This document provides guidance on the medical management of urinary incontinence in older adults. It discusses the different types of incontinence, including stress, urge, and mixed incontinence. It recommends assessing incontinence through patient history, examination, investigations like bladder diaries and scans, and potentially urodynamic testing. Treatment options discussed include lifestyle changes, pelvic floor exercises, medications like antimuscarinics and duloxetine, procedures like Botox injections, and catheters if needed. The guidance stresses treating the predominant symptom first through non-invasive means before more invasive options.

1. Medical Management of
urinary incontinence in old age
Anoja Rajapakse
Consultant Geriatrician
30th November 2019

2. Kings Mill Hospital
Sherwood Forest NHS Foundation Trust
United Kingdom

3. Urinary incontinence
 Continence is one of the Geriatric Giants
 A complaint of any involuntary leakage of urine
International Continence Society (ICS)
 Abnormality of function of the lower urinary tract or
systemic illness.
 Affect all ages, both genders, varying severity

4. Types of urinary incontinence
 Stress Incontinence
 Urge Incontinence or Over Active Bladder (OAB)
 Mixed Incontinence
 Other types – Bladder outlet obstruction, Functional

5. Prevalence by age groups

6. Assessment
 Always ask about urinary incontinence
 If yes, ask more details
◦ Frequency, urgency, hesitancy
◦ Precipitating factors
◦ Medication
◦ Comorbidity/previous surgery
◦ Details of childbirth
◦ Mobility
 What containment products?

7. Treatable causes -DIAPPERS
 Delirium/Depression
 Infection
 Atrophy of vulva
 Pharmacological - medication
 Pelvic pathology and Pregnancy
 Excess urine production
 Reduced mobility
 Stool impaction

8. Examination
 General, abdominal and neurological examination.
 Pelvic examination in women
- muscle strength
- uterine prolapse
- Bladder stress test
 Rectal examination
 prostate size

10. Investigations
 Basic blood investigations
 Prostate specific antigen
 Urine analysis
 Blood or protein look for renal tract pathology
 Glucose look for diabetes Mellitus
 Nitrates +/- leucocytes look for infection
 Bladder/Void diary
 Post-void bladder scan

11. Voiding diary for 3 days
Record to understand bladder function
 Day + night frequency
 Precipitating symptoms - coughing, laughing
 Was there leaking of urine?
 Urine volume lost involuntarily
 Warning of full bladder and for how long?
 How many pads were used during day and during
night?
 Were the pads damped or soaked in urine

12. 3-day Bladder Chart
Time Drink
type
Drink
volume
Volume
of urine
Leak
Y/N?

13. Bladder Chart
 What is taken by person
◦ Caffeine containing drinks
◦ Carbonated drinks
◦ Medication
 How much is taken by person
 Too little fluids and too much fluids both can
cause bladder problems

14. Assessment of residual urine
 Post-void bladder scan
 With ageing post-void residual urine volume
increases
 In-out Catheterization
 Higher incidence of urinary tract infection

15. Red flags
 Persisting bladder or urethral pain
 Pelvic masses
 Associated faecal incontinence
 Suspected neurological disease
 Symptoms of voiding difficulty
 Suspected urogenital fistulae
 Previous pelvic surgery
 Previous pelvic irradiation

16. Urodynamic testing
 After lifestyle changes
 Helps confirm detrusor instability
 Voiding dysfunction due to uterine prolapse or
benign prostatic enlargement
 Previous surgery – BPH, stress incontinence

17. Urodynamic testing

18. Stress incontinence
 Commoner in younger women, post-TURP
 Small volumes of urine leaked
 Precipitating factors – coughing, sneezing, bending
 Symptoms mainly during daytime

19. Lifestyle change
 Weight reduction
 Drink enough fluids
 Avoid bladder irritants
 Medication antipsychotics, alpha agonist
 Caffeine  decaffeinated
 Carbonated drinks
 Alcohol

20. Treatment for stress
incontinence
 Pelvic floor exercises at least for 3 months (level -1
evidence)
 Electrical stimulation and biofeedback for women
who cannot actively contract pelvic floor muscles
 Duloxetine has evidence to improve symptoms
 Transurethral bulking agents, Perineal sling,
artificial urinary sphincter

21. Urgency incontinence
 Symptoms of urgency, hesitancy, poor stream
 Daytime and night time frequency is similar
 Larger volumes of urine is leaked
 BPH, neurological conditions, medication

22. Urgency incontinence
 Bladder re-training for 6 months (level -1 evidence)
 Antimuscarinic drugs
 ß3 agonist - mirobegron
 Transdermal oxybutinine is available
 Need to take for about 4 weeks to see benefit
 Botox therapy to the bladder

23. Antimuscarinics
 Oxybutynin
 Solifenacin
 Tolterodine
 Side effects – confusion, dry mouth, urine retention

24. Neurostimulation
 Transcutaneous sacral nerve stimulation,
transcutaneous posterior tibial nerve stimulation in
OAB – no evidence
 Percutaneous sacral nerve stimulation and
percutaneous posterior tibial nerve stimulation -
some success

25. Percutaneous sacral nerve
stimulation

26.  Cause pain,
bleeding, infection
 Need repeated
therapy
Botox therapy

27. Urinary catheters
 Indications:
◦ Retention
◦ Skin wounds, pressure ulcers contaminated by urine
◦ Distress or disruption caused by bed and clothing changes
 Intermittent urinary catheter
 Indwelling urethral catheter
 Indwelling suprapubic catheter

28. Mixed incontinence
 Treat pelvic floor exercise when stress
incontinence symptoms are predominant problem
 Bladder re-training when OAB symptoms are
predominant
 Treat the predominant symptom with medication
when above has failed

29. Nocturnal enuresis
 More than 1/3 the total urine passed at night
 Look for fluid overload - congestive cardiac failure
 Limiting oral fluid intake after 1800 hours
 Medication
◦ Diuretics around midday
◦ Desmopressin - sodium monitoring

30. Oestrogen
 Transvaginal oestrogen is beneficial to control OAB
symptoms with vulvar atrophy.
 Reduce recurrent urinary tract infection
 Do not use systemic oestrogen

31.  NICE has guidelines for management of urinary
continence in women (CG 171) – November, 2015
 NICE Guideline (NG123) April 2019

32. Thank you
a.rajapakse@nhs.net