Managing urinary incontinence in older people
Department of Care of the Elderly, Freeman Hospital, Newcastle upon Tyne NE7 7DN S Thirugnanasothy firstname.lastname@example.org
Cite this as: BMJ 2010;341:c3835 doi: 10.1136/bmj.c3835
Urinary incontinence is defined by the International ContinenceSociety as involuntary urinary leakage.1 The condition is common among older people. It affects more than a fifth of people aged over 85 years, according to a recent cohort study,2 although this is probably an underestimate. Urinary incontinence has both physical and psychological consequences, including damage to skin, urinary tract infections, an increased risk of falls, avoidance of going far fromhome, and a feeling of alienation.3 Urinary incontinence can also be difficult for carers to manage, and a cohort study of about 6000 patients found that urinary incontinence was second only to dementia as a reason for admission to long term care.4 In the United Kingdom, the 2001 report National Service Framework for Older People highlighted a need for continence services to be integrated acrossprimary, acute, and specialist care.5 A recent national audit of continence care for older people found that urinary incontinence is poorly managed both in the community and in secondary care. Fundamental assessments such as rectal examination and measurement of the post-void residual volume (the volume of urine remaining in the bladder after voiding) were rarely performed and management plans reliedon containment rather than treatment of the underlying cause.6 This review will examine evidence from systematic reviews, randomised controlled trials, cohort studies, and case series and discuss current guidelines for the management of stress and urge urinary incontinence in older people.
SOURCES AND SELECTION CRITERIA I searched Medline, PubMed, and the Cochrane database for evidence fromsystematic reviews and clinical trials. I also searched the websites of the National Institute for Health and Clinical Excellence, the Royal College of Physicians, and the British Geriatrics Society for published guidelines. My search terms included “stress urinary incontinence”, “urge urinary incontinence”, and “elderly”. Where appropriate, we conducted additional searches relating to themeshighlighted in the original searches
How common is it? Estimates of the prevalence of urinary incontinence vary widely owing to differing study populations, definitions of incontinence, and methods of study. A study of individuals living in community dwellings reported a prevalence of 21%, with higher prevalence in women and in individuals aged over 65 years.7 In a recent cohort study of individualsaged over 85 years, severe or profound urinary incontinence was reported by 21%.2 Urinary incontinence is probably under-reported, and older people are more likely to delay seeking help. Embarrassment, the erroneous belief that urinary incontinence is part of normal ageing, and a lack of awareness that treatment is available are reasons for under-reporting.8 How is urinary continence maintained?Continence is maintained by bladder wall stability and an intact pelvic floor and nerve supply to the bladder (figure). Continence also requires mobility, manual dexterity, and the cognitive ability to react to bladder filling. Often the cause of urinary incontinence is multifactorial, but loss of any one of these mechanisms can compromise continence. As people age, physiological changes in thelower urinary tract can predispose to urinary incontinence. Bladder capacity and urethral closure pressure decrease with age, while the post-void residual volume and overactivity of the detrusor muscle increase.9 How do patients present? Chronic urinary incontinence is classified according to how it presents and its cause (box 1). Stress incontinence is caused by weakness of the pelvic floor...