Managing urinary incontinence in men and women

Urinary incontinence (UI) is the involuntary leakage of urine from the bladder. It affects both men and women but is more common in women and older people.

The combined effects of multiple system impairments (such as lower urinary tract changes, brain changes, or comorbidities affecting urinary tract function) make older people vulnerable to incontinence.¹

It is highly prevalent and profoundly affects well-being and quality of life, while also being of immense economic importance for the health service. Men report greater impact than women, despite experiencing less severe incontinence. Men identify “being out of control” as UI’s most important effect, while most women say “feeling impelled to take precautions” is most important.²

Prevalence of urinary incontinence

Prevalence increases with age, and in women aged 70 years and above, more than 40% of the female population is affected. Prevalence rates are even higher in older people and amongst nursing home patients.³

In one study, researchers selected a random sample of 559 subjects aged 65 years and over living in the community and in institutions. The prevalence of UI was 11.6%. In those 80 years and over, the prevalence rose to 21.7%. Those with dementia were more likely to be incontinent than those with normal cognitive function. In the majority of those over 80 years who were incontinent, the incontinence was associated with either confusion or a combination of factors.⁴

Risk factors and causes of urinary incontinence

As with all the ‘geriatric giants’, UI is often multifactorial and can result from various risk factors and modifiers. Some changes are physiological whereas others are pathological. The following risk factors and causes are commonly identified in patients with UI.

• Diminished mobility
• Constipation
• Bladder irritation
  • UTI
  • Cystitis

• Neurological
  • Cerebrovascular accidents
  • Parkinson disease
  • Multiple sclerosis
  • Spinal cord injuries

• Cognitive impairment
  • Delirium
  • Dementia

• Metabolic causes
  • Poorly controlled diabetes
  • Hypercalcemia

• Urological
  • Prostatitis
  • BPH
  • Prostatic carcinoma
  • Bladder stones
  • Urethral irritability e.g. atrophic vaginitis, candidal infection

• Iatrogenic
  • Prostatectomy
  • Urological and gynaecological surgeries
  • Pelvic radiation

Classification of UI

Incontinence can be classified as transient or chronic.⁵ Transient incontinence is urinary leaking that spontaneously reverses after the underlying cause is resolved. Chronic urinary incontinence does not typically resolve spontaneously, and is classified into five types: stress, urge, mixed, overflow, or functional.⁶

Types of chronic urinary incontinence

Stress incontinence: Involuntary leakage during effort or exertion, e.g., sneezing or coughing. The urethral closure force is inadequate and cannot resist the transient increase in intra-abdominal pressure.

Urge incontinence: Involuntary urine leakage accompanied by or preceded by urgency. It is mainly related to detrusor (bladder) overactivity because of involuntary bladder contractions that occur inappropriately during urinary storage.

Mixed: Involuntary leakage associated with urgency and exertion.

Overflow incontinence: Urinary leakage resulting from an overfilled, distended bladder that cannot empty. Another term related to overflow incontinence is chronic urinary retention. Overflow incontinence develops most commonly due to bladder underactivity as a result of bladder muscle weakness.

Functional: “Functional incontinence” is not caused by extrinsic and intrinsic deficits of the urinary tract. It is not linked to bladder or urethra-specific factors. It is caused in patients with abnormal toileting habits, e.g.  patients with cognitive impairment, dementia, learning difficulties and impaired mobility, etc.⁷

Pathophysiology of urinary incontinence

The bladder undergoes age-related changes. As we grow older, bladder capacity diminishes and residual volume increases because ineffective bladder contractions fail to empty the bladder. Post-void residual volume (PVR) is the amount of urine retained in the bladder after a voluntary void. Residual urine can irritate the bladder lining, leading to symptoms of an overactive bladder, including frequent urination, urgency, and urinary incontinence.

There is increased frequency of uninhibited bladder contractions as well as an abnormal relaxation pattern of the detrusor that leads to symptoms of urge incontinence. This results from impaired corticoregulatory control of the bladder.⁸ Loss of pelvic floor and urethral sphincter musculature contributes to the onset of stress incontinence.

Sex specific changes are also seen, such as an increase in prostate size in males and urethral shortening, as well as sphincter weakness in females, which predispose to urinary incontinence.

Investigations

Routine blood tests: These include complete blood count, renal function tests, and C-reactive protein.

Bladder diary: An assessment tool that allows patients to record how much liquid they drink, how often they urinate and when they experience urinary leakage.

Urinalysis and midstream specimen of urine: Check the physical, chemical, and microscopic properties of urine

US-KUB and prostatic ultrasound: Used if obstructive uropathy is suspected.

Cytology and cystoscopy: Reserved for patients with a history of haematuria.

Residual volume: Normal residual volume ranges from 50 to 100 mL, and intervention is rarely required if it is under 200 mL. Causes of raised residual volume include benign prostatic hypertrophy, neurogenic bladder due to multiple sclerosis, Parkinson’s disease, spinal cord disease, disc herniation, bladder diverticulum, bladder carcinoma, urethral stricture and use of anticholinergic drugs.

Urodynamic studies: Urodynamics can help in difficult cases of urinary incontinence or in patients who do not respond to treatment.

Management of UI

The principal goals of management, whether non-pharmacological or pharmacological, are to lessen urgency and frequency, minimise complications (e.g. local skin breakdown and irritation, falls and fractures,⁹ social isolation or depression, sleep disruption,¹⁰ decrease adverse effects, and improve patients’ quality of life, whenever possible.

Non-pharmacological treatment

Lifestyle changes: These may include cutting down on caffeine and alcohol intake and losing weight.

Pelvic floor exercises: Pelvic floor muscle exercises improve control of bladder and bowel function. Weakened pelvic floor muscles can be caused by childbirth, hysterectomy, prostate surgery, obesity, and straining from chronic constipation. It leads to urinary incontinence.

Pelvic floor muscle (Kegel) exercises and bladder retraining have proven effective in managing urgency, stress, and mixed UI and should be considered for those with sufficient cognition, regardless of age and level of frailty.¹¹

Regular toileting: Encourage toileting every 2 to 4 hours for patients with dementia and overactive bladder syndrome (OAB).

Pharmacological management of urinary incontinence

Topical oestrogens

These are generally indicated for urgency and incontinence associated with atrophic vaginitis. They also reduce the incidence and recurrence of urinary tract infections in postmenopausal women.¹²

Anticholinergics

These include tolterodine, oxybutynin, solifenacin and darifenacin. The indication is OAB syndrome and bladder overactivity. A study in 2018 found that people diagnosed with dementia were up to 30% more likely to have been prescribed anticholinergic medications for Parkinson’s, bladder problems, or depression. The study also found that people who developed dementia took the anticholinergic medication for between four and 20 years before being diagnosed, and the longer they took the drugs, the greater their risk.¹³

Adverse effects: constipation, confusion, dry mouth, dizziness, dry eyes/skin, increased heart rate, memory impairment, pruritus, restlessness, urinary retention, urinary tract infection (UTI), vision disturbances. The likelihood and severity of AEs depend on anticholinergic potency and dose.

Contraindications: Antimuscarinic agents are contraindicated in myasthenia gravis, urinary or gastric retention and uncontrolled narrow-angle glaucoma.

Due to the antagonistic effect, antimuscarinic medications for UI should not be combined with anticholinesterase inhibitors (AChEIs) (e.g., rivastigmine, donepezil, galantamine).

Beta-3 agonists

Mirabegron is a beta-3 adrenergic receptor agonist that relaxes detrusor smooth muscle in the urinary bladder and increases bladder capacity. It is indicated for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency.

Adverse effects: It avoids anticholinergic side effects but may precipitate hypertensive crisis. Also use with caution in vasculopaths.⁸

Trospium chloride

Trospium chloride is a quaternary amine with anticholinergic properties. It is used to treat overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency.

The hydrophilicity and quaternary amine structure of trospium may limit its ability to cross the blood–brain barrier, minimising its impact on cognition in older patients.¹⁴

Adverse effects: constipation, blurred vision, dizziness and drowsiness, etc.

Botulinum toxin A (Botox)

In some patients with spinal cord injury, intravascular Botox is approved when there is refractory overactive bladder or neurogenic detrusor overactivity. Botox is administered via cystoscopy in specialised clinics or hospitals. Botox decreases urgency incontinence with consistent benefits over three years.^15,16,17

Adverse effects: dysuria, urinary retention, and UTI.

Desmopressin

This medication reduces urine production by mimicking antidiuretic hormone (ADH). It is commonly used for nocturia.

Adverse effects: Hyponatremia (low blood sodium), headache, nausea.

Alpha blockers

These medications help relax the muscle fibres in the prostate and bladder neck, making it easier to empty the bladder. Examples include Tamsulosin, Alfuzosin, Doxazosin, Terazosin.

Adverse effects: Dizziness, orthostatic hypotension, headache, fatigue.

5-alpha reductase inhibitors

These drugs reduce the size of the prostate in men, improving urinary flow and decreasing symptoms of overflow incontinence. Examples include Finasteride and Dutasteride.

Adverse effects: Decreased libido, erectile dysfunction, breast tenderness.

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Dr Irfan Muneeb, Consultant Geriatrician

Ms Mai Omer, Geriatric pharmacist

Rohan Qazi,  Medical student

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References

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14. Fröhlich G, Bulitta M, Strosser W. Trospium chloride in patients with detrusor overactivity: meta-analysis of placebo controlled, randomized, double-blind, multi-center clinical trials on the efficacy and safety of 20mg trospium chloride twice daily. Int J Clin Pharmacol Ther 2002 Jul; 40(7): 295–303
15. Duthie JB, Vincent M, Herbison GP, et al. Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database of Systematic Reviews. 2011(12).
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