For an overview of normal bladder function, including images, see:
Incontinence is not a normal part of aging; however, many factors can increase an older adult’s risk of incontinence, including:
Age-related changes to the urinary system can include:
These changes may results in a variety of symptoms, including:
(Wagg et al. 2017, pp. 1316-1321)
It is important to understand what may be adding to the risk of incontinence and reduce the impact of these factors as much as possible
(Wagg et al., 2017; Palmer, 2016)
The pelvic floor functions to support the pelvic organs and oppose downward pressure. These muscles may weaken or have a harder time supporting the urinary system with increased weight or a decrease in estrogen in menopause. Childbirth and surgeries (e.g. prostate) can also impact the function of pelvic floor muscles (Doughty, 2016).
Pelvic Floor Muscle Training (PFMT) is the most beneficial conservative option to address UI, in particular for stress urinary incontinence (SUI). PFMT should be offered if a physiotherapist with specialized training is available (Dumoulin et al., 2017). A physiotherapist can address incontinence that happens with day-to-day activities with functional training. Further explanation can be found in the video, It's Not TMI Episode 2: All About Kegels. Resources such Physiocanhelp.ca and consultation with a physiotherapist may help
Obese women have higher intra-abdominal pressures, which increases the risk of urinary incontinence (UI) and potentially weakens pelvic floor supports. Lifestyle modifications that decrease body weight by 5% reduce the odds of developing UI at one year by 3% for every kilogram lost (Dumoulin et al., 2017). Resources such Canada’s Food Guide and consultation with a dietitian may help with weight reduction.
Other lifestyle modifications, such as smoking cessation, can reduce urinary symptoms. A study looking at overactive bladder symptoms (OAB) found that smoking increased the risk of more severe UI. When smoking was stopped, a decrease in urinary frequency was observed (Dumoulin et al., 2017).
Further information about the causes of urinary incontinence is available on the Canadian Continence Foundation website.
Exercise & Physiotherapy
There is a natural reduction in estrogen with ageing that contributes to an increase in overactive bladder symptoms and recurrent urinary tract infections.
Genitourinary Syndrome of Menopause (GSM) is a new term used to describe the vulvovaginal atrophy as well as the urinary symptoms of urgency, dysuria and recurrent urinary tract infections.
Estrogen creams, tablets or rings used locally (i.e. vaginally) have been found to improve these symptoms, whereas systemic estrogen may actually worsen urinary incontinence (UI) (Andersson et al. 2017; Engberg, 2016).
The International Continence Society describes miscellaneous techniques for bladder control such as distraction techniques, urgency suppression and double voiding.
For many patients, not voiding with every urge will be a new concept. Healthy bladder emptying takes place every 3-4 hours. The goal is to increase bladder storage but avoid urinary retention (Yates, 2019).
The ‘Knack’ is a functional pelvic floor technique where a patient is taught to contract the pelvic floor muscle (PFM) before coughing, sneezing or other activities that increase intraabdominal pressure to reduce the risk of stress urinary incontinence (SUI).
Frail older women with SUI may report that activities like getting up from a chair cause leakage, for example. Being taught to contract their pelvic floor muscles strongly (knack) before and during these activities may help (Engberg, 2016).
If the patient is unable to stand, the same exercises to locate the muscles can be done by turning legs and feet as described while lying down.
Intake of fluids impacts urine output, so getting an accurate idea of amount and types of fluids (e.g. water, alcohol, and caffeinated) is necessary (Palmer, 2016). Everyone's fluid intake requirement to stay hydrated is individual. Assessment of intake and output, timeframes, patterns of behaviour, incontinence, safety risk, and patients' preferences will impact fluid intake changes recommended.
You’ll find useful advice on bladder leakage control from The Canadian Continence Foundation. Here are a few core recommendations:
Caffeine may worsen urinary incontinence (UI) and increase overactive bladder (OAB) symptoms, urgency and frequency, though the association is not consistent.
High caffeine intake (over 400 mg/day) is associated with OAB. Reducing below 100 mg/day decreases urgency and urgency incontinence. Switching to decaffeinated beverages lessens urgency and frequency. A trial and evaluation of reduced caffeine intake is recommended (Dumoulin et al. 2017; Gibson & Wagg, 2016).
|DISEASE OR ILLNESS||INTERVENTION|
High blood sugars cause more urine to be produced to try and get rid of extra glucose
|Gain better control of diabetes|
Makes getting to the bathroom harder
|Treat pain with medications and other things such as heat|
Lung problems, such as COPD, can lead to coughing causing leakage (stress incontinence)
|Try and reduce coughing with medications|
|Extra Body Fluid
Things such as leg swelling (edema) and heart-pumping problems (congestive heart failure) increase the amount of fluid the kidneys need to get rid of and cause people to void more often, especially at night
|Controlling heart failure, reducing sodium, wearing support stockings, raising legs during the afternoon will help the body get rid of the fluids during the day|
If very bad, constipation can make it more difficult to pass urine
|Treat constipation by eating lots of fruits and vegetables, increasing fiber and water, and taking medications to soften stool if needed|
|Stroke and Parkinson's
Affect a person's mobility causing a sense of urgency to try and make it to the bathroom in time
|Regular help to go to the toilet is needed|
Have more difficulty with locating the toilet and being able to care for themselves properly after
|Regular help is needed|
(Palmer, 2016 pp. 180-191; Wagg et al., 2017 pp. 1322-1323)
There are two types of overactive bladder: with incontinence (OAB wet) and without (OAB dry).
Overactive bladder is linked to comorbidity, lower quality of life, depression, and reduced work productivity. It increases with age and increases the risk of falls and fractures (Wagg et al., 2017; Diaz et al. 2017; Milsom et al., 2017). Urinary urgency is reported more often by people with benign prostatic hyperplasia (BPH), pelvic organ prolapse (POP) and mental health problems than those without (Milsom et al., 2017).
(Milsom et al., 2017)
Urgency can be experienced by people with or without overactive bladder.
Urgency can be a brain-to-bladder learned behaviour from certain stimuli, the most common:
Behaviour treatments that delay or distract from the urgency can be helpful.
(O’Connell, Torstrick & Victor, 2014)
Urgency contributes to increased risk of falls in the case of those with poor mobility. For example:
(Chung, Katz & Love, 2017; Wagg et al., 2017)
It is important to assess contributing factors and, where possible, reduce risk.
A 2014 study found that at least 4% of women and 2.12% of men in Nova Scotia have urinary incontinence (The Canadian Continence Foundation, 2014).
Many people do not discuss urinary incontinence (UI) with their health care provider because they think it is a normal part of aging, or they are embarrassed. It is important to assess not only the severity of symptoms (frequency, leakage amounts, etc.), but also the impact on activities, quality of life, and how much the patient is bothered by it (Milsom et al., 2017).
The Canadian Continence Foundation (2014) found that people with UI:
UI that happens suddenly, lasts less than six months, and can usually be reversed is known as acute or transient incontinence. The common causes of Acute/Transient UI can be remembered using the mnemonic TOILETED.
UI that lasts longer than six months is chronic. The most common types of chronic UI are stress, urgency or a combination of both known as mixed UI.
When both SUI and UUI are present (MUI), assess which is the most problematic for the patient and address those concerns first.
(Harris & Riggs, 2020)
Dubeau (2006) states that things outside of the urinary system can affect a person's ability to get to the bathroom in time to void; commonly known as functional incontinence.
Possible causes of functional incontinence:
(as cited in Palmer, 2016)
Not all incontinence can be cured. Some patients may require a containment device or absorbent product on a temporary basis or long-term. Correct usage and skin care are essential (Wilde & Fader, 2016).
Key elements to assess are:
(Cottenden et al. 2016)
Consultation with an occupational therapist or nurse specializing in continence care (i.e. NSWOC, NCA) may be helpful, especially for less familiar products such as sheaths, body worn urinals, internal urethral devices (women), penile compression devices, fecal pads, fecal collectors and anal devices.
Incontinence Associated Dermatitis (IAD) is a risk for frail elderly skin who are incontinent of urine or feces. Gentle cleansing with a pH-balanced no-rinse cleanser, hydration of dry skin, protection with a barrier product, and ongoing monitoring to prevent further injury such as a pressure injury is recommended (Beele et al., 2018).
Bladder Diaries provide comprehensive, objective information when assessing for urinary incontinence, and support the evaluation of treatments.
Important information includes:
ICS Standards (2019) recommend a bladder diary should be kept over a three day period and include any days that are routine variations (i.e. work/weekdays versus weekend).
When patients find it challenging to collect for three days, a 24-hour collection can also be useful.
A bladder diary can also be helpful as a way for the patient to see changes with treatment. For example, timing of fluid intake and reduction in nocturia (Diaz et al., 2017).
(Dumoulin et al., 2017; International Continence Society, 2020)
Timed voiding is a fixed voiding schedule that doesn’t change over time.
(Dumoulin et al., 2017; International Continence Society, 2020)
Habit training is a toileting schedule that is based on the patient's voiding pattern.
A bladder diary could be done to evaluate if there was any improvement in the number of UI episodes.
(Dumoulin et al., 2017; International Continence Society, 2020)
Prompted voiding is a voiding program that works towards increasing the number of initiated requests to go to the bathroom.
(Dumoulin et al., 2017; Registered Nurses' Association of Ontario, 2020)
It is important to review medications to assess if they are contributing to the signs and symptoms reported by the patient (e.g. frequency, urgency, incontinence). This review should include all prescription and over-the-counter medications.
Pharmacists are a very valuable resource when evaluating medications for potential risks. Medication review is particularly important for elderly patients. The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults (2019) is a great tool.
Many types of medications can cause or contribute to the development of urinary incontinence in older patients, such as:
|MEDICATION||POSSIBLE SIDE EFFECTS|
|Alpha-adrenergic agonists (e.g. Methyldopa, Guanabenz)||Increased urethral tone may cause urinary retention|
|Alpha-adrenergic antagonists (alpha-blockers) (e.g. Doxazosin, Prazosin)||Reduces urethral tone increasing the risk of stress incontinence|
|Angiotensin-converting enzyme (ACE) inhibitors (e.g. Enalapril, Ramipril)||Chronic cough is a common side effect, increases the risk for stress incontinence|
|Anticholinergics (e.g. Dimenhydrinate, Amitriptyline, Oxybutynin)||May affect bladder emptying, the potential for urinary retention, constipation and dry mouth. Risk of confusion can lead to a decline in awareness of the need and ability to toilet.|
|Calcium channel blockers (e.g. Diltiazem, Verapamil)||May affect bladder emptying, potential urinary retention, and constipation. Increased nocturia due to contributing to leg edema.|
|Cholinesterase inhibitors (e.g. Donepezil, Galantamine, Rivastigmine)||Increase bladder contracts which may increase urgency and/or emptying incontinence|
|Diuretics (e.g. Furosemide)||Increase urine output, frequency, and urgency, and risk urgency incontinence|
|Opioid analgesics||May cause delirium, urinary retention and constipation|
|Sedatives and Hypnotics||May cause drowsiness, cognitive impairment which can affect recognition of the need to void, ability to mobilize and toilet|
|Decongestants (e.g. pseudoephedrine-Sudafed)||Increase urethral tone and risk for retention in men with prostate enlargement|
(Finck et al., 2019; Nelles, 2016; Wagg et al., 2017)
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