Urinary Incontinence in the Elderly

Article contributed by:

Dr Ee Chye Hua Senior Consultant, General Geriatrics Alexandra Hospital

Dr Lawrence Tan Consultant, Department of Geriatric Medicine Khoo Teck Puat Hospital

 
for New Dimension - biannual newsletter of the Society for Continence, Singapore

 

Urinary incontinence (UI), the involuntary loss of urine severe enough to have social and/or hygiene consequences, is a geriatric syndrome and a common condition among the elderly.  It is a long recognised problem which has been plagued by myths and misconceptions over the years.  One such myth of UI is that it is a normal part of ageing and therefore ‘nothing can be done’.  While normal ageing is not a cause of urinary incontinence per se, age-related changes in lower urinary tract function can predispose the elderly to UI. This lack of understanding of UI often led to ineffective and even harmful treatments.  Wilkins’ remedy for ‘involuntary urine’ in 1814 was “use the cold bath, or take a spoonful of powdered agrimony in a little water, morning and evening, or a quarter of a pint of alum posset… drink every night, or foment with rose leaves and plantane leaves, boiled in a smith’s forge water.  Then apply plaster of alum and bole armoniae, made up of oil and vinegar.  Or apply a blister to the os sacrum… this seldom fails”
 
The prevalence of UI in community dwelling and hospitalised elderly aged 65 and above in Singapore is 4.6 and 22% respectively.  In institutionalised elderly, the prevalence ranges from 24 to 79%.  Urinary incontinence has important medical, psychological and economic complications and implications. Medically, UI is associated with urinary tract infections, perineal rashes, pressure sores, falls and even death.  The psychological complications of UI include low self-esteem, social isolation, diminished quality of life and depression.  There is an increased burden of care and UI is one of the leading causes of institutionalisation. Despite its obvious impact on affected individuals, UI remains undetected, under-reported and under-treated because many elderly are reluctant to initiate discussions about their incontinence for fear of embarrassment.  Therefore, a system of screening is important in order to identify elderly with UI.
 

On this page: ► Causes of Urinary Incontinence ► Types of Established Incontinence	► Evaluation of Urinary Incontinence ► Management of Urinary Incontinence

 

Causes of Urinary Incontinence

Normal micturition requires the proper functioning and coordination of several physiologic systems which include the lower urinary tract, central nervous system and skeletal/muscular systems.  Urinary incontinence can therefore result from problems within and outside the lower urinary tract.  Neurological, psychological, urological, environmental and iatrogenic factors may all play a part.  Examples of neurological factors would be dementia, strokes and spinal cord disorders.  Drugs are an important iatrogenic factor that can contribute to UI, in particular diuretics (which increase urine output), psychotropics (which impair cognition) and anticholinergics (which can cause urinary retention).  Environmental factors include inaccessibility to the bathroom and use of restraints.  So, a supposedly simple trip to the bathroom requires intact cognition, good bladder control, muscle strength and balance, mobility, manual dexterity and easy accessibility.
 
The cause of UI can be classified into transient and established causes (Figure 1).

▲ Figure 1: Causes of urinary incontinence

 
1. Transient Causes

Transient causes of UI are usually potentially reversible and are from external or systemic factors that act on the urinary tract to cause incontinence.  The mnemonic DIAPPERS succinctly summarises these causes:
 

►	Delirium
►	Infections
►	Atrophic vaginitis
►	Pharmacological agents ( eg. anticholinergics, sedatives and antipsychotic) (Table 1)
►	Psychological causes ( eg. depression and anxiety)
►	Endocrine causes (eg. diabetes insipidus)
►	Restricted mobility
►	Stool impaction

 

Medication Anticholinergics     Antipsychotics Tricyclic antidepressants Cholinesterase inhibitors Calcium channel blockers Opioid analgesics Loop diuretics Alpha adrenergic agonists Effect on Continence Impairment of detrusor contractility (impaired emptying), sedation, faecal impaction (overflow incontinence) Anticholinergic effects Anticholinergic effects Frequency and incontinence Impairment of detrusor contractility Anticholinergic effects Polyuria, frequency, urgency Bladder outlet obstruction   ▲ Table 1: Medication and effect on continence

 
2. Established Causes

a) Functional incontinence

This is a term used to describe urinary incontinence that occurs as a result of impairments in cognition and/or mobility without any dysfunction of the lower urinary tract.
 
b) Failure to Store

(i) Detrusor overactivity
 
This is the most common cause of UI in the elderly and is characterised by uninhibited detrusor contractions which occur well before the bladder is full with resultant frequency, urgency and urge incontinence.  Detrusor overactivity can be found in conditions of defective central nervous system inhibition or increased afferent sensory stimulation from the bladder.  Examples of disorders which impair the ability of the brain to send inhibitory signals include strokes, tumours, Parkinson’s disease, Alzheimer’s disease and demyelinating disease. Increased afferent stimulation from the bladder can result from cystitis, bladder calculi and tumours.  In men, benign prostatic hyperplasia (BPH) can cause detrusor overactivity in addition to bladder outlet obstruction.
 
(ii) Outlet incompetence
 
This can occur as a result of a weak pelvic floor which is common in multiparous and post-menopausal women.  In men, damage to the external urethral sphincter during transurethral resection of the prostate (TURP) and radical prostatectomy can result in outlet incompetence.  The typical symptom is stress incontinence.
 
c) Failure to Void

(i) Detrusor underactivity
 
Also known as detrusor hypocontractility, this occurs when the bladder has lost its tone and contractions become weak or absent.  As the bladder fills and distends, the intravesical pressure increases.  When the intravesical pressure exceeds the urethral closure pressure, overflow incontinence occurs.  Detrusor hypocontractility can result from diabetic or alcoholic neuropathy, sacral spinal cord lesions or medications with anticholinergic activity such as antipsychotics and tricyclic antidepressants.  Over-distension of the bladder from chronic urinary retention is also a cause of detrusor hypocontractility which can take several weeks to resolve.
 
(ii) Outlet obstruction
 
The most common cause of bladder outlet obstruction is BPH.  In women, pelvic organ prolapse, benign uterine tumours (fibroids), malignant tumours of the pelvis, urethra or vagina must be considered.  The typical symptoms are hesitancy, poor stream, terminal dribbling, a feeling of incomplete emptying, urinary retention and incontinence.  In men with BPH, frequency, urgency and urge incontinence may be present because of associated detrusor overactivity.  Functional outlet obstruction can occur because of detrusor-sphincter dyssynergia.  In normal circumstances, the external urethral sphincter relaxes when the detrusor contracts, allowing voiding.  In detrusor-sphincter dyssynergia this coordinated muscle action is lost and the external urethral sphincter and detrusor contract at the same time.  It is caused by lesions between the brainstem and sacral spinal cord eg. multiple sclerosis and traumatic spinal cord injury.

 

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Types of Established Incontinence

1. Stress incontinence

Elderly with stress incontinence have involuntary leakage of urine during activities that raise intra-abdominal pressure eg. coughing, sneezing and laughing.  Common causes include pelvic prolapse, urethral hypermobility and intrinsic sphincter deficiency.  In men, stress incontinence is most commonly due to poor urethral sphincter function and prostate surgery.
 
2. Urge incontinence

Urge incontinence is the most common type of UI in elderly above the age of 75 and results from detrusor overactivity causing involuntary bladder contractions.  These contractions can occur because of irritation or inflammation within the bladder resulting from calculi, cystitis or tumours.  Neurological conditions such as Parkinson’s disease, dementia and strokes can also cause urge incontinence.  Lastly, the rapid introduction of large volumes of urine into the bladder (eg. diuretic therapy) can trigger bladder contractions and urge incontinence.
 
3. Overflow incontinence

Overflow incontinence is characterised by poor stream and incomplete voiding.  Bladder outlet obstruction (BPH, urethral stricture, faecal impaction) and detrusor hypocontractility (diabetes mellitus, spinal cord compression, anticholinergic drugs) are the usual causes.  It is important to recognise overflow incontinence caused by urinary retention because it is reversible and can lead to complications such as hydronephrosis if left untreated.

 

▲ Figure 2: Types of incontinence   (Photo courtesy of Society for Continence, Singapore)

 

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Evaluation of Urinary Incontinence

1. History

The evaluation of UI begins with a detailed history focusing on the presenting symptoms (especially lower urinary tract symptoms), past medical, surgical and genitourinary history.  The history should also include reviewing the medication list, examining voiding pattern (through a bladder diary) and assessing the living environment.  From the history cause ie. transient or established and the type of UI ie. stress, urge or overflow may become apparent.
 
Symptoms of UI can be elicited by the following questions:
 
Do you ever leak urine when you don’t want to?

Do you ever leak urine when you cough, laugh or exercise?

Do you ever leak urine on the way to the bathroom?
 
2. Physical examination

A targeted physical examination should be performed, checking for signs of neurological disorders (strokes, dementia, delirium, Parkinson’s disease, spinal cord compression) and palpating the abdomen for a distended bladder.  It should also include a rectal examination (faecal impaction, perianal sensation, anal tone, rectal masses, prostate size and contour) and a pelvic examination (atrophic vaginitis, pelvic masses, pelvic prolapse).  Atrophic vaginitis causes UI because, in many women, the oestrogen-sensitive mucosa of the vagina extends into the urethra and bladder trigone.  If atrophic vaginitis is present, atrophic urethritis and trigonitis may also be present and these can cause bladder contractions.
 
3. Basic investigations

a) Urinalysis
 
Because UI is often precipitated by urinary tract infections, urinalysis (pyuria, haematuria, glycosuria and proteinuria) and urine culture are important initial tests which should be routinely done.

b) Post-void residual urine volume (PVRU)
 
This simple test, using either ‘in-out’ catheterisation or bladder ultrasounds, measures the amount of urine left behind after voiding. In general, a PVRU of less than 50ml is considered adequate emptying whereas a PVRU greater than 200ml is considered inadequate and suggestive of detrusor hypocontractility or bladder outlet obstruction.

c) Bladder chart/diary
 
An accurate three-day record of the oral intake/urine output, noting the time/number of voids, voided volumes and episodes of UI is very useful and can provide clues to the cause/s of UI. Besides helping in the diagnosis of UI, a bladder chart can also help in the planning and monitoring of treatment progress.

d) Blood tests
 
If there is concern about urinary retention, serum creatinine should be checked. In patients with urinary frequency, polydipsia and polyuria, calcium and fasting glucose levels should be obtained to exclude nephrogenic diabetes insipidus and diabetes mellitus. Prostate specific antigen (PSA) testing should be considered in men who present with UI as prostate cancer can present as urgency and urge incontinence from detrusor overactivity.
 
4. Further investigations

Based on the findings from the basic investigations, more specialised tests can be done.

a) Radiological
 
Computed tomography or magnetic resonance imaging should be obtained if the history or physical examination suggests disc herniation manifesting of UI.
 
b) Urological
 
Many types of urological studies are available to evaluate UI including uroflowmetry, cystoscopy, cystometry, urethral pressure profilometry and electrophysiologic sphincter testing. Uroflowmetry can be a valuable screening test for men with symptoms of bladder outlet obstruction. Cystometry can identify involuntary bladder contractions or sphincter weakness. The indications for urodynamic studies are controversial. Routine urodynamic testing is not recommended in the initial evaluation of UI. Urodynamic testing is expensive, invasive and technically difficult to perform and is often not necessary to make the diagnosis.
 
5. Specialist referral

Indications for specialist referral include:
 
a) Associated abdominal or pelvic pain

b) Neurologic disease eg. Parkinson’s disease, spinal cord injury

c) Abnormal physical examination findings eg. abdominal or pelvic mass

d) History of pelvic surgery/irradiation or prostatectomy

e) Persistently elevated PVRU

f) Failure of therapeutic trial

g) Uncertain diagnosis

 

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Management of Urinary Incontinence

1. General measures

a) Lifestyle advice

 
This includes smoking cessation (coughing exacerbates stress incontinence), weight loss, maintaining good fluid intake (about 1.5 to 2L daily unless contraindicated) and bowel regulation (preventing constipation by an adequate consumption of fruits and vegetables)
 
b) Dietary changes

 
Limiting intake of alcoholic/carbonated/caffeinated beverages should be considered. Caffeine is both a diuretic and bladder stimulant and can therefore cause bladder contractions and UI.
 
c) Environmental modifications

 
Appropriate environmental modifications such as making toilet substitutes readily available and removal of clutter in the home are very important
 
2. Specific therapy

a) Transient causes

 
Treat each cause accordingly bearing in mind that in elderly, the cause of UI is often multifactorial
 
b) Established causes

 
(i) Detrusor overactivity
 
Behavioural therapy is the initial step in treating urge incontinence.  Bladder retraining aims to gradually increase bladder capacity and extend the voiding interval by improving the ability to suppress urgency.  Pelvic floor contractions are used to inhibit the urge and postpone voiding.  Pelvic floor exercises, biofeedback techniques and electrical stimulation help strengthen the pelvic floor muscles to augment urethral closure and inhibit bladder contractions.  Anti-cholinergic drugs (oxybutynin, tolterodine, darifenacin, solefenacin, trospium) are the main pharmacologic agents for the treatment of urge incontinence.  Alpha blockers are used in men with urge incontinence associated with BPH.  Anticholinergics reduce involuntary bladder contractions by blocking the muscarinic receptors on the detrusor muscle cell wall.  Adverse effects include dry mouth, constipation, blurred vision and impaired cognition.  Mirabegron, a beta-adrenergic agonist, has shown modest benefit for urge incontinence but long term data on efficacy and safety is limited.  In patients who fail to respond to medical therapy, other treatment options include sacral nerve stimulation, injection of botulinum toxin via cystoscopy and augmentation cystoplasty.
 
(ii) Outlet incompetence
 
Pelvic floor exercises (also known as Kegal exercises) strengthen the muscular urethral closure mechanism and is the treatment of choice for stress incontinence.  They can effectively decrease UI in cognitively intact and motivated patients.  Biofeedback can be used to help patients identify, isolate and selectively contract the pelvic floor muscles.  Performed properly and consistently, pelvic floor exercises can improve pelvic floor tone after six to eight weeks.  Continence pessaries are an inexpensive and effective form of treatment for elderly women with stress incontinence.  They can be used either as an adjunct or substitute for pelvic floor exercises.  Pharmacologic therapies for stress incontinence can be considered when pelvic floor exercises alone are ineffective.  Vaginal oestrogen therapy improves symptoms of stress incontinence related to atrophic vaginitis.  Systemic oestrogen, on the other hand, given for menopausal symptoms appears to worsen UI Duloxetine, a serotonin and noradrenaline reuptake inhibitor, is commonly used in Europe for treatment of stress incontinence in women.  For elderly men and women with refractory stress incontinence, a variety of surgical procedures are available such as perineal slings and transurethral bulking agent injections.
 
(iii) Detrusor underactivity
 
Specific treatment is limited.  Potentially reversible causes of detrusor weakness should be identified and addressed eg. stopping medications that impair detrusor contractility (calcium channel blockers) or increase urethral tone (alpha-adrenergic agonists).  Bethanechol, a bladder stimulator can be used to improve detrusor contractility but good evidence for its efficacy is lacking.  Clean intermittent catheterisation remains the treatment of choice for detrusor hypocontractility.  Failing which, indwelling catheterisation would be the final option.
 
(iv) Outlet obstruction
 
Bladder outlet obstruction occurs more commonly in men and the cause is usually BPH.  The typical symptoms are hesitancy, poor stream and terminal dribbling.  Detrusor overactivity with resultant urgency can occur.  The decision to treat is based on the severity of symptoms, the patient’s tolerance for these symptoms (impact on quality of life) and the risk of complications (hydronephrosis, renal injury, urinary retention, recurrent urinary tract infections).  Two classes of drugs, alpha-adrenergic antagonists and 5-alpha-reductase inhibitors, are used in the treatment of BPH.  Alpha-adrenergic antagonists (terazosin, alfuzosin, tamsulosin) act on the smooth muscle in the prostate and bladder neck while 5-alpha-reductase inhibitor (finasteride, dutasteride) act by reducing the size of the prostate gland.  With 5-alpha-reductase inhibitors, treatment for 6 to 12 months is generally required for symptomatic improvement to occur. Combination therapy with alpha-adrenergic antagonists and 5-alpha-reductase inhibitor is effective in men with larger prostates (prostate volume ≥ 30ml) and appears to be superior to either drug alone in reducing BPH symptoms.  Another class of drugs, the phosphodiesterase-5 (PDE-5) inhibitors, which are primarily used as treatments for erectile dysfunction, have been shown to improve lower urinary tract symptoms.  In subgroup analyses of pooled data from four randomised trails, the PDE-5 inhibitor tadalafil was found to improve lower urinary tract symptoms suggestive of BPH.  Some men with BPH may experience symptoms related to detrusor overactivity eg frequency, urgency and urge incontinence.  In such cases, the addition of an anticholinergic agent to an alpha-adrenergic antagonist may help alleviate these irritative symptoms with minimal risk of increased PVRU or acute urinary retention.  Surgery offers the most effective resolution of bladder outlet obstruction symptoms.  Most procedures used in the treatment of BPH are performed transurethrally eg. transurethral resection of prostate (TURP), transurethral needle ablation (TUNA), transurethral laser enucleation, plasma vaporisation, microwave thermotherapy and radiofrequency ablation. Complications associated with transurethral procedures including bleeding, erectile dysfunction, retrograde ejaculation and urinary incontinence.
 

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Article contributed by:

Dr Ee Chye Hua Senior Consultant, General Geriatrics Alexandra Hospital

Dr Lawrence Tan Consultant, Department of Geriatric Medicine Khoo Teck Puat Hospital

 
for New Dimension - biannual newsletter of the Society for Continence, Singapore

Dated: April 2015

 

 

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