Med Clin N Am 90 (2006) 825–836

Urinary Incontinence: Selected

Current Concepts
Marget-Mary G. Wilson, MD, MRCPa,b,*
a
Division of Geriatric Medicine, St. Louis University Health Sciences Center,
1402 South Grand Boulevard, Room M238, St. Louis, MO 63104, USA
b
Geriatric Research, Education, and Clinical Center, Veterans’ Administration Medical
Center, Jefferson Barracks Division, 1 Jefferson Barracks Drive, St. Louis, MO 63125, USA

Introduction
Urinary incontinence (UI) in older adults is a potentially life-threatening
problem. Potential consequences include significant functional decline, im-
paired quality of life, frailty, institutionalization, and death [1,2]. Reported
prevalence for urinary incontinence ranges from 15% among relatively
healthy community-dwelling older adults to 65% among frail older adults
[3,4]. Available figures most likely underestimate the true prevalence of UI
for several reasons, including patient embarrassment, low rates of clinical
detection, and lack of awareness of effective treatment options [5]. Health
care costs for UI exceed $20 billion annually [6]. Additionally, the lifetime
medical cost of treating an older adult who has urinary incontinence ap-
proaches $60,000 [7]. Added costs arising from complications of UI, such
as loss of wages, poor quality of life, depression, and loss of self-esteem, in-
crease the financial burden of UI even further [6].

Pathophysiology of urinary incontinence in older adults

Age-related changes in bladder function set the stage for UI (Fig. 1).
These include an increased frequency of uninhibited detrusor contractions,
impaired bladder contractility, abnormal detrusor relaxation patterns, and
reduced bladder capacity. There is also an age-related increase in the volume
of nocturnal urine production. In men, prostatic size increases, whereas

* Division of Geriatric Medicine, St. Louis University Health Sciences Center, 1402
South Grand Boulevard, Room M238, St. Louis, MO 63104.
E-mail address: wilsonmg@slu.edu

0025-7125/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.mcna.2006.06.005 medical.theclinics.com
826 WILSON

Gender
Anatomic
Cultural
Environmental
Neurologic disease
Childbirth
Tissue disruption
Pelvic surgery
Constipation
Occupation
Obesity
Surgery
Advanced age
Disease
Dementia
Drugs
Debility
Disease
Environment
Medications

Urinary Incontinence

Fig. 1. UI in the older adult: risk and predisposing factors.

urethral shortening and urethral sphincter weakening occur in women

[8–11]. Aside from advancing age, other risk factors for UI include coexist-
ing morbidity, cognitive dysfunction, functional impairment, gait abnormal-
ity, diuretic therapy, and obesity [3,12]. Female gender is an irreversible
predisposing factor and mandates routine screening for UI in all women
regardless of age. Anatomic genital abnormalities such as hypospadias, epis-
padias, and ambiguous genitalia may compromise continence. Coexisting
illness, such as cerebrovascular disease, radical pelvic surgery, or autonomic
neuropathy, may increase the risk for UI further [13,14]. Available data
indicate that the occurrence of cerebrovascular disease doubles the risk
for UI in the older woman. Obesity, frailty, and diabetes are strong predic-
tors of the occurrence of UI Additionally, older adults are more likely to
become incontinent following the onset of UI-promoting factors, such as
constipation, obesity, and polyuria from uncontrolled hyperglycemia,
hypercalcemia, or diuretic therapy [3,15,16].

Mechanistic classification of urinary incontinence

UI can be categorized into five major groups: overactive bladder (OAB),
stress incontinence, overflow incontinence, and functional incontinence;
combinations of these categories constitute the fifth category, which is re-
ferred to as mixed incontinence. Symptoms of bladder hyperactivity and im-
paired contractility may coexist in patients who have diabetes mellitus.
Likewise, benign prostatic enlargement can present with symptoms of blad-
der overactivity and urinary retention [17–19].
OAB occurs in one in four adults over the age of 65 years and accounts
for 40% to 70% of all cases of UI in this cohort. Symptoms of OAB arise
 URINARY INCONTINENCE 827

from involuntary contractions of the detrusor muscle at unusually low vol-

umes of urine, resulting in a strong urge to pass urine. Clinically, OAB man-
ifests with urgency, frequency, and nocturia, with or without urge incontinence
[20]. People who have urge incontinence present with involuntary urine
loss preceded by an urgent and compelling desire to void.
Several physiologic mechanisms underlie detrusor muscle contraction.
The major mechanism is cholinergic and is mediated through the effect of
acetylcholine (Ach) on muscarinic bladder receptors. A second mechanism
(purinergic) involves adenosine triphosphate- (ATP) mediated bladder con-
traction. A third non-neuronal mechanism probably exists, involving local
uroepithelial Ach production and subsequent paracrine action on local mus-
carinic bladder. Available data indicate age-related compromise in choliner-
gic and purinergic bladder transmission. Purinergic transmission seems to
play a greater role in bladder contraction with aging, suggesting dispropor-
tionate age-related compromise in cholinergic function. Available data also
suggest an age-related compromise of non-neuronal uroepithelial Ach pro-
duction [10,21].
Twenty-five percent of women who have UI present with symptoms of
stress incontinence usually arising from anatomic or pathologic disruption
of the angle between the bladder neck and the urethra. Causes of stress in-
continence include vaginal childbirth and pelvic surgery, such as hysterec-
tomy in women or prostate surgery in men. Generally, stress incontinence
presents with involuntary urine loss associated with increases in intra-
abdominal pressure in the presence of a relatively incompetent urethral sphinc-
ter mechanism. In such patients, involuntary urine loss characteristically
occurs when the patient laughs, coughs, or sneezes. In severe cases, UI
may occur with a change in posture from supine or sitting to standing
[22–24].
Overflow incontinence arises from bladder outlet obstruction that results
in progressive bladder distension with a gradual increase in intravesical pres-
sure until the mechanical outlet obstruction is overcome by sheer pressure.
People who have overflow incontinence may complain of persistent trickling
of urine in the presence of suprapubic distension or discomfort. In men,
prostatic enlargement is the most common cause of overflow incontinence.
Pelvic masses, such as uterine fibroids or cystoceles, may cause similar ob-
structive symptoms in women [25–27].
Functional incontinence refers to involuntary urine loss resulting from in-
ability to gain prompt access to toileting facilities for reasons such as limited
mobility, impaired cognition, lack of motivation, environmental barriers, or
restricted access. This problem occurs commonly in frail elders who have de-
mentia, cerebrovascular disease, Parkinson disease, or delirium. Altered
mental status from narcotics, sedatives, or neuroleptic agents also may
lead to functional UI [28,29]. Inappropriate use of physical or chemical re-
straints, poor vision, depression, reduced exercise tolerance, gait abnormal-
ity, or fear of falling are other causes of functional incontinence.
828 WILSON

Complications and consequences of urinary incontinence in elders

Older adults who have urinary incontinence often experience embarrass-
ment, loss of self-confidence, and poor self-esteem. Sixty percent develop
depressive symptoms. Unpredictable episodes of UI may lead to with-
drawal and social isolation. Limitation of physical activity in affected elders
may compromise functional status and hasten progression to frailty. Inti-
mate relationships may be avoided because of the fear of involuntary urine
loss during sexual intercourse. Studies have shown an independent associ-
ation between sexual dysfunction and urinary incontinence in older men
[1,30–32].
Financially, UI can become burdensome. Protective garments and bed-
ding often are not covered by insurance plans and are relatively expensive.
Productivity of older adults in the workforce may be negatively affected by
the threat of frequent and unpredictable episodes of incontinence. Likewise,
the productivity of caregivers of patients who have UI may be compromised
by their inability to cope with the demands of a relative who has urinary in-
continence. Available data highlight UI as the most common cause of insti-
tutionalization of elders. Similarly, in long-term care facilities the resident
who has urinary incontinence imposes an additional annual financial burden
of approximately $5000 to total health care costs. [1,33].
In women aged over 65 years who have incontinence the incidence of falls
and consequent fractures increases significantly. Approximately 20% to
40% of women who have UI will fall within 12 months and of these falls
about 10% will result in fractures, usually of the hip. Available data show
a strong association between UI, acute hospitalization, institutionalization,
and death [34,35]. Thirty percent of women who have UI over the age of
65 years are likely to be hospitalized within 12 months. Older men are twice
as likely to be hospitalized over a 12-month period. Of the myriad complica-
tions associated with UI, the most alarming is the independent association
between UI and increased mortality [35].

Clinical assessment of the older adult who has urinary incontinence

Health care providers should screen all older adults at risk for UI because
few patients volunteer this information as a presenting complaint. Delayed
presentation is not unusual and patients may not complain until symptoms
become severe [36,37]. Providers should ask about the volume of urine lost,
strength of urinary stream, body posture in which urine loss is most likely to
occur, number of pads used, and associated fecal incontinence. Quality of
life and caregiver burden should also be assessed. Additional information
should be sought regarding risk factors and predisposing factors. Patients
should be asked about a coexisting history of diabetes mellitus, hypercalce-
mia, impaired cognition, functional disability, or impaired sensory percep-
tion. Medication history is critical because diuretics or hyperosmolar
 URINARY INCONTINENCE 829

infusions may contribute to polyuria and precipitate UI. Additionally, anti-

cholinergic medications can cause obstruction and consequent overflow in-
continence. Narcotics, sedatives, and hypnotics may impair cognition or
cloud consciousness, thereby precipitating functional incontinence.
An accurate voiding diary facilitates quantification, classification, and
characterization of UI. Short voiding diaries (48 or 72 hours) have been
shown to be just as reliable and valid as traditional 7-day diaries and are
perceived as less burdensome by patients [38,39]. Physical examination
must include a complete neurologic, abdominal, urogenital, pelvic, and rec-
tal examination. Both the anal and bulbocavernosus reflexes should be as-
sessed. Urethral sphincteric response to the cough reflex should be
evaluated during pelvic examination to enable exclusion of stress inconti-
nence. People who have stress incontinence may lose urine during coughing,
whereas patients who have intact perineal reflexes exhibit tightening of the
anal sphincter during coughing.
Bedside measurement of postvoid residual volumes is helpful in the clin-
ical diagnosis of overflow incontinence attributable to bladder outlet ob-
struction. Postvoid bladder residual volumes greater than 150 mL in the
older adult suggest inadequate bladder emptying. Postvoid residual volumes
greater than 200 mL indicate urinary retention. Where available, noninva-
sive bladder ultrasound measurements of postvoid residual volumes are pre-
ferred over direct measurement using a urethral catheter to minimize the risk
for complicating urinary tract infection [40,41].

Practical management strategies

Comprehensive physical examination should yield preliminary informa-
tion relating to postvoid residual volumes and urethral sphincter compe-
tence. Providers should be aware of specific indications that prompt
referral for specialist urologic evaluation. These include urinary retention at-
tributable to obstructive uropathy, hematuria, prostate disease, recent pelvic
surgery, recurrent urinary tract infections, and stress incontinence. Most
older patients who have functional UI or urge incontinence associated
with overactive bladder can be managed effectively by geriatric or primary
care providers.
Although urodynamic studies are frequently requested, available data in-
dicate that results of these tests are unlikely to alter management in a signif-
icant proportion of older adults. Urodynamic studies are likely to be most
helpful in older patients being considered for surgical intervention or in
whom the diagnosis remains unclear after a thorough history and physical
examination [42,43]. Guidelines issued by the Agency for Health care Policy
and Research recommend limitation of initial diagnostic workup to urinal-
ysis and measurement of postvoid residual volumes. The American Medical
Director Association’s (AMDA) guidelines for the management of UI are
830 WILSON

even more conservative, recommending urinalysis only in patients who have

suspected urinary tract infection and new or worsening UI. AMDA guide-
lines recommend postvoid residual measurements only in men and in female
patients at risk for retention because of coexistent neurologic disorders or
diabetes mellitus [44,45]. Bedside cystometric studies are no longer recom-
mended for evaluation of UI because of poor correlation with results of ur-
odynamic studies. In addition, bedside cystometry results usually do not
alter management initiated based exclusively on clinical criteria [46,47].
The increased risk for urinary tract infection associated with urethral cath-
eterization is an additional disadvantage of bedside cystometry [48].
Nonpharmacologic management should be the first line of therapy in all
cases. In the subset of patients who fail to respond, the addition of pharma-
cologic agents is a viable option [49,50]. The increased risk for adverse drug
effects and interactions in older adults, however, mandates due caution with
drug selection and dosing. Invasive procedures or definitive surgical inter-
vention occasionally are warranted in older adults who can tolerate such
procedures.

Nonpharmacologic treatment
Nonpharmacologic intervention strategies vary with the type of UI. In
patients who have OAB the mainstay of nonpharmacologic management
is behavior modification tailored to suit the individual patient. Mentally
competent, functionally intact, and highly motivated people are good candi-
dates for patient-dependent intervention, such as biofeedback therapy.
Caregiver-dependent toileting protocols are more appropriate in dependent
or cognitively impaired patients. Prompted voiding is a caregiver-dependent
strategy that offers the patient a regular opportunity to toilet. The desig-
nated caregiver offers toileting assistance at scheduled intervals, usually
starting with a short period of about 2 hours. Prompted voiding has the
added advantage of providing the patient an opportunity for social interac-
tion and positive reinforcement. Habit training is a more complex variant of
this method in which people who have UI are encouraged to link voiding to
specific activities, such as meals, drinks, or just before outings. Eventually,
regular toileting becomes a habit and involuntary urine loss is preempted.
In older adults who have severe cognitive impairment and are unable to
respond to communication a simple timed toileting schedule may be more
helpful. In such cases the caregiver toilets the patient consistently at prede-
termined intervals. Prompted voiding and habit training also are helpful in
the management of older adults who have functional incontinence. Environ-
mental assessment, and modification if indicated, is critical to the effective
management of functional UI. Adaptive equipment and assistive appliances
may help facilitate efficient toileting and reduce incontinent episodes.
Rehabilitative exercises focusing on pelvic muscles and biofeedback ther-
apy can be helpful in patients who have stress incontinence or mixed
 URINARY INCONTINENCE 831

incontinence. In patients who have mixed incontinence a combination of

pelvic floor exercises and bladder sphincter biofeedback therapy has been
shown to result in a reduction in episodes of involuntary loss [51].

Pharmacologic therapy
Detrusor muscle contraction depends on the action of Ach on bladder
muscarinic receptors. Antimuscarinic drugs therefore are effective in the
treatment of overactive bladder. Side effects, such as delirium, cognitive im-
pairment, orthostatic hypotension, falls, and cardiac arrhythmias, mandate
caution in the use of these agents in older adults. Data suggest that the
newer, selective antimuscarinic agents may provide a safer alternative, al-
though in older patients the occurrence of delirium, dry mouth, urinary re-
tention, constipation, and blurring of vision are still troubling concerns.
Five muscarinic receptor subtypes have been cloned (Fig. 2). M1, M4,
and M5 receptor subtypes predominate in the nervous system, whereas
M2 and M3 receptors predominate in smooth muscle. M2 and M3 receptors
are the major cholinergic receptors in the bladder. M3 receptors mediate di-
rect detrusor muscle contraction, whereas M2 receptors seem to play a role
in inhibition of bladder relaxation and modulation of bladder contraction in
pathologic conditions, such as denervation injury or spinal cord disease.
Differences in receptor subtype distribution are particularly important
when considering adverse events associated with antimuscarinic agents in
older adults.
Oxybutynin and tolterodine are the two most commonly used antimus-
carinic agents in the treatment of OAB. Oxybutynin is a relatively nonselec-
tive antimuscarinic agent and acts primarily on M1, M2, and M3 receptor

M1: CNS, salivary glands, stomach

M4: CNS, basal ganglia, striatum
M5: CNS: substantia nigra, eye

M2: Bladder, heart, smooth muscle

M3: Bladder, salivary glands, brain,
bowel, smooth muscle

Fig. 2. Distribution of human muscarinic receptor subtypes.

832 WILSON

subtypes. Although oxybutynin has been shown to reduce episodes of UI by

almost 50% in 60% to 80% of patients, there is a relatively high incidence of
anticholinergic side effects, such as dry mouth, constipation, and blurred vi-
sion. Additionally, neurologic side effects, such as dizziness, cognitive dys-
function, and delirium, have been reported in several studies, rendering
oxybutynin a poor choice for the geriatric patient. Tolterodine is a more se-
lective antimuscarinic agent that affects predominantly M2 and M3 receptor
subtypes. Although the efficacy of tolterodine is comparable to oxybutynin,
the incidence of peripheral anticholinergic side effects, such as dry mouth, is
much lower. Additionally, cognitive dysfunction related to tolterodine use
occurs only rarely. Available data favor use of the extended-release formu-
lations of tolterodine over the immediate release because of greater efficacy,
higher tolerability, and higher adherence rates [52].
M3 selective inhibitors, darifenacin and solifenacin, are another effective
pharmacologic treatment option for OAB. Adverse effects, such as constipa-
tion and blurred vision, in conjunction with the notable paucity of safety
and tolerability data in older adults, preclude objective comment regarding
prescription of these agents in geriatric practice [53,54]. Trospium has been
in use in Europe over the past three decades but has only been approved re-
cently by the Federal Drug Administration for the treatment of OAB. Un-
like the M2 and M3 selective agents, which are lipophilic tertiary amines,
trospium is a hydrophilic quaternary amine rendering the blood–brain bar-
rier relatively impermeable to trospium, thereby reducing the risk for un-
wanted central nervous system side effects. Trospium is not metabolized
by the cytochrome p450 system and therefore may be less prone to drug in-
teractions. Limited data are available regarding the safety of these agents in
the frail elder. Further studies in this area are needed [55–57].

Invasive procedures and surgical management

Periurethral sphincter collagen injections and vaginal pessaries are rea-
sonably effective options for older adults unable to tolerate surgery. Sacral
neuromodulation involves surgical implantation of a ‘‘bladder pacemaker’’
in the patient’s hip attached to a lead wire that is threaded to a site within
the sacral canal at the base of the spine. External programming results in
delivery of a painless electrical stimulus to the sacral nerves, which regulate
bladder function. This process allows patients to control urine storage and
expulsion. For some patients who have stress or overflow incontinence, sur-
gery may be the only effective treatment. Older men who have overflow in-
continence because of obstructive uropathy from prostatic hypertrophy may
respond to prostatectomy. Several operations have been developed for the
treatment of stress incontinence. Prolene suburethral sling insertion is a rel-
atively new technique, with a documented cure rate of greater than 80%.
Surgical complications of this procedure include retropubic hematoma, uri-
nary tract infections and fibrosis, pubic osteomyelitis, urinary fistula, and
 URINARY INCONTINENCE 833

transient postoperative urinary retention. Late complications include dys-

uria, urinary retention, detrusor instability, genital prolapse, sexual disor-
ders, chronic pain, chronic urinary tract infections, and complications
related to the use of biomaterials, including screws, synthetic tape, and ar-
tificial urinary sphincter. Nevertheless, quality-of-life studies after surgery
for stress incontinence in younger patients show consistent improvement.
Data in older adults are lacking. Tension-free vaginal tape surgery is a highly
effective and minimally invasive alternative for treating patients who have
stress urinary incontinence. Surgical complications include bladder perfora-
tion, urinary retention, pelvic hematoma, suprapubic wound infection, per-
sistent suprapubic discomfort, and intravaginal tape erosion [58–60].

Summary
UI is highly prevalent in older adults and associated with excess comor-
bidity and increased mortality. Intensive screening and comprehensive clini-
cal examination of all elders enables prompt detection, accurate classification,
and appropriate treatment. OAB is the most common cause of persistent
incontinence in the older adult. As with other types of UI, behavior modifi-
cation is first-line treatment of OAB. Although antimuscarinic agents have
been shown to be highly effective in the treatment of OAB, limited data are
available regarding the safety and tolerability of these agents in older adults.
Patients who fail to respond to noninvasive treatment or those in whom sur-
gery may be appropriate should be referred to the urologist for evaluation
and further management.

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