“I know where every bathroom is at the mall, and my wife rolls her eyes every time I have to visit one when we just arrived – even after I went before leaving the house! What can I expect? Most old guys are in the same boat!”
If you opened this article, you probably relate to the quote above, and you’re not unlike millions of other older adults.
Incontinence doesn’t always mean wetting yourself. It can involve urgent needs to use the toilet, frequent bathroom trips, or losing tiny amounts of urine with certain activities.
Incontinence is more than inconvenient, it can be life-altering, leading to early retirement or social withdrawal, depression, and loss of independent function. Important incontinence stats include:
- 1 in 3 older women and 1 in 12 older men have lower urinary tract symptoms that can include incontinence
- Urinary incontinence cost the US economy $66 billion in 2012
- 6-10% of nursing home admissions are due to urinary incontinence
- Only 22% of men with urinary incontinence seek help for the problem, as compared to 45% of women
For this reason, in geriatrics, we often ask our patients about incontinence.
I recently had the opportunity to talk to Dr. Adrian Wagg, a Geriatrician-Internist and international expert in urinary incontinence. You can listen to this interview, and find out how to download a transcript of it here. In this article, I’ll share some of his insights about the management of incontinence in older adults, and why it remains undertreated too often.
In particular, I’ll cover:
- How urinary function changes with age
- Types and causes of urinary incontinence in both men and women
- What to do if you’re experiencing urinary incontinence and want help
- How to help manage urinary incontinence in an older person you’re caring for
What happens to the Urinary System with Aging?
The urinary system includes:
- the kidneys
- the ureters (tubes connecting the kidneys to the bladder)
- the bladder
- the urethra (tube that connects the bladder with the outside world)
- the muscles of the pelvic floor.
There are sphincters that open or close the urethra, and nerves that run to the bladder muscles and sphincters which helps to control urinary release and flow. The brain and legs are also part of the urinary system: a person has to be able to decide when it’s time to go to the toilet, and have the ability to get to one when the time is right.
In this article, we’ll focus mainly on the bladder and urethra, and the bladder outlet.
With age, some of the muscle fibers in the bladder are replaced with stiffer, fibrotic tissue, and the neurological responses that we rely on to maintain normal urinary function decline slightly.
In practical terms, this means that:
- The sensation that the bladder needs to be emptied happens when the bladder is fuller than in a younger person
- The bladder muscle contracts less forcefully
- The urethral sphincter (valve at the bladder outlet) is looser in older women
- The larger prostate gland can obstruct the urethra in men
- There’s a more frequent need to pass urine
- 80% of those over 80 get up at least once in the night to pass urine
Nighttime urination or nocturia is a urinary symptom that’s hard to ignore, or cope with. As Dr. Wagg told me: “The magic number for nighttime frequency where it has an effect on your quality of life is two and more. And intriguingly, daytime frequency. If you look at people’s self reported quality of life and daytime frequency, the unlucky number is indeed 13.”
On top of the normal changes of aging, some age-associated conditions can also worsen incontinence, such as limitations in mobility, cognitive impairment, diabetes, obesity, congestive heart failure, medications that can affect urine output, and more.
Types and Causes of Incontinence in Aging Adults
Simply put, the bladder does two things: it stores urine (98% of the time) and empties of urine.
When storage goes wrong, this can result in symptoms of urgency, frequency, and stress incontinence. When these symptoms are severe, like having to void more than 13 times a day, or more than twice at night, quality of life can be significantly impaired.
There can also be problems with getting the bladder to empty at the right time and place. Two types of issues that often come up for older adults are:
- Blockage of the bladder outlet, which can happen with a large prostate gland, a constipated bowel, or some other cause, and leads to constant minor dribbling of urine all the time
- Functional incontinence (also known as disability-associated incontinence), where the incontinence is related to difficulty getting to the toilet in time and using it effectively.
Here’s a chart reviewing the different types of incontinence:
|Urgency||Sudden need to pass urine that is hard to ignore|
|Frequency||Needing to pass urine more than 8 times a day, or more than once at night|
|Stress||Leakage of urine with certain activities (coughing, laughing, jumping)|
|Overflow Incontinence||Usually due to bladder outlet obstruction or an underactive bladder muscle. The overly full bladder leaks small amounts of urine as a constant small dribble|
|Functional incontinence||Also called “Disability-associated” incontinence where getting to and using the toilet successfully is the main barrier. This is often a big part of incontinence in people living with dementia.|
|Mixed symptoms||A mixture of the above symptoms|
So far, I’ve talked mostly about chronic incontinence, but there can be a few reasons why an older person would suddenly start losing bladder control. As a geriatrician, I always want to rule out these potentially treatable issues before embarking on a long-term continence management plan.
Common Causes of Urinary Incontinence in Older Adults:
Here’s a list of issues that a Geriatrician would consider when sorting out incontinence in an older person. It makes a little mnemonic ”DIAPPERS”:
Delirium – a sudden change in thinking and alertness, caused by an underlying acute medical illness. When this condition is present, a person could be too drowsy or too confused to get to the toilet on time. For more on delirium, see here.
Infection – When there’s a urinary tract infection in an older adult, it can cause burning, pain, confusion, and also urinary frequency and urgency, and often incontinence.
Atrophic urethritis and vaginitis – in women, shrinkage of the urinary and genital tissues leads to urinary incontinence, and can get better with topical hormone therapy (creams or gels).
Pharmaceuticals – it’s not just diuretics, or “water pills” that can cause incontinence., but they do top the list (see more below).
Psychologic disorders – especially depression, and delirium as mentioned above. Dementia can worsen incontinence, especially in the later stages when overall function is more severely impaired.
Excessive urine output (eg, from heart failure or hyperglycemia) – this may be obvious if there are other symptoms like shortness of breath and swelling in the legs, but it may require lab tests or x-rays to diagnose these conditions.
Restricted mobility – not getting to the bathroom on time because of arthritis or Parkinson’s disease, for example, leads to more accidents
Stool impaction – also known as constipation, when the bowel is full of stool, it can restrict the release of urine from the bladder, which causes a dribbling overflow pattern of wetting.
Mediations that can worsen urinary incontinence include:
- Some antidepressants (Tricyclics, SNRI’s)
- Allergy medications (antihistamines and decongestants)
What to Do About Urinary Incontinence
In this section, I’ll review what you and your healthcare provider can do to prevent, diagnose, and treat incontinence.
Urinary incontinence, like most syndromes affecting older adults, is rarely simple. Dr. Wagg shared that “The maintenance of continence in later life isn’t just about staying dry. It’s about successful toileting, and that requires quite a lot of adequate functioning of many different systems.” Some of the management options depend on the type of incontinence, but there are some approaches that are likely to help in any case.
What You Can Do
Physical exercise, a Mediterranean diet, blood pressure management, and maintenance of a healthy weight are all strategies that can reduce the risk of incontinence. Those habits can reduce the risk of obesity, stroke, diabetes, and reduced mobility, all of which increase the risk for urinary incontinence.
Incontinence and physical activity seem to have a “two-way relationship” says Dr. Wagg, such that those who are incontinent are less physically active, and those who are less active are at higher risk for incontinence.
Keep asking for help
Many are simply resigned to incontinence being a normal part of aging. Dr. Wagg told me that in Canada for example “up to 2/3 of older women think that it’s normal to wet yourself, when clearly that isn’t the case”.
More concerning is that doctors often feel that there is little to offer those with urinary complaints or may prescribe a course of antibiotics that do little to alleviate symptoms. “The average delay to care-seeking is about three years. And clearly the more bothersome and the more interruption to normal daily activities the incontinence has, the more likely people are to seek care,” reports Dr. Wagg, underlining the importance of patients and sometimes family members being persistent in advocating for help.
Think before you drink
Most adults need about 2 liters of fluid per day to maintain health, and people with certain health conditions may need to restrict fluids. So, overdoing things with fluid intake can exacerbate an incontinence issue without any added health benefit. (For more how much older adults should drink, see How to Prevent, Detect, & Treat Dehydration in Aging Adults.)
Drinking alcohol at night can appear to help with sleep, but it’s almost certain to worsen nighttime urination patterns.
Caffeine restriction may also help, although it seems to be most problematic for those who drink in excess of six to eight cups per day.
How a Health Professional Can Help
The first health professional that you’re likely to talk to about incontinence is your primary care provider, but they may refer you to another physician or professional who can better help. Urologists and gynecologists are surgeons who see men and women for incontinence, and nurse continence advisors can run specialized interprofessional clinics.
Diagnosing the cause(s) of incontinence
What your doctor will ask about: The treatment of incontinence depends on the cause of the symptoms, which your doctor will evaluate by asking questions, doing a physical examination, and probably order a few preliminary investigations.
Your doctor will review your personal medical history, especially any history of prostate surgery for men, and for women, the history of any pregnancies and number and types of births. Lifestyle issues like smoking, alcohol intake, caffeine consumption, exercise (especially high-impact activities like running and jumping), and body weight are likely to come up.
A careful review of the patterns of incontinence will help to determine the cause of urine loss.
To review, three common patterns of urinary incontinence are:
- Stress: if you lose urine when doing certain activities,
- Overflow: you lose urine all the time in a dribble,
- Urge: feeling an urgent need to get to the toilet that you sometimes can’t meet,
In older adults, it’s common for there to be a mixture of more than one pattern (known as Mixed incontinence).
Your doctor will want to know:
- What activities cause urine to leak?
- Is the leaking constant or intermittent?
- How many times do you go to the toilet in a day?
- How many cups of coffee, cans of pop, or bottles of water do you drink in a day and at what times?
- What medications do you take?
To help your doctor pinpoint the cause(s) of incontinence, it’s a good idea to spend a few days completing a “bladder diary”. It’s a record of your fluid intake and number of trips to the toilet, as well as the volume of urine passed if possible. It can also be used later to monitor the effect of your treatment plan. You can find an example of a bladder diary here.
The physical examination
For women, this ideally will include a pelvic examination, to examine the pelvic floor muscles and to check for any kind of organ prolapse (a condition in which the bladder or uterus pokes out of the vagina).
For men, a rectal examination allows your doctor to check the size and texture of the prostate gland.
These exams might be done by your primary care provider, or after a referral to a specialist, like an OB/GYN or urologist, or a continence nurse. (Geriatricians often perform these examinations, too!)
The first test is usually a urinalysis. This can help detect signs of potential infection, as well as blood, glucose, and other abnormalities that can be related to incontinence.
Next, a post-void residual volume is determined. This is the volume of urine left behind in the bladder after a person urinates. It can be done using a portable bladder scanner (I have one of these in my clinic), an ultrasound test after voiding, or by inserting a catheter into the bladder after voiding and measuring the volume of urine left. A residual volume of more than about 200 ml (7 ounces or so) may indicate urinary retention (incomplete emptying of the bladder) and may be a cause for more investigation or specialist referral.
How to treat urinary incontinence depends on what type of incontinence it appears to be.
Here’s what a health professional may suggest:
Pelvic floor exercises
These exercises, also called “Kegels” are exercises that strengthen both the muscles of the pelvic floor, to better support the bladder, and the valve at the bladder opening. A therapist or nurse can guide you through the exercises, which can then be practiced, almost anywhere at any time. It may take weeks or even longer to see the results, but they do work. Women who do pelvic floor exercises are twice as likely to get improvement in their incontinence than women who do not.
If you have stress incontinence, pelvic floor exercises are the first line of treatment, but learning how to do them can come in handy for those with urge incontinence as well.
According to Dr. Wagg: “Two or three good strong pelvic floor contractions can also turn off a contracting bladder, and allow people with urgency incontinence to hold on for longer.” Frail older adults can also benefit from pelvic floor exercises, and men who are planning to undergo prostate surgery should practice pelvic floor exercises in order to regain continence as quickly as possible post-op.
This is a routine of trying to increase the interval between trips to the toilet and can be used to treat urge and stress incontinence. It’s most likely to work in individuals who keep a bladder diary and get encouragement from a health professional at regular intervals. It may be more effective when combined with meds and other strategies. Bladder training probably works best in younger individuals and in those with less cognitive impairment. Dr. Wagg shared that: “That’s largely because it seems to be that older people are unconsciously using more brain power to suppress urinary urge than younger people.”
Timed toileting – also known as prompted voiding — involves cueing or assisting someone to use the toilet at regular intervals. It’s a good strategy for disability-associated incontinence, and can be helpful for people with dementia (more on that below).
Simply put, timed toileting includes monitoring (asking if a toilet trip is needed), prompting (reminding the person to go to the toilet), and positively reinforcing the person when a trip is successful, or when they’re able to stay dry longer). It may be less successful in someone with more severe cognitive difficulties, and if the incontinence is of the stress or overflow types.
Medication doesn’t always eliminate incontinence, but for those with overactive bladder or urge incontinence, mediations can help defer a bathroom visit for longer or altogether. There are a few important things to note:
- About 50% of those with urge incontinence can achieve complete continence
- Medication works better when used along with other lifestyle changes
- It may take 3 months of use to see results
- Some bladder medications are not geriatric-friendly, and are even on the Beers list of drugs older adults should avoid.
There are two main types of medications for urge incontinence:
- Antimuscarinics – These include oxybutynin, solifenacin, trospium, fesoterodine, tolteradine and darifenacin. The main side effects are dry mouth, constipation, and drowsiness (especially in the case of oxybutynin which is also highly anticholinergic, and on the Beers list, although the patch form of this drug is usually much better tolerated). These medications should be used cautiously in older adults, especially when there’s cognitive impairment.
- Beta-adrenergic agonists – Mirabegron is a beta-receptor agonist that helps to relax the bladder muscle and reduce overactivity symptoms. There are fewer side effects like the ones described above with mirabegron, and it is about the same in terms of effectiveness as the antimuscarinics. In some cases, both mirabegron and an antimuscarinic medication can be taken at the same time.
For older men experiencing overflow incontinence or dribbling related to an enlarged prostate, two types of medications are sometimes used:
- Alpha-1 adrenergic antagonists (like tamsulosin or doxazosin). These medications relax the muscles in the bladder outlet, and can improve urination. However, they also often lower blood pressure when standing, which can contribute to dizziness and falls.
- 5-alpha-reductase inhibitors (like dutasteride or finasteride). These reduce the size of the prostate and can take 6-12 months to work. Side effects can include erectile dysfunction and lowered libido.
And as always, a thorough review of the other medications a person is taking, can often identify those that are worsening the incontinence problem and can be stopped or adjusted.
Dr. Wagg told me that as part of his research: ”We’ve actually asked people about their expectations of treatments and the things that they would put up with. And … surgery is one of the great fears of older people, but the majority of incontinence can be treated very successfully without recourse to surgery.” Nonetheless, for some older individuals, surgery is the way to go.
When thinking about bladder surgery, it’s worth considering:
- Is there a less invasive option? For example, could an injection of a “bulking agent” into the urethra (the tube from the bladder to the outside) be effective? This would avoid an overnight hospital stay, but you may need an additional procedure in 6 months or a year.
- Is the person fit for surgery? In an older adult, we look at overall health but also things like cognition, mobility, and overall frailty. Surgery is a higher risk venture for a frail older adult and non-surgical interventions are probably preferable.
The type of surgery depends on the pattern of incontinence:
- Stress incontinence: Up to 90% of women with stress incontinence can get considerable improvement or complete continence with a surgical procedure involving placing a mesh sling to support the urethra. Other surgical procedures involve lifting and suspending the bladder or can be as simple as getting injections in the bladder neck, which can be done as an outpatient.
Men with stress incontinence can benefit from a “sling” surgical procedure as well, usually after prostate surgery. Or a clamp can be used, usually for short periods of time, such as overnight, or for an occasion where going to the bathroom will be too inconvenient, to prevent leakage of urine.
- Urge incontinence: Botox injections to the bladder muscle can significantly reduce urgency and urge incontinence, but there is a risk of urinary retention of up to 6.5%, so patients need to learn how to self-catheterize.
Catheters can also be used, mostly in men if there is a bladder outlet obstruction. This is usually done under the guidance of a urologist. To reduce the risk of urinary tract infection, it’s generally safer to use “intermittent” catheterization (also known as “straight cathing”) rather than leave an indwelling catheter in place.
Caring for someone with incontinence
So far, we’ve covered managing your own incontinence, but what if you’re caring for an older adult? Incontinence is a common issue faced by dementia caregivers, and can be one of the most challenging parts of providing care. Research shows that:
- Those with dementia have a 2-3-fold increased chance of urinary incontinence
- The more severe the dementia, the more likely that there will be incontinence
- Urinary incontinence contributes to caregiver burden and increases the risk that someone will be admitted to a nursing home.
Steps to take
Dementia may not be the only cause of incontinence, so the first step is to look for other causes, like those reversible ones mentioned earlier (DIAPPERS).
If there doesn’t seem to be any of those issues going on, then “managed continence” is the approach that is most likely to help. Rather than using the bladder medications, which can worsen confusion and dampen alertness, managed continence includes the use of continence products (pads or diapers) and a schedule of timed toileting (reminders, cues, and hands-on help to use the toilet every few hours if needed).
In some cases, environmental adjustments and equipment, like bedside commodes, catheters, and urinals, can make frequent toileting easier and less disruptive, especially overnight.
The Bottom Line
- Urinary incontinence is not normal but is common in older adults and can severely impair quality of life and independence.
- A sudden change in continence should prompt a search or reversible issues like infection, constipation, or a medication side effect.
- There are 4 main types of urinary incontinence: stress, urge, overflow, and mixed, depending on the pattern of urinary symptoms. Disability-associated incontinence is more common in those with dementia and other medical issues.
- Lifestyle changes can reduce the risk of incontinence and help to manage symptoms.
- Pelvic floor exercises, medications, surgery, and incontinence products can be a part of incontinence treatment, depending on the type of incontinence, sex, and other health issues.
- For those with dementia, timed toileting and use of incontinence products might be most likely to be effective, and medications are often avoided.
If you want to learn more about urinary incontinence, here are some websites that might be helpful:
- Canadian Continence Foundation: https://www.canadiancontinence.ca/EN/about-us.php
- Continence Product advisor: https://www.continenceproductadvisor.org/
- International Urogynecological Association leaflets – available in multiple languages: https://www.yourpelvicfloor.org/leaflets/
- National Association for Continence: https://www.nafc.org/
- Bladder diaries:
- https://myhealth.alberta.ca/Alberta/AlbertaDocuments/bladder-bowel-diary-printable.pdf (asks patient to measure urine output)
As always, if you have any questions or comments about urinary incontinence, please post them below, and I will answer them personally!
(There’s nothing to be embarrassed about and…you can of course post as “Anonymous” if you prefer. Because there’s nothing wrong with wanting a little privacy too.)