Urinary Incontinence in Elderly: Definition

Urinary Incontinence In Elderly
Definition:
it’s the involuntary loss of urine.
 It’s a major problem of elderly population.

 Age represent a risk factor for UI however UI is not consider
abnormal consequence of aging.
 It is about 2-3 times more common in women until 80 year of age,
after which UI rates are similar.
 Up to half of cases may not be reported because:-

1) Embarrassment
2) Perception that UI is an expected consequence of aging.
Both common factor in lack of treatment.
2
TYPES OF UI:
UI is categorized according to pathophysiology & clinical

presentation into:-
 Mixed types of Incontinitance are common and may

complicate diagnosis & treatment.
Type Definition Causes
Stress Involuntary loss of urine (small 1. Weak pelvic floor

amounts) with increasing muscles.
intraabdominal pressure. 2. Bladder outlet or
urethral sphincter
weakness.
3. Post-urologic surgery
Urge Leakage of urine (large volumes) 1. Detrusor overactivity.
because of inability to delay voiding 2. CNS disorder (e.g.,
after sensation of bladder fullness is stroke,
perceived. Parkinsonism,
dementia).
Overflow Involuntary release of urine from an 1. Anatomic obstruction
overfull urinary bladder, often in the 2. Neurogenic
absence of any urge to urinate. associated with
multiple sclerosis or
other spinal cord
lesions
3. Medication effect
Functional Urinary accidents associated with the 1. Severe dementia or

inability to toilet because of other neurologic
impairment of cognitive and physical disorder
3
functioning, psychological 2. Psychological factors
unwillingness or environmental such as depression
barriers. and hostility
CLINICAL EVALUATION & DIAGNOSIS:

 Screening is necessary to identify patients because many patients
do not report symptoms.
 Screening questions such as:
“Do you ever leak urine when you do not want to?” and “Do you ever
leak urine when you cough, sneeze, or laugh?
 A bladder diary: liquid intake, number of trips to the bathroom,

activities during leakage, strength of urge to void, and accidental
leaks. And can measure treatment efficacy.
 An abdominal, rectal, and genital physical examination should be

performed.
 Urinalysis to rule out infection or glucosuria.
4
 PVR should be determined for patients with high risk of UI, as
diabetics, those are taking anticholinergic drugs, have a
neurologic disorder, or have symptoms of voiding difficulty or
retention.
 Urodynamic is not necessary during initial evaluation and treatment.
 Identification of reversible causes are very important; UTIS,

atrophic vaginitis, urinary tract surgeries (prostatectomy),
constipation, uncontrolled diabetes, chronic venous insufficiency,
delirium, and mobility restraint.
Drugs that cause urinary incontinence:
5
6
Treatment:
7
1) Non-Pharmacological Treatment :-
 Behavioral therapies require functional capacity, learning ability, and

patient motivation.
 Lifestyle and behavioral interventions are the first-line treatment of
choice in the elderly population.
 Lifestyle modifications include smoking cessation, caffeine and
alcohol reduction, weight loss, and modified fluid intake.
1. Bladder training: is an urge suppression technique. The patient

gradually increases toileting intervals by resisting or inhibiting the
sensation of urgency. Patients learn to urinate according to a
scheduled timetable. Distraction and relaxation techniques help
delay voiding and allow the development of increased bladder
capacity.
2. Pelvic muscle rehabilitation (Kegel exercises): Repetitive

contraction and relaxation of the pelvic floor muscles is used to
improve the reflex inhibition of involuntary detrusor contractions and
enhance the ability to voluntarily contract the external sphincter.
8
3. Sacral nerve stimulation (SNS): use in the treatment of patients
with severe refractory UI when behavioral management and
medications fail or are not tolerated. In SNS, a generator device is
inserted subcutaneously in the lower back or buttocks. A lead is
attached to the S3 sacral nerve, and electrical stimulation results in
decreased contraction of the detrusor muscle.
4. Urinary catheters: are reserved for patients with chronic bladder-

emptying difficulty and elevated PVR, Severely or terminally ill
patients with chronic UI who are bedridden.
 Women with good manual dexterity are candidates for

intravaginal support devices or urethral occlusion inserts.
 Pessaries are often employed in older women who have not
responded to behavioral therapies.
9
2) Invasive Treatment :
1. Surgery: it is the most effective treatment for UI.
2. Periurethral injection of bulking agents: (e.g., collagen)

improves urethral closure in SUI.
3. Artificial urinary sphincters: are the most effective treatment

for intractable post-prostatectomy UI in men. Although not a
first-line therapy
Complications: infections, tissue atrophy resulting in worsening
incontinence, urethral erosion, and device defects).
10
3) Pharmacology Therapy:
 Pharmacotherapy do not cure UI. It is often add to behavioral

therapy to help alleviate symptoms.
1. Antimuscarinics: The most commonly prescribed UI

Drug. Oxybutynin remains the gold standard and the
first approved Antimuscarinic agent for UI.
New Drugs:
1. Solifenacin 5 &10 mg
2. Daritenacin 7.5 &15 mg
2. Duloxetine: Recommendations Duloxetine to both men

and women with UI.
Duloxetine is not recommended when the crcl is Less
Than 30 ML / Minute.
3. α-agonist: not as common now, that duloxetine is

considered a first-line agent.
4. Estrogens: Oral and topical estrogen therapy was thought

to improve the symptoms of UI by increasing a-receptors
and local circulation.
5. Botulinum Toxin: Onabotulinum toxin A for use in

patients with detrusor overactivity associated with a
neurologic condition (e.g. Spinal cord injury, multiple
11
sclerosis) and inadequate response to anticholinergic
therapy.
6. Mirabegron: a new β3-adrenergic receptor agonist

approved for the treatment of OAB with urgency symptoms.
Stimulation of the β3-receptor causes bladder relaxation
during filling.
Q1.Involuntary loss of urine with increasing intraabdominal pressure

a) Overflow
b) Functional
c) Stress
d) Urge
Q2. What would be the best treatment option for a 48-year-old woman
with no relevant past medical history who presents with symptoms of
stress urinary incontinence?
a) Anticholinergics
b) Autologous fascial sling
c) Colposuspension
12
d) Pelvic floor muscle training
e) Tension-free vaginal tape (TVT)
Q3. Consider the most effective treatment of UI.

a) Oxybutynin
b) Periurethral injection of bulking agents
c) Bladder training
d) Surgery
Q4. What would be the best treatment option for a 63-year-old man
who developed severe stress urinary incontinence following a radical
prostatectomy for prostate cancer 3 years previously followed by
radiotherapy. He has been performing pelvic floor exercises since his
operation with no significant benefit and continues to wear seven
heavy pads a day.
A Duloxetine
B Artificial urinary sphincter
C Ileal conduit urinary diversion
D Male sling
E Sacral neuromodulation
Answers:
1. C
2. D
3. D
4. B
13

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Urinary Incontinence In Elderly

 It’s a major problem of elderly population.

 Up to half of cases may not be reported because:-

UI is categorized according to pathophysiology & clinical

 Mixed types of Incontinitance are common and may

Type Definition Causes

Stress Involuntary loss of urine (small 1. Weak pelvic floor

Functional Urinary accidents associated with the 1. Severe dementia or

CLINICAL EVALUATION & DIAGNOSIS:

 A bladder diary: liquid intake, number of trips to the bathroom,

 An abdominal, rectal, and genital physical examination should be

 Urinalysis to rule out infection or glucosuria.

 Urodynamic is not necessary during initial evaluation and treatment.

 Identification of reversible causes are very important; UTIS,

 Behavioral therapies require functional capacity, learning ability, and

1. Bladder training: is an urge suppression technique. The patient

2. Pelvic muscle rehabilitation (Kegel exercises): Repetitive

4. Urinary catheters: are reserved for patients with chronic bladder-

 Women with good manual dexterity are candidates for

1. Surgery: it is the most effective treatment for UI.

2. Periurethral injection of bulking agents: (e.g., collagen)

3. Artificial urinary sphincters: are the most effective treatment

 Pharmacotherapy do not cure UI. It is often add to behavioral

1. Antimuscarinics: The most commonly prescribed UI

2. Duloxetine: Recommendations Duloxetine to both men

3. α-agonist: not as common now, that duloxetine is

4. Estrogens: Oral and topical estrogen therapy was thought

5. Botulinum Toxin: Onabotulinum toxin A for use in

6. Mirabegron: a new β3-adrenergic receptor agonist

Q1.Involuntary loss of urine with increasing intraabdominal pressure

Q3. Consider the most effective treatment of UI.

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