Geriatric urinary incontinence

Abstract

Urinary incontinence (UI) is now recognized as a prevalent, physically and emotionally disruptive, and costly health problem in the geriatric population. Because incontinence may be a manifestation of a subacute or reversible process within or outside of the lower urinary tract, and because effective treatment is available, it is important for primary care physicians to identify and appropriately assess incontinence in their geriatric patients. The initial evaluation of an incontinent geriatric patient includes a targeted history and physical examination, urinalysis, and simple tests of lower urinary tract function. Potentially reversible conditions that may be causing or contributing to the incontinence, such as delirium and urinary tract infection (UTI), should be identified and managed. Patients who may benefit from further testing, including urologic or gynecologic examination and/or complex urodynamic tests, should be identified and referred. Several therapeutic modalities can be used to treat geriatric UI. Behavioral therapies are noninvasive and effective, both in functional community-dwelling geriatric patients and in functionally impaired nursing home residents. Behavioral therapies include bladder training, pelvic muscle exercises, biofeedback, scheduled toileting, habit training, and prompted voiding. Pharmacologic therapy is often used in conjunction with behavioral therapy. For stress incontinence, α-adrenergic drugs are used and can be combined with topical or oral estrogen therapy in women. For urge incontinence, pharmacologic treatment involves drugs with anticholinergic and direct bladder muscle relaxant properties. Pharmacologic therapy for overflow incontinence is generally not effective on a longterm basis. Surgical treatment is indicated when a pathologic lesion such as a tumor is diagnosed, or when anatomic obstruction is believed to be the cause of the patient's symptoms. Surgical treatment of stress incontinence can be highly effective in properly selected women. Nonspecific, supportive treatments are also important in managing geriatric UI. Education for patients and caregivers is critical for the success of most therapies. Environmental manipulations and the appropriate use of toilet substitutes are especially important in frail, functionally impaired patients. Highly absorbent adult undergarments are helpful for managing many patients, but should not be used as the initial response to incontinence, and are best used in conjunction with more specific treatment whenever possible. Chronic indwelling catheterization should only be used to manage incontinence when it is associated with clinically significant urinary retention, skin conditions that cannot heal because of incontinence, or severe illness that makes the catheter the most comfortable method of management. Research is ongoing to develop newer and more effective technologies and strategies to manage this prevalent and costly health problem.