Urine leak in elderly men and women

Urine leak in elderly

Urine leak afflicts unto 30% of older people living at home. It is associated with embarrassment, stigmatization, isolation, depression, anxiety and risk of institutionalization. It predisposes to perineal rashes, ulcers, urinary tract infections, urosepsis falls and fracture. Also the cost of management of geriatric incontinence is high. Despite these considerations geriatric incontinence remains neglected by patients and physicians alike or dismiss it as a normal part of growing old. But it is abnormal at any age. More ever its increased prevalence relates more to age associated diseases and functional impairment than to age itself.

Regardless, incontinence is usually treatable and often curable at all ages even in frail elderly but the approach differs significantly from that used in younger patients.

Pathophysiology

At any age, continence depends on integrity of lower urinary tract and presence of adequate mentation, mobility, motivation and manual dexterity. lower urinary tract changes with age even in the absence of disease. Bladder controllability, sensation and ability to postpone voiding decline in both male and female. 

However there are more changes in female urethra w.r.t sphincter, pelvic muscles and length of urethra.

Involuntary bladder contraction increases in both sexes and elderly often excrete most of the fluid intake at night.

There may be associated prostate enlargement and obstruction of outflow due to prostate, renal disease, heart failure etc. The above changes predispose to urine leak.

In most of the cases the onset or exacerbation of urine leak is probably due to precipitants outside lower urinary tract that are amenable to medical treatment and treatment of these precipitants alone may be sufficient to restore incontinence.

Transient urine leak

Incontinence is transient in upto one third of elderly and more than half of hospitalized patients. Although termed incontinence it may persist if left untreated.

Urinary tract infections(UTI) are commonest cause of transient urine leak when urgency and burning sensation are so prominent that the older person is unable to reach the toilet before voiding. Incontinence is occasionally the only symptom of UTI and traetment of UTI resolves the incontinence.

Atrophic urethritis and vaginitis causes incontinence and urine leak in upto 80% of elderly women with incontinence. It is associated with urgency and occasionally sense of scalding that mimics a UTI and also exacerbates stress incontinence. Recognizing atrophic vaginitis is important as it may respond to low dose estrogen. This also prevents recurrent UTI's. 

Stool impaction (chronic constipation) may cause both fecal and urinary incontinence in 10% of older individuals. Disimpaction and healthy bowel habits restores continence.

In addition many drugs are associated with urinary incontinence. Excess urine production due to diuretics, caffinated beverages, diabetes and congestive heart failure may lead to incontinence , treatment of which corrects incontinence.

Incontinence due to lower urinary tract abnormality

Bladder(detrusor) over activity is the most common type of lower urinary tract dysfunction in a incontinent male or female elderly. It occurs due to increased spontaneous activity of bladder muscles. Over activity may be due to central nervous system abnormality or due to bladder abnormality. Anticholinergics, injection therapy helps in most of the cases.

Incontinence in the setting of outlet obstruction is second most common cause of incontinence in older men.

It may be due to urgency or overflow and treatment of enlarged prostate  relieves the symptoms.

In older women urethral stenosis due to fibrotic changes and atrophy may lead to incontinence. resolves by use of low dose estrogen cream and dilatation.

Stress incontinence is second most common cause of incontinence in women. Occurs due to birth and operative trauma and also due to age related atrophy. stress incontinence can be cured by sling surgery, pelvic exercises injection therapy etc.

Evaluation of urine leak involves identification of contributing factors lab testing for kidney functions. Urodynamics is strongly considered in certain group of patients with bladder weakness and over activity.

Successful treatment of urine leak in elderly is usually feasible.

Treatment of contributing factors such as medications and systemic problems can improve the incontinence.

Incontinence due to obstruction is treatable by removal of obstruction such as prostate surgery.

Multifactorial creative, persistent and optimistic approach increases chances of successful outcome.