MEDICINE IN OLDER ADULTS
Urinary incontinence in
older adults
Christina Shaw
Adrian Wagg
Abstract
Lower urinary tract symptoms and urinary incontinence are very com-
mon in the general population and increase in prevalence in associa-
tion with age. Urinary incontinence in particular is still seldom
discussed by patients, many of whom delay seeking healthcare for
the condition. Urinary symptoms have a considerable impact on
morbidity and quality of life. Older people encounter multiple barriers
in gaining treatment for their problem and are unfortunately less likely
to be given evidence-based treatment than younger people. Despite
the increasing body of evidence for the effective management of the
symptoms and conditions underlying incontinence, older people
often fail to be assessed and treated for the condition. This article dis-
cusses the assessment and management of the main subtypes of in-
continence likely to be encountered in generalist practice for both
physiologically robust and more frail elderly individuals.
Keywords Assessment; frailty; overactive bladder; treatment; urinary
incontinence
Introduction
Urinary incontinence (UI), defined as the complaint of involun-
tary loss of urine, is a common and undertreated problem in
older adults. Epidemiological studies show a positive association
between age and both the accumulation of symptoms and the
prevalence of UI and other lower urinary tract symptoms (LUTS).
In the EPIC study, the prevalence of incontinence increased in
men from 2.4% in those <39 years to 10.4% in those >60, and in
women from 7.3% to 19.3%, respectively.1 With individuals
living longer and older adults making up an increasing portion of
the population, the impact of UI on society and on the healthcare
system continues to increase.
As with all the ‘geriatric giants’, UI is often the result of
multiple risk factors and modifiers. Physiological, pathological
and functional changes can result in a loss of continence. Older
adults tend to not seek help from healthcare providers for a va-
riety of reasons, including perceived stigma and social embar-
rassment, belief that UI is a normal part of ageing and an
Christina Shaw BSc is an Undergraduate Medical Student at the
Division of Geriatric Medicine, Department of Medicine, University of
Alberta, Edmonton, Alberta, Canada. Competing interests: none
declared.
Adrian Wagg MBBS FRCP(Lond) FRCP(Edin) FHEA Capital Health Endowed
Professor of Healthy Ageing, Division Director, Geriatric Medicine,
University of Alberta, Edmonton, Alberta, Canada. Competing
interests: he, or his institution has received support from Astellas,
Pfizer, SCA, Duchesnay (Canada) for any of research, speaker fees or
consultancy.
MEDICINE 45:1
Key points
C Urinary incontinence is not a diagnosis but has multiple un-
derlying risk factors and potential contributing factors, akin to
any geriatric syndrome
C Where there is a dearth of data, there is no reason not to offer
a frail older individual treatments that have proven efficacy in
robust older persons
C A systematic approach to urinary incontinence affords a
symptomatic diagnosis of the most likely underlying causes in
most cases, allowing a management plan to be formulated
C There is accumulating evidence for the efficacy of treatment for
incontinence in both robust and multimorbid older persons
assumption that there is no available effective treatment.
Therefore, in line with current guidelines, a case-finding question
about bladder and bowel problems is recommended as part of all
interactions between older adult patients and clinicians (see
Wagg, 2015, in the further reading list) to overcome this and
offer an appropriate assessment and management plan.
Definitions
Several disorders result in urinary incontinence, but the majority
is accounted for by stress UI (involuntary loss of urine on effort
or physical exertion, or on sneezing/coughing) and urgency in-
continence (involuntary loss of urine associated with urgency). A
combination of the two is referred to as mixed UI. A closely
related problem is that of overactive bladder (OAB), which is
defined as urinary urgency, usually accompanied by frequency
and nocturia, with or without urgency UI, in the absence of
urinary tract infection or other obvious pathology. Other, less
common but no less important, entities are nocturia (frequent
nocturnal micturition), nocturnal enuresis (adult bedwetting)
and ‘functional’ incontinence (incontinence caused by either
physical or cognitive impairment, with no identifiable lower
urinary tract disorder), all being associated with a considerable
patient burden (Table 1). Age-related changes in the lower uri-
nary tract can play a role in predisposing an older person to fail
to maintain continence (Table 2).
Several recent publications have demonstrated, using func-
tional magnetic resonance imaging, that OAB is associated with
changes in cerebral blood flow to certain areas of the brain. The
amount of white matter changes (seen as areas of hyperintensity
on MRI) may link several geriatric syndromes, including decline
in cognition, mobility and continence. There is also increasing
evidence that suppression of urinary urgency may require more
subconscious effort in older persons, and that this may be related
to the amount of white matter hyperintensities.
Assessment
History
For most older adults, a systematic history allows a symptomatic
diagnosis to be formulated (Table 3). A medication history and
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 MEDICINE IN OLDER ADULTS

Common subtypes of urinary incontinence

Overactive bladder Stress UI Mixed UI Voiding inefficiency Functional incontinence

Urinary urgency, with or Urinary loss in association Symptoms of both urgency Incomplete emptying is not Incontinence unrelated
without urgency with exertion such as incontinence and exertional well reported by men, but to an underlying
incontinence often with coughing, laughing or lifting incontinence (take a careful more so by women. A large disorder of lower urinary
urinary frequency and history as ‘urgency’ or post-void residual volume tract function, perhaps
nocturia ‘precipitancy’ is often without symptoms related to either physical
reported by women with (recurrent urinary tract or cognitive impairment
stress UI only) infections, frequency,
dribble, upper tract
involvement) does not need
treatment (a 250-ml residual
volume may be acceptable
in older people)

Table 1

Age-related changes in the lower urinary tract
Decreased Increased
Bladder capacity Urinary frequency
Sensation of filling Prevalence of post-void
Speed of contraction residual volumes
of detrusor Outflow tract obstruction (men)
Pelvic floor muscle bulk
Sphincteric ‘resistance’
Urinary flow rate
Table 2
physical examination are also necessary to exclude other dis-
eases and diagnose or identify other factors or co-morbidities that
may be adversely affecting the patient’s continence. A bladder
diary of a minimum 3 days’ duration can be useful to provide an
additional history; however, the benefits may not outweigh the
considerable burden of achieving an accurate and complete
diary. During the history, account should be taken of the impact
the condition has on quality of life, patient’s and caregivers’
expectations and, depending on the treatment offered, the pa-
tient’s remaining life expectancy and functional level.
Co-morbidities
Co-morbidities are common in the older adult population, and UI
can be caused by, associated with or worsened by these. One
study found UI to be independently associated with having at
least one geriatric condition in 60% of study participants, at least
two in 29% and at least three in 13%. These co-morbidities can
be chronic diseases such as hypertension, congestive heart fail-
ure or arthritis. Diabetes mellitus can cause UI by multiple
mechanisms leading to detrusor overactivity and culminating in
diabetic cystopathy with incomplete bladder emptying or via
poor glycaemic control causing osmotic diuresis and polyuria.
Co-morbidities associated with UI also include depression and
anxiety. Depression in older persons with UI may be under-
diagnosed and undertreated, leading to an increased burden by
Systematic history for continence in older persons
C Chief complaint
C Duration
C Treatment thus far, if any
C Storage symptoms: diurnal frequency, nocturnal frequency,
nocturnal enuresis, urinary urgency, urgency incontinence,
stress UI
C Voiding symptoms: hesitancy, straining, slow stream,
intermittency, splitting or spraying
C Post-micturition symptoms: incomplete emptying, terminal
dribble, post-micturition dribble
C Pads: type, number
C ‘Red flags’: haematuria, pain on micturition, dysuria (internal or
external)
C Bowel habits: frequency, faecal urgency, faecal incontinence,
acute change, laxative usage
C Sense of prolapse (women)
C Frequency of urinary tract infection
C Fluid intake volume (including caffeinated beverages, alcohol)
C Obstetric history (including instrumental deliveries)
C Gynaecological history
C Functional and cognitive state
C Impact of condition on quality of life
C Goals for treatment
C Assessment tools: bladder/bowel diary, validated condition-
specific questionnaires, quality-of-life assessment
Table 3
decreasing life satisfaction and self-rated health. Geriatric syn-
dromes, such as falls, are also associated with urinary urgency
and urgency UI. Data from nursing home residents suggest that
older persons with urgency incontinence are significantly more
burdened by multimorbidity than those without.
UI is commonly associated with neurological conditions
including Alzheimer’s disease, multi-infarct dementia (or a
combination of these), stroke, dementia with Lewy bodies, Par-
kinson’s disease, normal pressure hydrocephalus, and multiple

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 MEDICINE IN OLDER ADULTS

system atrophy. UI manifests differently in different types of
dementia: in Alzheimer’s disease UI is more frequently associ-
ated with the onset of severe cognitive decline, whereas in Lewy
body dementia it precedes severe cognitive impairment. In a
recent study, the prevalence of UI increased with decreasing
mini-mental state examination scores. In any patient who pre-
sents with new-onset UI in association with gait disturbance and
cognitive impairment, normal-pressure hydrocephalus should be
ruled out as a potential cause.
Medications
Polypharmacy is increasingly common in older adults, and some
medications predispose an older person to incontinence.
Although the list of medications that theoretically worsen in-
continence is long (Table 4), there is little published evidence of
the associations between these and incontinence. Evidence exists
for diuretics, prostaglandin inhibitors, a-adrenoceptor blockers,
selective serotonin reuptake inhibitors, cholinesterase inhibitors
and systemic hormone replacement therapy. Medication lists
should always be reviewed and potentially implicated medica-
tions discontinued, if feasible.
Cholinesterase inhibitors for dementia are of particular rele-
vance as their use appears to be associated with an increased risk
of urinary urgency and urgency incontinence.2 Gliflozins can
lead to an osmotic diuresis and predispose to incontinence and
perhaps urinary tract infection. Prescribers should also be aware
that many drugs have antimuscarinic effects and that there is a
consequent total ‘antimuscarinic burden’ on the patient. In a
number of epidemiological studies, this has been associated with
cognitive decline and an increased incidence of dementia
diagnosis.3 The use of antimuscarinic drugs for urgency UI and
cholinesterase inhibitors for dementia does not appear to worsen
cognition or cause delirium. Indeed, these can achieve positive
continence outcomes if used carefully and with due regard to the
necessity of dual prescribing.
Physical examination
The initial step is to perform a relevant urogenital examination to
assess for urogenital atrophy, prolapse, prostate size and masses,
faecal loading and the presence of a palpable bladder. Dipstick
urinalysis and ultrasound post-voiding residual volume should
be carried out for all men, and for women if they complain of
voiding symptoms. This should be done in association with a
general physical examination that includes cognition, as well as
examination for relevant neurological conditions including Par-
kinson’s disease, stroke, spinal stenosis, cauda equina syndrome
and multiple system atrophy. Mobility and dexterity can be
assessed when obtaining the routine dipstick urinalysis, by
observing the patient preparing to collect a sample and returning
for the physical examination.
Management
Older adults, especially frail older persons, should not be denied
any intervention that has proven utility in the care of
community-dwelling, robust older adults for the treatment of UI
(see Wagg, 2015, in the further reading list). Interventions should
be employed with regard to the likely benefits, harms, and
feasibility of the treatment, as well as to the expectations and
concerns of the patient and their caregiver(s).

Medications that can worsen urinary incontinence

Medication Potential or actual effect

a-Adrenoceptor antagonists Decrease smooth muscle tone in the urethra and can cause stress UI in women
Angiotensin-converting enzyme inhibitors Cause cough that can worsen stress UI
Agents with antimuscarinic properties Can cause ineffective voiding and constipation that can contribute to incontinence.
May cause cognitive impairment and reduce effective toileting ability (high dose,
if cognitively at risk)
Calcium channel blockers Can cause constipation (verapamil) that can contribute to incontinence. Can cause
dependent oedema (amlodipine, nifedipine), which can contribute to nocturnal polyuria
Cholinesterase inhibitors Can cause urgency incontinence through cholinergic action
Diuretics Cause diuresis and incontinence
Lithium Can cause polyuria due to a diabetes insipidus-like state
Opioid analgesics Can cause constipation, confusion, and immobility e all of which can contribute
to incontinence
Psychotropic drugs Can cause confusion, impaired mobility and incontinence
Sedatives, hypnotics, antipsychotics Most have anticholinergic effects
Histamine-1 receptor antagonists
Selective serotonin reuptake inhibitors Increase cholinergic transmission and can lead to urgency UI
(sertraline identified)
Gabapentin Can cause oedema, lead to polyuria while supine and worsen nocturia and
Non-steroidal anti-inflammatory agents night-time incontinence
Glitazones Can lead to an osmotic diuresis and predispose to incontinence and perhaps
urinary tract infection

Table 4

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 MEDICINE IN OLDER ADULTS
Initial management
Several general management strategies are applicable to all
subtypes of UI but can have varying results depending on the
particular circumstances. Management of fluid intake is impor-
tant, aiming to achieve a balance between dehydration and
excessive drinking, as well as avoiding alcohol and caffeine if
identified as causative factors. Weight loss via dieting or medi-
cation can be beneficial but be difficult to achieve, especially in
frail elderly individuals. Good diabetic control allows patients to
manage the hyperglycaemic symptoms of osmotic diuresis and
polyuria. Constipation management is also important.
Once these strategies have been implemented, interventions
can be used for certain subtypes of UI. For OAB or urgency
efrequency syndrome, bladder retraining is the mainstay of
conservative management. For stress and mixed incontinence,
pelvic floor muscle therapy (Kegel exercises) is recommended.
The benefit depends on adhering to the exercise regime, but
patients may not return to baseline even with strict adherence. A
3-month supervised course involving at least 10 repetitions three
times daily appears to be the minimum requirement. Pelvic floor
muscle contractions can also be used to avoid an incontinence
episode when confronted with urgency. For voiding inefficacy,
double-voiding techniques can be effective.
Behavioural management
The following conservative management techniques are pre-
dominantly used in frail older persons:
 Prompted voiding e this involves prompts to use the
lavatory with encouragement when prompting is success-
ful. It is designed to increase patients self-initiating or
requesting toileting and to decrease the number of UI
episodes.
 Habit retraining e the incontinent person’s individual
voiding pattern is identified, usually by means of a bladder
diary. A schedule is then devised to pre-empt UI episodes.
 Timed voiding e the patient involves lavatory visits at
fixed intervals, such as every 3 hours. It is considered a
passive toileting programme.
 Combined prompted voiding and exercise therapy e
functional intervention training involves direct care givers
(nursing assistants / care aides) incorporating strength-
ening exercises into toileting routines.
All techniques require active caregiver participation and
considerable input. For the prompted voiding intervention, a 3-
day trial should be conducted in patients who might benefit. If
there is <20% reduction in wet episodes, the intervention should
be considered ineffective, and a reversion to ‘check and change’
of continence pads, the usual method of managing continence in
dependent older persons, is required.
Pharmacological management
Urgency incontinence is the main cause of incontinence in older
people. Antimuscarinic medications have remained the first line
pharmacological treatment since the introduction of oxybutynin
over 30 years ago. Since then, there has been refinement in the
tolerability and adverse effect profiles of medications for OAB,
but little additional efficacy over and above that reported with
treatment with oxybutynin.
MEDICINE 45:1
Although these medications are undoubtedly of benefit to
many people, their tolerability and perceived efficacy are still a
problem. As a result, many patients stop their medication, and
their use is associated with poor persistence rates in the com-
munity, although perhaps less so in older people.4 Many patients
also stop their medications because of unrealistic expectations of
the results of therapy, which should be modifiable by the
healthcare provider. Suggestions that these medications lead to
an increase in falls or widespread impairment in cognition, often
used as justification for not using them, have largely been
refuted. With cautious use, there is little reason not to try to
control symptoms pharmacologically, and there is widespread
evidence of benefit, even in ‘vulnerable’ elderly patients. Oxy-
butynin should, however, probably be avoided in older people at
risk of cognitive impairment.
More recently, the b3-adrenoceptor agonist mirabegron has
been licensed in the UK for treatment of OAB. Early analysis of
results in community-dwelling older people suggests benefit with
acceptable safety (see Gibson and Wagg, 2014, in the further
reading list). LUTS in older men, unless there is a complete
absence of voiding symptoms, should initially be treated with an
a-adrenoceptor antagonist, for example tamsulosin (those with a
large prostate [>40 grams e the size of a golf ball] will also
benefit from a 5-a-receptor antagonist such as finasteride or
dutasteride). Where storage symptoms do not resolve, the addi-
tion of an antimuscarinic agent is recommended (see Lucas et al,
2013, in the further reading list). For stress UI, duloxetine is not
recommended for use on the basis of cost-effectiveness (see
Smith et al, 2013, in the further reading list). Its use is unfortu-
nately also limited by a high incidence of nausea, leading to
cessation of treatment. A recent systematic review and Delphi
process specifically for LUTS drugs in older persons grades the
appropriateness of each for its indication (see Oelke et al, 2015,
in the further reading list).
Surgical management
If conservative and medical attempts to manage UI fail, there is
good evidence for the efficacy of onabotulinumtoxin A injection
into the bladder for refractory detrusor overactivity and OAB.5 The
risk of large post-void residual urine volumes has been markedly
reduced by the use of lower doses of toxin. Mid-urethral tapes for
stress UI can be of benefit, although they appear less effective in
older than younger women. De-obstructing surgical interventions
(transurethral resection of prostate or alternative methods) should
be used for outflow tract obstruction.
Containment products (pads and appliances)
An abundance of products is available for the management of UI.
Current national guidelines recommend that these are used
following an appropriate assessment, or are used in the interim
period while definitive management is being arranged. The In-
ternational Continence Society in collaboration with the Inter-
national Consultation on Incontinence hosts a comprehensive
online products directory, the Continence Product Advisor, for
use by patients and caregivers, enabling them to gain advice on
the suitability of different products (http://www.
continenceproductadvisor.org/). Additionally, a more regional-
specific directory of most available UK products and appliances
26 Ó 2016 Elsevier Ltd. All rights reserved.
 MEDICINE IN OLDER ADULTS
is available online from PromoCon (http://www.disabledliving.
co.uk/PromoCon/About).
The first step in assessment should not be the provision of free
pads. These should only be offered as part of a planned assess-
ment and management plan, in accordance with current guid-
ance. However, there should be recognition that, for many,
containment forms an essential part of management regardless of
efforts at cure.
Intermittent catheterization may be required for older people
with voiding symptoms, a significant post-void residual volume
and detrusor failure, should de-obstructing surgery not be
required or indicated. Many older people only need once- or
twice-daily catheterization, which can be performed by some
frail older persons themselves or by community services if this is
impractical for the individual. Condom catheters can be prefer-
able to pads for older men, but some may find them difficult to
use. The use of indwelling urethral catheters is clinically indi-
cated in a limited set of circumstances and should not be
considered as a substitute for nursing care of older adults with
incontinence. End-of-life catheterization can be used for comfort.
The National Institute for Health and Care Excellence quality
standard for UI states that active treatment is better than
containment. A
KEY REFERENCES
1 Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of
urinary incontinence, overactive bladder, and other lower urinary
tract symptoms in five countries: results of the EPIC study. Eur Urol
2006; 50: 1306e14. discussion 1314e1315.
2 Sink KM, Thomas 3rd J, Xu H, Craig B, Kritchevsky S, Sands LP.
Dual use of bladder anticholinergics and cholinesterase inhibitors:
MEDICINE 45:1
long-term functional and cognitive outcomes. J Am Geriatr Soc
2008; 56: 847e53.
3 Lechevallier-Michel N, Molimard M, Dartigues JF, Fabrigoule C,
glat A. Drugs with anticholinergic properties and
Fourrier-Re
cognitive performance in the elderly: results from the PAQUID
Study. Br J Clin Pharmacol 2005; 59: 143e51.
4 Wagg A, Compion G, Fahey A, Siddiqui E. Persistence with pre-
scribed antimuscarinic therapy for overactive bladder: a UK expe-
rience. BJU Int 2012; 110: 1767e74.
5 Schulte-Baukloh H, Weiss C, Stolze T, et al. Botulinum-A toxin
detrusor and sphincter injection in treatment of overactive bladder
syndrome: objective outcome and patient satisfaction. Eur Urol
2005; 48: 984e90. discussion 990.
FURTHER READING
Gibson W, Wagg A. New horizons: urinary incontinence in older
people. Age Ageing 2014; 43: 157e63.
Lucas MG, Bosch RJ, Burkhard FC, et al. European Association of
Urology guidelines on assessment and nonsurgical management of
urinary incontinence. Actas Urol Esp 2013; 37: 199e213.
Oelke M, Becher K, Castro-Diaz D, et al. Appropriateness of oral drugs
for long-term treatment of lower urinary tract symptoms in older
persons: results of a systematic literature review and international
consensus validation process (LUTS-FORTA 2014). Age Ageing
2015; 44: 745e55.
Smith A, Bevan D, Douglas HR, James D. Management of urinary
incontinence in women: summary of updated NICE guidance. BMJ
2013; 347: f5170.
Wagg A, Gibson W, Ostaszkiewicz J, et al. Urinary incontinence in frail
elderly persons: report from the 5th International Consultation on
Incontinence. Neurourol Urodyn 2015; 34: 398e406.
27 Ó 2016 Elsevier Ltd. All rights reserved.