the segment of this population with the
greatest need for health care, those age 85 and older (the “oldest old" or “frail
elderly"), is predicted to undergo a rapid expansion, from 10% to 19% by the year
2040.1 The lower urinary tract consists of a group of interrelated structures that
function in the adult to bring about efficient and low-pressure bladder filling and
low-pressure urine storage with perfect continence. In healthy people, periodic

S38 VOL. 4 SUPPL. 4 2002 REVIEWS IN UROLOGY


voluntary urine expulsion occurs at
low pressure. (The definition of low
pressure varies widely and differs for
men, women, and elderly people.)
Urinary dysfunction is the most
prevalent problem in the geriatric
population, particularly among those
admitted to nursing homes (with a
prevalence estimated up to 67%).
Most urinary dysfunction in the eld-
erly is attributable to lower urinary
tract disorders, with incontinence the
predominant symptom. Incontinence
alone has been shown to occur in up
to 30% of the community-dwelling
and 50% of the institutionalized eld-
erly.2,3 Overactive bladder (OAB) has
Treatment strategies that are effective in the population at large require
significant modification in the elderly.
the symptom complex of frequency
and urgency, with or without incon-
tinence, and is common, with almost
equal incidence in men and women
even after controlling for pathologic
and metabolic conditions that can
cause OAB-like symptoms. This new
finding supports the idea that OAB
should not be overlooked in men and
is not only a women’s health issue.
The prevalence of OAB without
incontinence in elderly women
increases slower than that in men.
Conversely, the prevalence of OAB
with incontinence increases sharply
after age 35 years in women, while it
increases gradually with age in men.4
The term elderly is ill defined.
A 70-year-old community-dwelling,
independent individual is in a signif-
icantly different category from that of
a frail elderly individual of 85 living
in a nursing home. There is a whole
spectrum in between.
The majority of the elderly
patients having OAB and urinary
incontinence (UI) are effectively
treated and/or have their symptoms
Treatment of OAB and Incontinence in the Elderly
alleviated, provided the type of
incontinence present and its cause
are determined. Treatment strategies
that are effective in the population at
large require significant modification
in the elderly. Recognizing the prob-
lems faced in the treatment of the
elderly forms the basis of a success-
ful strategy.
Assessment Difficulties
Underreporting
The elderly are notorious for under-
reporting of their incontinence.
Experience has shown that the elderly
often regard certain symptoms as
normal consequences of the aging
process, and it is therefore prudent to
probe beyond the evaluation of the
chief complaint. In the case of the
elderly patient who is unable to ade-
quately relate his or her symptoms as
a consequence of dysarthria or aphasia
secondary to a dominant hemispheric
stroke, dementia, or an organic brain
syndrome, it is much more useful to
interview the primary caregiver, such
as an aide or relative, to help complete
the historical picture.
Technical Difficulties in
Urodynamic Studies
Most urodynamic studies are per-
formed when the patient is awake, to
allow direct patient assessment of
the sensations of filling and urge to
void. Sound orientation, good cogni-
tion, and active patient participation
during the urodynamic studies are
required for precise diagnosis of the
cause. This may not be feasible in
some elderly patients. Thus, studies
may need to be repeated, or treatment
may need to be initiated based on
partial information.
VOL. 4 SUPPL. 4 2002
Difficulty in Interpretation of Findings
When interpreting urodynamic data
in the elderly patient, it is important
to realize that normal age-related
physiologic changes may significant-
ly alter the measured urodynamic
parameters; which may be present
independently of the patient’s pre-
senting symptoms. Several normal
age-related changes occur in the
lower urinary tract,5 including the
development of uninhibited detrusor
contractions in at least 10% of
women and 25%–35% of men; an
increase in nocturnal fluid excretion;
prostatic enlargement in men; urethral
shortening and sphincter weakening
in women; a decrease in bladder
capacity in both sexes; and possibly
a decrease in detrusor contractility.
General Condition of the Patient
OAB with or without incontinence is
considerably more common among
men and women with cancer, diabetes,
congestive heart failure, or neuro-
genic disorders.6 Associated illnesses,
comorbidities, vision loss, decreased
hand dexterity, memory loss, cognitive
dysfunction, or use of medication for
other health problems make assess-
ment and therapy more complex.
Multifactorial Etiology
In addition to anatomic and physio-
logic changes in elderly patients lead-
ing to voiding dysfunction, the mul-
tiplicity of conditions that can affect
the lower urinary tract confuses the
picture. Thus, coexisting cerebrovas-
cular accident and bladder outlet
obstruction secondary to benign pro-
static hypertrophy (BPH) can both lead
to OAB; separation of the two requires
sophisticated urodynamic techniques
such as micturating urethral pressure
profile.5 Detrusor instability and stress
UI in females is another example. The
most difficult to correctly diagnose
and treat is detrusor hyperactivity
with impaired contractility (DHIC).7
REVIEWS IN UROLOGY S39
Treatment of OAB and Incontinence in the Elderly continued
Treatment Strategies
Transient Incontinence
Incontinence secondary to transient
causes is present in 33% of communi-
ty-dwelling elderly people and in more
then half of patients who are hospital-
ized.8 The reversible or transient caus-
es of incontinence can be recalled
using the mnemonic DIAPPERS.5
Delirium- and confusion-related
incontinence needs treatment of the
underlying cause of the confusional
state, and the patient needs medical
rather than bladder management.5
Symptomatic urinary tract infection
(UTI) causes urgency, dysuria, and
incontinence mainly in the elderly.
Asymptomatic bacteruria does not
cause incontinence.9 In atrophic
vaginitis and urethritis, incontinence
is usually associated with urgency
and occasionally a sense of scalding
dysuria. Low-dose estrogen (eg,
0.3–0.6 mg of conjugated estrogen
per day orally or vaginally) relieves
vaginal dryness and atrophy, but
patients need concomitant behavioral
therapy or anticholinergic drugs for
their urge incontinence. Among
women assigned to treatment with
hormone therapy alone, inconti-
nence was more likely to worsen and
less likely to improve than among
women assigned to placebo.10
Pharmaceuticals associated with UI
include sedative-hypnotics, diuretics,
and anticholinergic and adrenergic
agents. The drug may have to be dis-
continued and/or the patient switched
over to a similar agent with fewer side
effects affecting the urinary tract.11
Psychological causes of inconti-
nence, seems to affect elderly less
frequently as compared to younger
individuals. Once the psychological
disturbances (depression, life-long
neurosis, etc) has been treated, per-
sistent incontinence needs further
evaluation. Excess urine output sec-
ondary to excessive fluid intake,
diuretics, or metabolic abnormalities
S40 VOL. 4 SUPPL. 4 2002 REVIEWS IN UROLOGY
(hyperglycemia and hypercalcemia)
can lead to frequency. Disorders
associated with fluid overload (eg,
congestive heart failure, hypoalbu-
minemia, drug-induced peripheral
edema) and calcium channel blockers
can cause incontinence in elderly
individuals. Excess output is a likely
contributor when incontinence is
associated with nocturia. Restricted
mobility is a very common cause of
geriatric incontinence. Mobility
restriction can result from many
treatable conditions, such as arthritis,
hip deformity, postural or postpran-
dial hypotension, claudication,
spinal stenosis, heart failure, poor
eyesight, fear of falling, stroke, foot
OAB with or without incontinence is considerably more common among
men and women with cancer, diabetes, congestive heart failure, or
neurogenic disorders.
problems, and confusion.5 A careful
search for and identification of these
or other correctable causes can
decrease urinary symptom scores. If
not, a urinal or bedside commode
may still improve or resolve the
incontinence. Stool impaction stimu-
lates opioid receptors,12 leading to
urge and/or overflow incontinence.
Typically there is associated fecal
incontinence as well. Disimpaction
restores continence.
Behavioral and Environmental
Changes
Once the diagnosis is established,
targeted therapy is initiated. Treatment
for nocturnal polyuria, the most
common complaint, includes evening
fluid restriction, mid- to late after-
noon or early evening diuretics,
compressive stockings, and leg ele-
vation throughout the day whenever
patient is sitting.13,14 For elderly
patients who do not have any evi-
dence of sphincteric incontinence
and those who are not fit to undergo
surgery, behavioral therapy and
environmental changes may decrease
the magnitude of symptoms.15 In
habit training, or timed voiding,
patients with UI attempt to void vol-
untarily on a schedule at predeter-
mined intervals. Patient involvement
and appropriate level of cognitive
function is required in this therapy. In
elderly people who are community
dwellers, this program is easier to
implement and has minimal side
effects.16,17 An option in patients with
poor cognition, memory loss, or
impaired ability to initiate voiding
voluntarily is prompted voiding, in
which a caregiver prompts the
patient to void at specific time inter-
vals. One can expect a 50% or more
reduction in frequency of inconti-
nence following prompted voiding
treatment in elderly chronic care
patients.18 This method is labor inten-
sive, as stopping the intervention
often leads to reversal of improve-
ment. Patient-perceived improvement
in one study was greatest for behav-
ioral treatment (74% “much better"
vs 50.9% and 2.9% for drug treat-
ment and placebo, respectively).
Only 14% of patients receiving
behavioral treatment wanted to
change to another treatment, versus
75.5% in each drug treatment and
placebo group.19 When behavioral
and drug therapy for urge inconti-
nence were combined in older
patients, additional benefit was noted,
with improvement from a mean 57%
reduction of incontinence with single-
mode therapy to 85% reduction of
incontinence with combined therapy.20

Pharmacologic Therapy
Bladder suppressant medications are
added only as necessary, to augment
rather than supplant the toileting
regimen. The urologist’s goal in
treating OAB and incontinence in the
elderly is to restore a socially accept-
able level of urinary continence,
requiring the minimal use of pads.
Bladder contraction is a result of
acetylcholine-induced stimulation of
postganglionic parasympathetic
muscarinic receptor sites in bladder
smooth muscle. Atropine and
atropinelike agents therefore depress
involuntary contraction of any etiol-
ogy.21 While none may be superior to
propantheline for uninhibited contrac-
tions in vitro, they differ substantial-
ly in their side effects; propantheline
may be the worst such agent for frail
elderly patients because of its
propensity to induce or exacerbate
confusion.5 Immediate-release oxy-
butynin and imipramine have been
well studied but still have side effects,
such as moderate to severe dry mouth.
Both once-daily controlled-release
and immediate-release oxybutynin
chloride yield reductions in urge
incontinence and total incontinence
episodes (statistically much better)
compared to placebo. A lower inci-
dence of dry mouth was reported for
controlled-release than for immedi-
ate-release oxybutynin.22 Tolterodine,
a new potent and competitive anti-
cholinergic developed for the treat-
ment of OAB, has been shown to be
selective for activity in the bladder
over the salivary gland in animal
studies.23 A randomized, double-blind
study comparing extended-release
oxybutynin with immediate-release
tolterodine for OAB concluded that
“evaluation of efficacy indicated
extended-release oxybutynin was
statistically significantly more effec-
tive than tolterodine, also yielding
fewer episodes of total incontinence
and micturition frequency."24
Treatment of OAB and Incontinence in the Elderly
In a study of healthy volunteers,
oxybutynin caused demonstrable
EEG changes compared to toltero-
dine and trospium chloride that
caused no demonstrable changes.25
Cognitive impairment is a clinical
concern with anticholinergics.
Extended-release tolterodine has
been shown to be marginally superi-
or to immediate-release tolterodine,
with further decline in dry mouth as
a side effect.26
Many of these trials have had a
limited number of patients more than
65 years of age and extremely small
numbers in the frail elderly group.
Thus, the theoretical benefits of
once-daily preparations are not well
established in elderly population.
In elderly women with mixed UI,
imipramine or phenylpropanolamine
hydrochloride–guaifenesin increase
bladder outlet resistance; imipramine
has an additional effect of increasing
bladder capacity.21 However, their use
When behavioral and drug therapy for urge incontinence were combined
in older patients, additional benefit was noted.
may be limited in patients with
hypertension and arrhythmias.
Pharmacologic treatment in elderly
patients predominantly having noc-
turnal polyuria consists of oral or
intranasal antidiuretic hormone with
caution. Close monitoring of serum
electrolytes for hyponatremia is
mandatory. Antidiuretic hormones are
not to be given to elderly patients with
a history of congestive heart failure.
Regardless of the drug employed,
the general principle for pharmacolog-
ic treatment of the elderly patient is
to start with a low dose and increase
it slowly, based on an understanding
of the agent’s pharmacokinetics and
pharmacodynamics.
For DHIC, the treatment is individ-
ualized. Therapy is directed at reduc-
VOL. 4 SUPPL. 4 2002
ing the post-void residual volume,
eliminating hydronephrosis (if pres-
ent) and preventing urosepsis. For
patients with retention > 600 mL, an
indwelling catheter is used to decom-
press the bladder for 7–14 days,
while potential contributing factors
to impaired detrusor function (eg,
fecal impaction, drug adverse effects)
are eliminated. If the decompression
does not fully restore bladder func-
tion, augmented voiding techniques
(double voiding or implementation
of Crede’s maneuver or the Valsalva
maneuver during detrusor contrac-
tion) may help. Bethanechol 40–200
mg/day orally in divided doses is
occasionally useful for a patient
whose bladder contracts poorly due
to use of an anticholinergic drug that
cannot be discontinued. Residual
volume should be monitored so that
bethanechol can be discontinued if
ineffective.27 In our experience,
bethanchol chloride is not efficacious
for improving bladder emptying in
DHIC. If the detrusor is acontractile
after decompression, any interven-
tion is likely to be futile, and the
patient should undergo clean inter-
mittent catheterization or have an
indwelling urethral catheter placed.
Antibiotic prophylaxis against UTI is
probably warranted, with intermit-
tent catheterization, if the patient has
frequent symptomatic UTIs or has an
abnormal heart valve or an orthope-
dic prosthesis; such prophylaxis is
not useful with indwelling catheteri-
zation. If intermittent catheterization
is performed in an institutional set-
ting, a sterile rather than a clean tech-
nique should be used because of the
prevalence and virulence of bacteria
in such a setting.28
REVIEWS IN UROLOGY S41
Treatment of OAB and Incontinence in the Elderly continued
Surgical Management
Surgical management of UI in the
elderly can play a role when medical
and behavioral treatment fails. The
surgical approach in the elderly is
based on the patient’s and/or the
family’s wishes and the patient’s
mental status; it may involve modi-
fication of standard surgical tech-
niques to decrease invasiveness,
decrease length of hospitalization,
decrease anesthesia use, and hasten
If intermittent catheterization is performed in an institutional setting, a
sterile rather than a clean technique should be used because of the
prevalence and virulence of bacteria in such a setting.
recovery. These factors override
the goal of long-term success.
Anesthesiologists recommend waiting
3–6 months after a hemorrhagic
stroke before giving elective general
or regional anesthesia. Elderly patients
receiving antiplatelet therapy or
anticoagulants should have these
medications stopped 7 days before
the day of surgery and restarted
24–48 hours after surgery.
Detrusor overactivity in elderly
males can be due to the normal aging
process, or it may be secondary to
outflow obstruction or neurologic
causes. Urethral obstruction in the
elderly can be treated as in young
patients. Alpha-adrenergic receptor
antagonists can be used safely even
in debilitated nursing home patients
with cardiovascular disease. The
quicker operative procedures, such
transurethral incision (TUIP) of the
prostate, may be performed in those
who are not fit to undergo
transurethral prostatectomy. Other
options are temporary or permanent
prostatic stents or catheters. The
Conticath29 (temporary stent) bridges
the space between the bladder neck
and the prostate, ending proximal to
the external sphincter, and can be
S42 VOL. 4 SUPPL. 4 2002 REVIEWS IN UROLOGY
used for up to 30 days. The Conticath
allows voiding with much less dis-
comfort, and there are few contraindi-
cations to its use. Its use is overstated
as only one trial demonstrated efficacy
in acute retention and not in chronic
retention. Additionally, in these high-
risk patients, a permanent prostatic
stent can be used. The UroLume30
(permanent stent) functions similarly
to the temporary stent and can be
placed with the patient under local
anesthetic for minimal discomfort. It
has proven to be an effective, low-
risk therapy. UroLume is placed in
same location as temporary stent
(prostatic urethra) for bladder outlet
obstruction secondary BPH. Efficacy
demonstrated up to 7 years in those
with detrusor function. Detrusor
function must be present for the
stent to work, unlike the catheter
that passively drains the urine.
In the patient with parkinsonism
and bladder outlet obstruction second-
ary to BPH, frequency and urgency do
not predictably respond to TUIP. In
fact, TUIP may make the condition
worse. Use of a temporary prostatic
stent is a novel idea as a way to try to
predict response to bladder outlet
resistance reduction surgery.
Less invasive endoscopic proce-
dures, such as transurethral
microwave therapy,31 transurethral
needle ablation,32 and holmium or
Indigo laser prostatectomy, may
prove useful in high-risk cases.
In elderly females with mixed
stress and urge incontinence and
stress UI causing significant bother,
detrusor dysfunction should be
addressed before treating urethral
incontinence. Urethral hypermobility
and/or intrinsic sphincter deficiency
may be treated using procedures
requiring local anesthesia. Periurethral
or transurethral collagen injection
has 20% to 30% 5-year success
rates;33 a pubovaginal sling, with or
without bone anchors, may use
autologous rectus fascia or fascia
lata,33 allogenic donor cadaver fascia,34
or synthetic polypropylene.35 Today,
pubovaginal sling procedures are
performed with minimal tension on
the sling, and new-onset incontinence
necessitating urethrolysis have been
decreased to 3% and 2%, respective-
ly.36 Tension-free vaginal tape proce-
dures are performed under local
anesthesia, with a success rate of
91%, a 7% improvement rate, and a
2% failure rate.37 Patients usually go
home within 24 hours of surgery with-
out a urethral catheter. In high-risk
patients without significant prolapse,
tension-free vaginal tapes or similar
devices (SPARC®, American Medical
Systems, Minnetonka, MN) may
become the preferred means of treat-
ing this type of stress UI.
The newest intervention providing
an option in the management of
women with OAB is sacral neuro-
modulation. Percutaneous peripheral
afferent nerve stimulation with
Percutaneous Stoller Afferent Nerve
Stimulator, a device manufactured
by UroSurge, Inc. of Coralville, IA,
presents a minimally invasive and
potentially therapeutic alternative
to other current treatment options
for patients with documented
urgency/frequency syndrome, with
no treatment-related side effects.38
Their efficacy in the elderly popula-
tion is not established.
Conclusion
The prevalence of OAB with or with-
out incontinence increases with age
in both women and men. It should
not be considered part of the “normal
aging process." It can be effectively

treated with behavioral changes;
judicious use of medication and/or
minimally invasive surgical inter-
ventions; improvement in quality
of life and self-esteem is an attain-
able goal.
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Main Points
• Normal age-related physiologic changes may affect urodynamic parameters independently of the presenting symptoms, making
interpretation difficult.
• Urinary incontinence (UI) is underreported among elderly patients, who may assume it to be a normal consequence of aging.
• Successful treatment of overactive bladder and UI in the elderly patient depends on correct determination of the type and cause
of the incontinence.
• UI in elderly patients may be transient or long-term.
• Many cases of UI respond to simple measures like fluid restriction or changes in toileting regimen.
• Drug treatment must be tailored according to etiology and patient condition, in some cases.
• An increasing number of options are available for surgical treatment should it prove necessary.
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