Urinary incontinence
Incontinence is a problem that can affect individuals of all ages. However, it is more frequently seen in older adults. It is a common geriatric syndrome, and its investigation should form part of a comprehensive geriatric assessment.
Article by Krishma Kataria and Amy Ilsley
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Overview
Incontinence is a common problem that can affect individuals of all ages, but is more frequently seen in older adults (Milsom and Gyhagen, 2019). Problems with continence are often overlooked or not volunteered by patients. However, with simple assessment and interventions, a significant improvement can be made for those living with incontinence.
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Definition
Urinary incontinence is defined as involuntary urine loss and is characterised by lower urinary tract symptoms. It is estimated that between 3 and 6 million people in the UK suffer from a degree of urinary incontinence (DeMaagd and Davenport, 2012). The prevalence of urinary incontinence increases with age. It affects 7% of women 20–39 years old, increasing to around 23% of those aged 60–79 years. The prevalence of urinary incontinence in men is lower than in women. It is seen in around 11–34% of older men (Buckley and Lapitan, 2010).
There are four main categories of urinary incontinence:
- stress
- urge
- overflow
- functional
The latter usually combines features of both stress and urge incontinence and is most commonly experienced in women (Biswas et al, 2017). Prostate problems in men can lead to overflow incontinence and, in turn, the treatment for this can lead to stress incontinence. These are the two most
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Types
Urge incontinence
Urge incontinence is characterised by the sensation of urgency to pass urine, which can lead to involuntary urination. It is caused by involuntary contractions of the detrusor muscle leading to excess signals from muscarinic receptors, causing the urge to pass urine even when the bladder is not full. Urge incontinence is most commonly caused by infection; however, it can also present in neurological disorders such as Parkinson's disease and multiple sclerosis (Steers, 2002).
Stress incontinence
Stress incontinence is characterised by small volumes of urine loss with coughing and sneezing. An increase in intra-abdominal pressure acts directly on the bladder, causing the pelvic floor muscles and the urethral sphincter to weaken. Age plays a big factor in the prevalence of stress incontinence. As women get older, it takes less pressure for the urethra to open and the pelvic floor muscles gradually weaken. Stress incontinence is
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Diagnosis
Differential diagnosis
Causes of urinary incontinence can be separated into acute and chronic factors. A large majority of people affected by incontinence are older people, so one major acute cause of incontinence is delirium. Acute delirium needs to be ruled out in older adults and so it is important to look at a patient's current medication, any new medication and also rule out any acute infections when diagnosing incontinence. Urinary tract infections are the second most common infection in older adults and can present as incontinence (Melo et al, 2017). Other symptoms of these infections include burning or stinging when urinating, frequent urination, having a fever or general acute confusion. Urinalysis in older adults can be misleading as bacteriuria is common in older adults and the presence of bacteria in a urine sample does not always mean true infection, but can indicate contamination or colonisation (Cortes-Penfield et al, 2017). A
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Treatment
The treatment for incontinence can be split into non-surgical and surgical management.
Non-surgical management
Lifestyle interventions such as weight loss, altering fluid intake and reducing caffeine should be encouraged for those diagnosed with an overactive bladder. The use of laxatives for constipation, or vaginal oestrogen cream in atrophy are simple yet effective conservative measures. Pelvic floor muscle training should be trialled for at least 3 months in women with stress incontinence. The National Institute for Health and Care Excellence (2019) guidelines suggest exercises should be done at least three times a day, with around 8–10 contractions each time. For patients suffering with urgency or mixed incontinence, bladder training lasting for around 6 weeks is usually the first approach as a management option. In older adults who cannot engage with pelvic floor muscle training because of severe dementia or functional impairment, it is important to ensure care is provided
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Resources
References
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. In: Volume 1. Basics and evaluation. Monaco: International Continence Society; 2005
Bang S, Belal M. Autologous pubovaginal slings: back to the future or a lost art? Res Rep Urol. 2016;8:11-20. https://doi.org/10.2147/RRU.S96957
Biswas B, Bhattacharyya A, Dasgupta A et al. Urinary incontinence, its risk factors, and quality of life: a study among women aged 50 years and above in a rural health facility of West Bengal. J Midlife Health. 2017;8(3):130-136. https://doi.org/10.4103/jmh.JMH_62_17
Buckley BS, Lapitan MCM. Prevalence of urinary incontinence in men, women, and children – current evidence: findings of the fourth international consultation on incontinence. Urology. 2010;76(2):265–270. https://doi.org/10.1016/j.urology.2009.11.078
Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary tract infection and asymptomatic bacteriuria in older adults. Infect Dis Clin North Am. 2017;31(4):673-688. https://doi.org/10.1016/j.idc.2017.07.002
Davila GW, Martin LM. Urinary incontinence in women. 2020. https://bestpractice.bmj.com/topics/en-us/169 (accessed 17 January 2022)
Dean N, Ellis G, Herbison GP, Wilson D, Mashayekhi A. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2017;7(7):CD002239.
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