This document discusses urinary incontinence, including its causes, types, evaluation, and management in older adults. It notes that storage and voiding involve complex interactions between the bladder, urethra, sphincter, and nervous system. Urinary incontinence is common in older adults due to age-related changes, pathology, comorbidities, medications, and environmental factors. The main types discussed are stress, urge, overflow, functional, and mixed incontinence. Evaluation involves history, exams, labs, voiding diaries, pad tests, and urodynamics. Management follows a stepped approach starting with conservative treatments like bladder training and pelvic floor exercises, followed by pharmacotherapy like antimuscarinics

1. URINARY INCONTINENCE
Dr. Doha Rasheedy
Associate professor of geriatric medicine
Geriatric medicine department
Ain Shams University

3. • Storage and voiding involves complex interactions between:
1. the bladder
2. urethra,
3. urethral sphincter,
4. and nervous system.
• The urinary bladder, with a typical adult capacity of 400 to
500 ml

4. • The urinary sphincter, composed of an internal
component, a continuation of detrusor smooth muscle that
converges to form a thickened bladder neck controlled by
the autonomic nervous system, and a somatically
controlled external component (striated muscle), must
relax to allow for the contracting bladder to expel its load.

5. URINARY INCONTINENCE
• Urinary incontinence (UI), defined as the involuntary
leakage of urine, is a common clinical condition that
occurs frequently in older adults
• Urinary incontinence is not a normal part of aging. It
is a loss of urine control due to a combination of:
-Age related changes.
-Genitourinary pathology.
-Comorbid conditions and medications.
-Environmental Obstacles.
•

6. Normal ageing
Bladder capacity and contractility decrease
Bladder residual volume increases
Involuntary detrusor contractions common (uninhibited
contraction)
Urine excretion at night increases, causing nocturia
Estrogen decreases
Urethral length decreases, maximal closure pressure of
urethra decreases (in women)
Laxity of pelvic floor ligaments

7. Epidemiology
• 25% to 30% of all adults will experience UI at some point
in their lives.
• In people older than 65 years, the estimated prevalence
of UI ranges from approximately 35% for those who
reside in the community to more than 60% for those who
live in long term care facilities

8. Adverse Effects of UI
• Depression
• Embarrassment
• Social isolation
• Falls, fractures
• Sexual dysfunction
• Disturbed sleep rhythm
• Practical inconvenience associated with the
leakage(bathing and changing frequently…,)
• Poor QOL
• Cellulitis, pressure ulcers, urinary tract
infections

9. Classification
Two broad categories of UI seen in older adults include:
• transient incontinence
• chronic incontinence.
Both can be subdivided into several additional categories.
• leakage of urine may be urethral or extra-urethral
(secondary to anatomical abnormalities such as fistulae
and ectopic ureters).

10. Transient Incontinence
• Potentially Reversible Causes of incontinence (
DIAPPERS Mnemonic):
1. Delirium
2. Infection (acute, symptomatic)
3. Atrophic vaginitis, urethritis
4. Pharmaceuticles for e.g: alpha-adrenergic agonists, alpha-
adrenergic blockers, anticholinergics, calcium channel
blockers, loop diuretics,NSAIDs, sedative hypnotics, narcotic
analgesics,antidepressants, antipsychotics
5. Excess urine (diabetes mellitus, caffeine intake, volume
overload, DI, Hypercalcuria).
6. Restricted mobility (illness, injury, gait disorder, restraint)
7. Stool Impaction

11. Chronic or established UI

12. Stress Incontinence
• Stress incontinence is characterized by loss of urine with
activities that increase intra abdominal pressure. Examples
include coughing, sneezing, lifting, or laughing. the pressure
inside the abdomen exceeds the closure pressure at the
urethral outlet leading to leakage of urine

13. URGE UI
• Urge incontinence is
typically associated
with sudden onset of a
sensation of needing
to void, with loss of
urine occurring before
the patient is able to
reach toilet facilities.

14. • Caused by uninhibited contractions of the bladder
detrusor muscle.
• The term „„overactive bladder,‟‟ this condition due to irritation of the
reflex arc. (causes include UTI, Stone)
• There are two forms, including OAB-dry, which is characterized by
urinary urgency and frequency but no leakage of urine, and OAB-
wet, which includes UI
• The term bladder hyperreflexia due to activation of neuronal
regulation above level of reflex arc : Common causes, multiple
sclerosis, Parkinson disease, stroke, spinal cord injuries, and
disorders such as spinal stenosis. Dementia may also be
associated with urge incontinence

15. Overflow Incontinence
• Overflow incontinence is typically associated with either outlet
obstruction or poor detrusor contractility and incomplete
bladder emptying.
• Causes:
1. Outlet obstruction: Urethral strictures, prior incontinence
surgery or large cystocele.
2. detrusor under activity: Idiopathic, Peripheral denervation or
neuropathy,
• Patients typically experience frequent loss of small volumes of
urine,

16. Functional Incontinence
• urinary leakage that occurs as a result of factors not
directly associated with the bladder, which may prevent
independent toilet use.
• The most common examples in older adults include
limitations in either mobility or cognition

17. Mixed UI
• more than one type of UI occurs at a time, the
combination of stress and urge UI is extremely
common.
• Another unique form of mixed incontinence that is
more common in older adults is termed „„detrusor
hyperactivity with impaired contractility (DHIC)‟‟. In
this condition, patients experience urinary urgency
and frequency caused by uninhibited contractions of
the detrusor. However, when they try to void
voluntarily, the bladder does not contract adequately,
and therefore does not empty completely. This may
lead to associated overflow incontinence

18. Total Incontinence
• A history of continuous, unaware loss of urine raises the
suspicion of a vesicovaginal, ureterovaginal, or
urethrovaginal fistula.
• Fistulas should be repaired surgically.
• An ectopic ureter also requires surgical management.
• Patients who have been managed with chronic indwelling
Foley catheters may develop urethral erosion and present
with total incontinence from a patulous and incompetent
urethra. Depending on the degree of erosion, these
patients may require a bladder neck closure and urinary
diversion.

19. Evaluation
• History:
• A full and detailed history is probably the most useful tool in
assessing patients with urinary incontinence. This can be
supplemented with the use of validated questionnaires, such as
ICIQ-SF (International Consultation on Incontinence Questionnaire
Short Form)
1. onset, frequency, volume, timing, precipitants ( eg, caffeine,
diuretics, alcohol, cough, medications).
2. Character:
• Sudden, compelling urgency suggests urge UI.
• Loss with cough, laugh, or bend suggests stress UI.
• Continuous leakage suggests intrinsic sphincter insufficiency or overflow.
• back problems/previous spinal surgery, neurological conditions,
chronic constipation, previous pelvic surgery and prior radiotherapy.
• details of current medications

20. • Medications
• (including alpha blockers, calcium channel blockers,
cholinergics, ACE inhibitors causing chronic cough,
benzodiazepines, systemic oestrogen, antidepressants,
diuretics, antihistamines, opiates)

21. Physical Examination
• Functinal status ( e.g, mobility)
• Mental status
• Findings as: bladder distension, cord compression, rectal
mass or impaction, anal sphincter tone, perineal sensation,
volume overload, edema.
• Female Genitourinary system: atrophic vaginitis, pelvic
support, cystocele, rectocele, prolapse.

22. Laboratory
• UA and urine C&S,
• glucose and calcium if polyuria
• renal function tests and B12 if urinary retention ;
• urine cytology if hematuria or pain.

23. Testing include:
• bladder diary which record time and volume of
incontinent and continent voids, activities and time of
sleep, knowing oral intake is sometimes helpuful
• standing full bladder stress Test ( for patients with
symptoms of stress UI ) relax perineum and cough once
immediate loss suggests stress, several seconds delay
suggests detrusor overactivity.

24. Voiding diary

26. Post- void residual
• bladder ultrasound after voiding is preferred to catheterization.
If > 100 ml repeat if still > 100 suggests detrusor weakness ,
neuropathy, medications, fecal impaction, outlet obstruction, or
DHIC.

27. Pad test:
• this involves the use of a continence pad to contain
urinary leakage over a period of time and therefore
quantify the volume of leakage. This can be conducted
over a variable length of time. Most commonly used are
the 1 or 24 h pad tests.
• Usual physical activities are done during the test :
standing up ,walking, coughing, rising stairs, etc.

28. Imaging:
• Can be used to investigate any anatomical or functional
abnormalities that may be contributing to urinary
incontinence. USS and MRI can both be used to provide
quantitative and qualitative date on the kidneys, bladder
neck and pelvic floor, but should generally be reserved for
cases of “complicated” urinary incontinence.

29. Urodynamics:
• from simple uroflowmetry to more complex ambulatory
urodynamic monitoring and videourodynamics
• not routinely indicated ; indicated before corrective
surgery, when diagnosis is unclear, when empric therapy
is ineffective or if postvoid residual volume > 200-300 ml

30. uroflowmetery

32. • the volume of urine evacuated from a patient‟s bladder per
time sequence during voiding
Allow Privacy
Factors affecting flow rate:
1. Detrusor contractility
2. Outlet obstruction
3. Urethral patency
4. Sphincter relaxation
5. Compensatory mechanism as abdominal straining
• female > 60 years max flow rate 25 ml/s and increased in
stress incontinence when outlet resistance is minimal.

33. Characteristic flow pattern
• Fast bladder= stress UI, DO
• Prolonged flow= BOO, DU
• Intermittent flow= BOO, DU compensated with abdominal
straining.
• Flat plateau= urethral stricture

34. Cystometry
• continuous measurement of the pressure/volume
relationship of the bladder to assess sensations, detrusor
activity, bladder capacity and bladder compliance.
• All three pressure,1)Bladder pressure, 2)Abdominal
pressure and 3) detrusor pressure is recorded
simultaneously during the test.
• Video Cystometry : the bladder can be filled with contrast
media, thus allowing the simultaneous screening of the ,
bladder and outflow tract during filling and voiding

35. filling cystometry
• Bladder sensation is assessed by recording the volume at
which the patient experiences: the first sensation of
bladder fullness the first desire to void, and a strong
desire to void and urgency.

36. Detrusor activity
• A normal detrusor allows bladder filling with little or no
change in pressure, with no involuntary phasic
contractions occurring during filling cystometry.
• The presence of involuntary phasic detrusor contractions,
occurring throughout filling, is diagnosed by detecting a
rise in the detrusor pressure line

38. Urethral function
• During the filling phase, in normal women, the urethral closure
pressure remains positive (i.e. it is greater than the intravesical
pressure), even at times of increased intra-abdominal pressure;
hence, continence is maintained.
• To allow voiding, closure pressure falls as the urethra relaxes.
• If involuntary loss of urine is observed without detrusor activity,
then the urethral closure mechanism is said to be incompetent.
• A diagnosis of urodynamic stress incontinence can be made if
leakage is associated with an increase in intraabdominal
pressure that causes the intravesical pressure to exceed the
intra-urethral pressure in the absence of a detrusor contraction

39. normal cystometry
• Residual urine of less than 50 ml;
• First desire to void between 150 and 200 ml;
• Capacity (taken as strong desire to void) between 300
and 600 ml;
• Little or no detrusor pressure rise on filling
• Absence of detrusor contractions during the filling phase;
• No leakage on coughing;
• No detrusor contraction provoked by coughing or running
water (precipitating factors);

40. MANAGEMENT

41. stepped approach
1- Conservative Treatments:
• Dietary Modification and Weight Loss:
• restriction or elimination of
dietary caffeine
acidic foods and beverages, including citrus fruits and juices
Alcohol
fluid intake
Smoking cessation
• Decreasing late-afternoon or evening fluid intake is often advocated for
elderly patients with nocturia.
• Weight loss may also be helpful for some patients, particularly women
with stress UI.

42. Nonpharmacologic Behavioral Therapy
• Bladder retraining:
• Timed voiding. When no incontinence for 2 d, increase voiding
interval by 30-60 min until voiding every 3-4 h.
• urgency control when urgency occurs, sit or stand quietly, focus on
letting urge pass, do muscle contraction when no longer urgent walk
slowly to the bathroom and void.
• prompted toileting for cognitively impaired individuals: ( ask if patient
needs to void, take them to toilet) starting at 2 to 3 hour intervals
during day; encourage patients to report continence status; praise
patients when continent and responds to toileting.
• Pelvic Floor Muscle Exercises (+ Biofeedback training)
(Kegel„s) exercises-isolate pelvic muscles (avoid thigh, rectal ,
buttocks contractions, 3-4 times/wk for at least 15-20 wk. vaginal
weights are an alternative for strengthening pelvic muscles

43. Pessaries
may benefit women with vaginal or uterine prolapse who
experience retention or stress UI.
DHIC:
Treat urge first with behavioral methods; may add detrusor
muscle relaxing medications but follow postvoid residual;
clean intermittent self-catheterization if needed

44. Nocturnal Frequency :
Two voidings per night is probably normal for older adults.
If between bedtime and awaking, the patient voids more than
one third of his or her total 24-hr output , this is excessive fluid
excretion.
All patients should restrict fluid intake 4 h before bedtime.
If stasis edema is present , patient should wear pressure graded
stockings.
a potent , short acting loop diuretic can be used in the afternoon
or early evening to induce a diuresis before bedtime, eg,
bumetanide 0.5-1.5 mg titrated to achieve a brisk diuresis.
Evaluate for other factors contributing to volume overload or
diuresis (eg, HF, poorly controlled diabetes).

45. Pharmacologic Therapy
• SNRI
• Benefit of topical postmenopausal estrogen therapy in urge
and possibly stress UI are limited.
• Medications
• Antimuscarinics: Oxybutynin, Tolterodine, Trospium can be
used but with common adverse effects as constipation, dry
mouth, delirium , dyspepsia and headache, also should be
used with caution in patients with liver dysfunction.
• Mirabegron, a beta-3-adrenoreceptor agonist, received FDA
approval for the treatment of OAB. Mirabegron relaxes the
smooth muscle of the bladder during the storage phase of the
micturition cycle. It improves OAB symptoms without causing
dry mouth and constipation. The most common side effects
for Mirabegron are hypertension, UTI, headache, and nasal
pharyngitis [

46. Surgical Therapy:
Sling Procedures.
Bulking Agent Injection Therapy.(silicone, microbeads,
hyaluronic, collagen)
Neuromodulation.

47. Neuromodulation
• When UI is inadequately managed by pharmacotherapy,
patients should be offered sacral neuromodulation (
Interstim), percutaneous tibial nerve stimulation (PTNS),
•

48. • Interstim‟s mechanism of action is through the
neuromodulation of somatosensory bladder
afferents projecting into the pontine micturition
center of the brainstem The process includes the
insertion of an electrode into the S3 transforaminal
space, followed by a trial phase to assess response,
and implantation of the neurostimulator if there is
signifi cant improvement of symptoms.
• Interstim is a durable treatment option for UI as the
failure rate at 2 years was only 2.9 %.
• The most common side effects are pain at the
stimulator or lead site, lead migration, and infection

49. • Another option for neuromodulation is via PTNS, whose
mechanism is retrograde neuromodulation through the
tibial nerve to the sacral nerve plexus. It requires 12 × 30
min weekly sessions.

50. or intradetrusor injection of Botulinumtoxin
A (Botox A).
• Intradetrusor injection of Botox A prevents acetylcholine
release at the neuromuscular junction and thereby
decreasing detrusor hyperreflexia and increasing
functional bladder capacity. A dose-range study performed
by Denys et al. found that the 100 unit dose has the best
safety-efficacy profile

51. Catheter
• Catheter should be used only for chronic urinary retention,
to protect pressure ulcers and when requested by patients
or families to promote comfort ( eg, at end of life).

52. Pads and Absorbent Products
• they do not cure incontinence and are generally not
regarded as an ideal form of therapy.

53. Thank you