Breaking the taboos and myths surrounding urinary incontinence

Urinary incontinence – the unintentional passing of urine “may be a common problem in older people. But its impact on physical and mental health can be substantial: it can cause skin infections, increase the risk of falls, and lead to depression and anxiety. Urinary incontinence can even be a sign of an underlying serious condition such as bladder cancer.

“Urinary incontinence is not a normal part of aging, contrary to many people’s beliefs,” stresses Aine McGovern, a member of the British Geriatrics Society’s Bladder and Bowel Health Special Interest Group. However, she says “older people have the highest known prevalence of urinary incontinence of any group, apart from those with specialist neurological disorders”.

It’s estimated that 3.4 million people over 65 in the UK experience urinary incontinence at some time in their life.¹ And the condition may be even more widespread than reported. Older people are often reluctant to seek professional help and advice, says Lesley Carter, clinical lead and senior health influencing manager at Age UK.

“Reasons for this include embarrassment, as well as not understanding that treatment is available, and some are not confident that anything can be done,” she says.

Ms Carter says there is “a need to raise awareness of problems with continence, break the taboo and invest in dedicated services and training to support people to manage continence effectively and remain independent.”

Further reading:

• Urinary incontinence still a taboo subject
• Urinary incontinence: management in general practice
• Management of post-stroke urinary incontinence

Practitioners caring for older people can help to break the taboos and myths surrounding urinary incontinence “such as it being an inevitable part of ageing –  offering advice and reassurance, and “having the knowledge and confidence to signpost people to further support,” says Karen Powell, clinical nurse manager with Clinisupplies, and a trustee of the charity Bladder Health UK.

Symptoms of urinary incontinence

There are four main types of urinary incontinence (UI): Urgency UI, Stress UI, Overflow UI and mixed UI, Ms McGovern explains.

In urgency UI, the predominant symptom is the overwhelming desire to void that is difficult to defer, resulting in involuntary leakage of urine, says Ms McGovern. Patients often have nocturia, and also need to urinate more frequently.

She says with stress incontinence, “involuntary leakage of urine occurs on any physical exertion which raises intra-abdominal pressure, such as during coughing, laughing, lifting or jumping.”

Overflow UI occurs when “a chronic residual urine reservoir exists in the bladder, due to either inadequate emptying of the bladder or obstruction”, says Ms McGovern. Symptoms include leakage with no warning, a feeling of incomplete emptying of the bladder, slow stream, intermittent stream, hesitancy and unconscious nocturnal leakage.

Mixed UI is a mixture of both Urgency UI and Stress UI and has the same symptoms, she says.

Causes of urinary incontinence may include: weak pelvic floor muscles, changes in the nerves controlling the bladder or pelvic floor, overactive bladder and in men, an enlarged prostate.²

Up to 70% of women relate the onset of their urinary incontinence to their final menstrual period.³ After this time women may also report an increase in urinary urgency which can lead to urgency incontinence and cystitis-like-symptoms including dysuria (burning or discomfort when passing urine). ³ These symptoms can all be related to a depletion of oestrogen and can worsen in severity the further post menopause that women become.³

Urgency incontinence has “a poorly understood psychological association”, says Ms McGovern. “The desire to void can be triggered by environmental influences including bizarre things such as a tap running, the sound of the rain or putting a key in the door of a house.”

Stress incontinence is triggered by physical exertion while overflow urinary incontinence is “often sudden and unpredictable therefore there are no specific triggers identified”, she says.

Other triggers for urinary incontinence include weak pelvic floor muscles, damage to the bladder, some long term conditions, not drinking enough, and urinary tract infections (UTIs), says Ms Carter.

To help practitioners diagnose urinary incontinence, in addition to tests – such as a urine test, blood test or ultrasound scan of the bladder – they can request the patient keeps a diary of their bladder habits.²

Urinary incontinence in older people can be a symptom of an underlying disorder. “You usually find with older people that there are a number of co-morbidities they’re dealing with and that incontinence can be secondary to this,” says Ms Powell.

To establish whether a patient is having issues with urinary incontinence, she suggests using trigger questions. “If I ask patients if they have any problems with their bladder the answer is likely to be ‘no’. But if I ask: ‘Is your bladder waking you up at night?’ the answer may be ‘yes’.”

Impact on quality of life

Urinary incontinence can have “a really big impact on people’s quality of life”, Ms Powell says. “People can become reclusive, and it can affect relationships, with people hiding their condition from their partner.”

Ms McGovern says urinary incontinence “compromises dignity, results in low self-esteem, depression, loss of independence and can put significant strain on carer relationships.”

She says that with older people, urinary incontinence is associated with skin breakdown and urine infections. These can in turn result in delirium, falls, fractures and head injuries requiring acute hospital admission. “Urinary incontinence significantly increases the level of dependency in frail older people and has been recognised as a leading factor associated with nursing home admission,” she says.

Helen Lewis, an advanced nurse practitioner (ANP) in a practice based in Wales, says that the perceived stigma of having urinary incontinence can result in women buying sanitary wear rather than incontinence pads. She says older people can become “frightened to leave the house”, while those with poor mobility will find urinary incontinence an even greater issue.

Treatment and management of urinary incontinence

Treatment and management depends on the cause of urinary incontinence, Ms McGovern advises. She says urgency UI is managed initially with lifestyle interventions, medical review and a six week bladder retraining programme in combination with pelvic floor rehabilitation. Medical review includes assessment of bowels, medication review and physical examination. Ms McGovern says there is a role for medication “if these conservative measures do not improve symptoms.”

“We have medications now that have a good evidence base and safety profile in the elderly population. Botox injections into the bladder or percutaneous sacral nerve stimulation can be considered for certain patients who do not respond to conservative and pharmacological therapies after an MDT discussion,” she says.

Stress UI, she says, is initially treated similarly with lifestyle advice, medical review and pelvic floor rehabilitation. “There is no role for medication to treat stress UI. There is a role for surgery in some instances and patients should be referred on to local urogynaecology teams for further review if conservative measures do not improve symptoms. And there is a role for intra-mural bulking agents in patients not deemed suitable for surgery,” she says.

Overflow UI treatment depends on the cause. Ms McGovern says that in males, most commonly this is due to benign prostatic hypertrophy and therefore treated accordingly. In females, she says underactive bladder (UAB) is usually the most common cause and prevalence increases significantly with age and those living in long-term care facilities.

“Treatment options for females with UAB are limited and generally are based on the evacuation of the lower urinary tract, independent of the aetiology. Intermittent self-catheterisation often works well,” she says.

Mixed UI management “depends on the predominant symptom complex”, she advises.

Lifestyle and diet and urinary incontinence

Prevention starts with “good toileting habits”, she says, “only voiding when needing and not ‘just in-case’. Patients are advised to be aware of lifestyle and diet choices, including avoiding excessive caffeine or alcohol intake, having a good fluid intake, smoking cessation, weight management, and avoiding constipation. And “everyone, no matter of age, can benefit from pelvic floor rehabilitation,” she says. NICE recommends at least three months duration, comprising of at least eight contractions performed three times per day.⁴

Possible complications with urinary incontinence include pressure ulcers, slips, trips and falls, UTIs, and fractures, advises Ms Carter. Ms Lewis says that an overactive bladder could indicate “something more sinister such as bladder cancer”, and she stresses the importance of taking a thorough history to help identify red flags, such as blood in the urine.

Getting the right incontinence products will help individuals to manage their condition and carry on with normal life, and it is important for practitioners to offer advice and to signpost them to sources of support (see resources box). Practitioners can also advise patients that charity Bladderandbowel.org provides ‘Just can’t wait’ cards, which are widely accepted in catering businesses, shops and other public places to give people confidence to access toilets when they are out.²

Dementia and incontinence

People with dementia may forget to visit the toilet, or be unable to communicate their needs. They may not recognise normal triggers that indicate a need to go to the toilet, not remember the way to the toilet, or recognise it when they get there. In these cases, carers can be advised that those in their care might need regular, gentle reminders, such as a notice or picture on the toilet door. A regular routine can also help, or carers may need to learn to recognise signs, and discreetly encourage those in their care to go to the toilet at these times.¹

For those living with urinary incontinence, embarrassment and denial can be major issues. “Talking about urinary incontinence is key,” says Ms Lewis. “Encourage people to open up and let them know help is out there.”

Charities play a major part in supporting people with bladder issues and practitioners should make sure individuals know where to go for additional help, signposting them to organisations such as Bladder Health UK, which has a telephone advice line, advises Ms Powell.

Ms McGovern says bladder problems are “incredibly important to our patients, but often are the neglected area of the comprehensive geriatric assessment.” But asking about bladder and bowel health should be “a priority”, she believes.

“We need to get rid of the stigma associated with urinary incontinence and educate people that it is a very treatable condition.”

References

1. Age UK (2017) Bladder and Bowel Problems. Common problems and how to manage them. https://www.ageuk.org.uk/globalassets/age-ni/documents/information-guides/ageukig15_bladder_and_bowel_problems_inf.pdf
2. Age UK (2022) Incontinence. https://www.ageuk.org.uk/information-advice/health-wellbeing/conditions-illnesses/incontinence/
3. NHS England (2017) Ageing, menopause and the silent symptoms. https://www.england.nhs.uk/south/2017/09/18/ageing/
4. NICE (2019) Guideline scope. Pelvic floor dysfunction: prevention and non-surgical management https://www.nice.org.uk/guidance/ng210/documents/final-scope

Useful resources/contacts

• Age UK Advice Line: 0800 678 1602. https://www.ageuk.org.uk/services/age-uk-advice-line/
• Bladder Health UK: https://bladderhealthuk.org/
• Bladder and Bowel Health Special Interest Group (SIG) https://www.bgs.org.uk/bladder-and-bowel-health

Kathy Oxtoby is a freelance medical journalist