Urinary incontinence in the older female population

Urine leakage can be caused by weakened pelvic-floor muscles.
Urine leakage can be caused by weakened pelvic-floor muscles.

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At a glance

  • Prevalence of urinary incontinence (UI) increases with age, partcularly among women.
  • UI occurs when there is dysfunction in the storage capacity and/or emptying mechanism of the lower urinary tract.

  • Initiate a dialogue by asking, “Do you ever leak urine or have difficulty getting to the toilet in time?”

  • Behavior modification, lifestyle changes, and environmental interventions are first-line treatments for UI.


Urinary incontinence (UI), the involuntary loss of urine in any amount, is very common in older adults. Unfortunately, some believe UI is a normal part of the aging process. While the prevalence of UI does increase with age, the condition is neither normal nor inevitable.1 With accurate evaluation and targeted interventions, UI and its associated symptoms can be relieved. 


Many older adults do not mention urine leakage at health-care appointments, and most clinicians do not ask about unintentional leakage or offer assessment and intervention. With the number of older adults increasing, clinicians can expect to see more people with UI in their practice settings. This article presents an overview of UI in the older woman and offers ways to assess and implement conservative management interventions.


Scope of the problem


UI is very common among older women.2,3 Prevalence increases with age, with one-third of women older than age 65 years experiencing some degree of UI and 12% reporting daily urine leakage.4 UI is less prevalent in men until they reach the ninth decade of life.5 Among women older than age 80 years living in the community, 57% have some form of UI.6

UI in women is a costly health concern in the United States. In 2004, estimated expenses were already in the billions of dollars, and they are continually rising, causing decreased quality of life (QOL) and excessive burden on older adults and the health-care system.7,8

UI can lead to loss of independence, depression, falls, dermatologic conditions (including rash and breakdown), urinary tract infections (UTIs) and placement in a care facility.9 In some studies, UI has been reported as a leading cause of institutionalization, possibly as a result of the stress experienced by caregivers of individuals who develop UI.5,10

The most profound effect of UI, however, may be on QOL. While clinicians working with older adults may recognize that maintaining function and independence is important, the connection between UI and QOL is not always obvious. Active older adults who develop UI or experience worsening UI symptoms often give up some aspect of their lives, including community involvement, hobbies, lifelong interests and travel.

Older women with UI also report a decreased desire for sexual intimacy because of concerns about urine leakage. Withdrawal from these important life events and experiences may eventually lead to social isolation, low self-esteem, spiritual distress, hopelessness, depression, functional decline, falls, fractures and loss of independence. 



Etiology


UI in older adults can be caused by a number of factors, not all of which are related to the genitourinary (GU) system. Problems associated with urine leakage manifest differently in older women than in younger women. These differences are related to physiologic changes in the aging GU tract, an accumulation of lifestyle choices or habits, the presence of comorbid conditions, functional impairments and the use of multiple medications.5,11 More studies are emerging that report race and ethnic differences in female GU anatomy and function, leading to potential increases in the incidence of UI and differences in treatment outcomes.12

Stated simply, UI occurs when there is dysfunction in the storage capability and/or the emptying mechanism of the lower urinary tract (LUT). Age-related changes may also predispose the older woman to UI. These changes are gradual, progressive and unique for each individual, and they occur in the GU tract as well as other body systems Clinicians must be knowledgeable about these changes and able to recognize them during assessment and evaluation. 

Clinicians also need to consider the risk factors for development of UI. The more risk factors an older woman has, the more likely she is to develop UI. But the more risk factors that can be successfully identified and addressed, the greater the potential for alleviating the urine leakage. 

The clinician and the older woman need to work together to identify and address as many risk factors as possible and increase the likelihood of arriving at an accurate diagnosis and developing an effective treatment plan with measurable outcomes.


Classification of urinary incontinence


The types of UI are identified primarily by the symptoms associated with the leakage. The main priority is to recognize that the patient has urine leakage, regardless of whether a definitive diagnosis of UI is initially established. Following recognition that a problem exists, a more complete evaluation should be carried out to determine the underlying cause and an appropriate management plan.

An accurate diagnosis and quickly implemented management plan can help to eliminate potentially harmful physical, emotional and negative spiritual effects of the impact of UI on the older woman. A thorough evaluation also allows the clinician to classify the UI according to one of the standard categories: stress, urge, mixed, overflow or functional. 


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