Key Facts

Urinary incontinence is common but not inevitable in ageing. It is often under-reported and under-treated. Many cases are modifiable with appropriate assessment and intervention.

Epidemiology

• Prevalence: 30-50% community-dwelling >65; >50% in care homes
• More common in women (stress incontinence) but urge incontinence is equally common in both sexes in old age
• Only 25-50% of affected individuals seek help

Aetiology

• Stress incontinence: pelvic floor weakness (multiparity, menopause, obesity, pelvic surgery)
• Urge incontinence (OAB): detrusor overactivity (idiopathic, neurological: stroke, Parkinson's, MS)
• Overflow: urinary retention (BPH, anticholinergics, faecal impaction, diabetic neuropathy, spinal cord disease)
• Functional: mobility impairment, cognitive impairment, environmental barriers
• Transient causes (mnemonic DIAPERS): Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Excess fluid, Restricted mobility, Stool impaction

Pathophysiology

• Stress: intrinsic sphincter deficiency and/or urethral hypermobility
• Urge: uninhibited detrusor contractions; age-related reduction in bladder capacity and detrusor compliance
• Overflow: detrusor underactivity or bladder outlet obstruction → chronic retention → overflow
• Functional: unable to reach toilet in time due to physical or cognitive barriers

Stress Incontinence

• Leakage with coughing, sneezing, laughing, lifting
• Small volumes
• No urgency

Urge Incontinence (OAB)

• Sudden compelling desire to void that is difficult to defer
• Leakage with urgency (before reaching toilet)
• Frequency (>8 voids/day), nocturia

Overflow Incontinence

• Constant dribbling
• Sensation of incomplete emptying
• Weak stream, straining
• Palpable bladder

Functional Incontinence

• Normal urinary system but unable to reach toilet
• Associated with immobility, dementia, environmental barriers

Red Flags

• Haematuria (malignancy, stones)
• Pelvic mass on examination
• Acute urinary retention
• New neurological symptoms (cauda equina)
• Recurrent UTIs
• Significant post-void residual

Bedside

• Bladder diary (3 days minimum): frequency, volumes, leakage episodes
• Urinalysis (UTI, haematuria, glycosuria)
• Post-void residual volume (bladder scanner; >100ml abnormal)
• Abdominal examination (palpable bladder, faecal loading)
• DRE (men: prostate; both: faecal impaction)
• Pelvic examination (women: prolapse, atrophic vaginitis)
• Cough stress test (observed leakage on coughing)

Bloods

• U&Es (renal function, especially if retention)
• Blood glucose/HbA1c (diabetes)
• Calcium (hypercalcaemia → polyuria)
• PSA (if prostate pathology suspected)

Imaging

• Renal USS: if retention, raised creatinine, or recurrent UTIs
• Abdominal X-ray: faecal loading

Special Tests

• Urodynamics: if diagnosis unclear, before surgery, or mixed incontinence
• Cystoscopy: if haematuria, recurrent UTIs, suspected bladder pathology
• Uroflowmetry (men: voiding assessment)

Non-pharmacological

• Bladder training (urge incontinence): scheduled voiding with gradual increase in intervals; aim for 3-4 hourly (minimum 6 weeks — NICE first-line)
• Pelvic floor muscle training (stress incontinence): 8 contractions × 3/day for ≥3 months (supervised by physiotherapist)
• Prompted voiding/timed toileting: for cognitively impaired patients
• Lifestyle modifications: reduce caffeine, manage fluid intake (1.5-2L/day), weight loss if obese
• Containment products: pads, sheaths (not a substitute for assessment)

Pharmacological

• Urge incontinence/OAB:
  • First-line: bladder training + antimuscarinic or mirabegron
  • Solifenacin 5-10mg OD or tolterodine 2-4mg MR OD (preferred over oxybutynin in elderly)
  • Mirabegron 50mg OD (β3 agonist): preferred in elderly (no anticholinergic cognitive effects)
  • Avoid oxybutynin in frail elderly/dementia (crosses BBB → cognitive impairment)
• Stress incontinence: duloxetine 40-80mg BD (limited evidence; SNRI; not first-line)
• Overflow (retention in men): tamsulosin 400mcg OD (alpha-blocker); finasteride 5mg OD (if prostate >30g)
• Atrophic vaginitis: topical vaginal oestrogen (estriol 0.01% cream)
• Nocturia: desmopressin 50-100mcg sublingual ON (caution: hyponatraemia; monitor Na+ at 3 days and 1 week)

Surgical/Interventional

• Stress incontinence: colposuspension, autologous fascial sling (mesh procedures under moratorium in UK)
• Urge incontinence (refractory): intravesical botulinum toxin A (100 units); sacral nerve stimulation; posterior tibial nerve stimulation
• Overflow (retention): intermittent self-catheterisation (preferred) or long-term catheter if not possible; TURP for BPH

Referral Criteria

• Haematuria: 2-week wait urology
• Recurrent UTIs or significant residual: urology
• Failed conservative/pharmacological treatment: continence service/urology
• Neurological symptoms: neurology/urology
• Prolapse: urogynaecology

• Bladder training: effective in 50-70% of women with urge incontinence
• Pelvic floor exercises: cure/improvement in 50-70% with stress incontinence (adherence is key)
• Antimuscarinics: reduce urgency episodes by 1-2/day
• Mirabegron: similar efficacy to antimuscarinics with better tolerability
• Botulinum toxin: 70% improvement; lasts 6-9 months; repeat injections needed
• Incontinence significantly impacts quality of life but is treatable in most cases
• Many older adults do not seek help; proactive assessment is important

Types of Urinary Incontinence Summary

DIAPERS — Transient Causes of Incontinence