Elderly Urinary Incontinence

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Last Updated: April 4, 2013

For many people, a trip to the bathroom is something they can easily delay. But for roughly 13 million Americans who suffer from urinary incontinence-the involuntary leaking of urine-holding it in isn't an option.

Although incontinence can happen at any age, it is more common in older adults. According to the National Association for Continence, one in five individuals over the age of 40 suffer from overactive bladder or urgency or frequency symptoms, some of whom leak urine before reaching a restroom. In the nursing home population, at least 50 percent of residents have elderly urinary incontinence.

"Incontinence is a common part of aging but it is never normal," says Dr. Lisa Rosenberg, M.D., of the University of Pittsburgh's geriatric department. "Because it is so common, people think that they should accept it. In almost all cases, it is something a well-trained physician or nurse practitioner can help with. We can actually cure most of those people."

Causes and Symptoms

The diversity of causes behind incontinence are vast and varied, from something as simple (and counterintuitive) as not drinking enough water to more serious conditions like an inflamed bladder wall. Several diseases can bring about incontinence, such as multiple sclerosis and Alzheimer's disease. In women, prior pregnancies, childbirth, and the onset of menopause can lead to incontinence. In men, prostate problems can hamper urination. Even drinking coffee or tea or taking prescribed medications can aggravate your bladder. As one ages, changes in the body can make elderly urinary incontinence a more likely occurrence.

Elderly urinary incontinence can take several forms. Some people may only leak urine occasionally, others may constantly dribble urine, while still others experience a complete lack of both bladder and bowel control. The five main types of incontinence help explain these various experiences.

Among older adults, the most common diagnosis isurge incontinence, an urgent need to urinate resulting in the loss of urine before one arrives at the toilet. "We believe urge incontinence is caused by involuntary contractions of the bladder that the patient can simply not stop," says Rosenberg. Urge incontinence, also called overactive bladder, can be caused by strokes, dementia, Alzheimer's disease, multiple sclerosis, Parkinson's, or injuries. Conditions such as pelvic floor atrophy in women, prostate enlargement in men, or constipation in either sex can also lead to urge incontinence.

Stress incontinenceoccurs when an increase in abdominal pressure overcomes the closing pressure of the bladder. Abdominal pressure rises when you cough, sneeze, laugh, climb stairs, or lift objects. According to Judith Veit, R.N., a nurse in the outpatient urology department at Virginia Mason Medical Center in Seattle, the bladder muscles of older people may be so weak that leaking can occur even when they get up out of a chair. Stress incontinence is more common in women due to pregnancy and childbirth, and a lack of estrogen in postmenopausal women can also cause muscular atrophy that may lead to the condition. Men who have enlarged prostates or who have had prostate cancer treatments or prostate surgery can also develop stress incontinence.

Overflow incontinenceis rarely diagnosed. Out of a random sampling of a hundred patients with incontinence, about 2 of them would suffer from this, according to Diane Smith, M.S.N., C.R.N.P., a geriatric nurse practitioner in the Philadelphia area. In this scenario, one's bladder never completely empties, so one frequently feels the need to go and often leak small amounts of urine. This is often caused by an obstruction in the urinary tract system or by a bladder that either has very weak contractions or is unable to contract at all. Causes include an enlarged prostate or damage from prostate surgery, constipation, fecal impaction, and nerve damage from stokes or diabetes.

An inability to reach the bathroom in time leads to the diagnosis offunctional incontinence. If arthritis makes unzipping one's pants difficult or a bad hip means a trip to the facilities takes longer than expected, accidents can ensue. Neurological disorders, stroke complications, Alzheimer's disease, or multiple sclerosis can also cause functional incontinence. Often the patient still feels the urge to void, but his mind cannot plan or carry out a trip to the bathroom.

If one experiences more than one type of incontinence, the diagnosis ismixed incontinence. Usually patients have a combination of stress and urge incontinence, especially women. But people who have severe dementia, Parkinson's disease, neurological disorders, or have had strokes can suffer from urge and functional incontinence.

Diagnoses

Your loved one may feel embarrassed by his or her accidents and avoid scheduling a doctor's appointment. Or perhaps one is unsure of whom to see: a primary care physician, a nurse practitioner, or a urology specialist. Maybe your loved one is using absorbent pads or protective underwear. But the best reason to see a doctor is this: elderly urinary incontinence is a very treatable condition.

If your loved one feels comfortable with his or her primary care doctor, start there. Women can also find a urogynecologist while men could visit a urologist; either can see a geriatrician. Often, you can locate nurse practitioners who specialize in incontinence issues.

Whomever one sees, Rosenberg says, you should expect the following from a visit:

a urinalysis to rule out infection or blood in the urine;
blood tests to check on kidney function, calcium and glucose levels;
a thorough discussion of one's medical history; and
a thorough physical exam, including a rectal exam and a pelvic exam for women and a urological exam for men.

Often, a patient will be asked to bring a bladder diary to the first visit, or create this before her second appointment. In this journal, she records what she drinks, when she urinates, how much she urinates (placing a special "measuring cup" over the toilet bowl to record volume), and describe her accidents. If the medical provider skips any of these important steps, you may want to consider finding someone whoiswilling to evaluate your loved one's situation properly and completely.

If the previous tests and exam don't point to a diagnosis, the patient could undergo one or more of the following procedures:

Postvoid residual: After urination, an ultrasound wand is placed on the abdomen, creating a bladder scan to show if any urine remains. Or a catheter is placed into the bladder to drain and measure any urine left.
Urodynamic testing: A catheter fills the bladder with water. This test measures the pressure in the bladder when it is at rest, when it's filling, and when it empties. This test looks at the anatomy of the urinary tract, the functioning ability and capacity of the bladder, and what sensations the patient feels.
Cystogram: A catheter is inserted through which dye is injected into the bladder. An x-ray is then taken while the patient urinates, highlighting the urinary tract system.
Cystoscopy: The doctor views the patient's bladder through a small telescope, checking for capacity, tumors, stones, or cancer.

Treatments and Practical Management

After a diagnosis is made, a treatment for elderly urinary incontinence can include behavioral therapy, medications, medical devices, and surgery. "For the majority of the people in the community, it is 100 percent treatable. Most of the time, it's a non-surgical treatment," Smith says.

Usually the first line of treatment is behavioral therapy, which will often cure the incontinence. Treatments can include bladder training, scheduled bathroom trips, pelvic floor muscles exercises, and fluid and diet management. "The nice thing about behavioral therapies is that there are no side effects and the response is proportional to the work of the patient," Rosenberg says.

Bladder training can involve learning to delay urination by gradually lengthening the time between bathroom trips. Or one can practice double voiding: after urinating, the patient waits a few minutes, and then urinates again. This teaches the patient to drain the bladder more thoroughly.

Scheduled bathroom trips are effective for people with mobility issues or neurological disorders, even if this means someone else is in charge of taking you to the restroom.

Pelvic floor muscle exercises, called Kegels, strengthen the muscles that help regulate urination. Usually one needs to practice these a few times a day, every day, for the rest of one's life-stopping can mean the return of incontinence. Learning how to contract the right muscles can be confusing, so a provider must check to see if the Kegels are performed correctly by inserting a finger in the anus or vagina to check pressure. Or one can work out with the aid of biofeedback. Transducers, connected to a computer, are placed on the body, and lines on a video monitor show when one is doing the exercises correctly.

Medications are frequently used in combination with behavioral therapies:

Anticholinergic or antispasmodic drugs: These are usually prescribed for urge incontinence, and examples include Vesicare^®, Detrol LA^®, Ditropan XL^®, Oxytrol^® skin patch, and Sanctura^®. The most common side effect is dry mouth. Less common side effects include blurred vision, constipation, and mental confusion.
Hormone replacement: Estrogen therapy-with a vaginal cream, ring, or patch-is used to counteract the atrophy of the skin lining of the urethra and vagina in post-menopausal women.
Antibiotics: These are prescribed when incontinence is caused by a urinary tract infection or an inflamed prostate gland.
Others: For men with enlarged prostates, medications either relax the muscles used in urination or shrink the prostate. Flomax^®, which relaxes the muscles, is commonly prescribed for this condition. If one's bladder doesn't contract enough, a provider can prescribe a medication to help it contract more often.

Medical devices can be prescribed for women:

Urethral inserts: This is a tampon-like insert that a woman places in her urethra, usually during activities related to her incontinence episodes, such as tennis. The woman removes it when she needs to urinate. These are not as commonly prescribed, says nurse practitioner Smith, as they can be uncomfortable and can cause urinary tract infections.
Pessary: This is an intra-vaginal device similar to a diaphragm that supports the bladder. A medical provider places the pessary, which needs to be taken out, inspected, and cleaned by the provider every three months.

If your loved one suffers from elderly urinary incontinence, self care helps avoid complications such as skin rashes and urine odors. For cleaning, use a mild soap such as Dove. Petroleum jelly or cocoa butter can protect skin. Make sure to pat the skin dry after urinating. If he or she rushes to the restroom, slip-and-fall accidents can ensue, so try to set up the home to make bathroom trips easier. Use pads and protective garments such as plastic or washable underwear until you find a successful cure, or if his or her treatment isn't 100 percent effective.

Surgery

Surgery is an option that is usually only discussed after all other treatment options have been tried. Although more than 150 surgical procedures exist, the following are the most common types:

For women, sling procedures support the urethra by placing abdominal tissue or synthetic materials under the urethra. Complications include the inability to void temporarily after surgery.
Women can also have a doctor inject collagen around the urethra, which is a two to three minute procedure. This fix typically lasts 3 months, so it must be repeated.
For men (and infrequently for women) with stress incontinence, an artificial urinary sphincter can be implanted around the neck of the bladder. This fluid-filled, doughnut-shaped device holds the sphincter closed and is attached to a valve implanted in the testicles or labia. To urinate, one presses the valve twice and the bladder empties.
A sacral nerve stimulator, which is a device implanted in the abdomen with a wire connecting to a nerve related to bladder function, is a fairly rare procedure, used in roughly .5 percent of the population, according to Smith. Electrical impulses transmitted from the device prompt the nerve, helping the bladder function.

Of course, the most important step is to seek professional medical help. If elderly urinary incontinence is keeping your loved one at home and away from his or her favorite pastimes, please realize that this is a highly treatable condition. With the proper and appropriate treatment, your loved one will soon be enjoying that stroll in the park or a night out at the movies again.

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