Urinary Incontinence Urinary incontinence (UI), the involuntary leakage of urine, is highly prevalent in older persons, especially in older

women, and has a profound negative impact on quality of life. Approximately 50% of American women will suffer from some form of UI over a lifetime. Increasing age, white race, childbirth, obesity, and medical comorbidity are all risk factors for UI. The three main clinical forms of UI are as follows: (1) Stress incontinence is the failure of the sphincteric mechanism to remain closed when there is a sudden increase in intraabdominal pressure, such as a cough or sneeze. In women, this condition is due to insufficient strength of the pelvic floor muscles, while in men it is almost exclusively secondary to prostate surgery. (2) Urge incontinence is the loss of urine accompanied by a sudden sensation of need to urinate and is due to detrusor muscle overactivity (lack of inhibition) due to loss of neurologic control or local irritation. (3) Overflow incontinence is characterized by urinary dribbling, either constantly or for some period after urination. This condition is due to impaired detrusor contractility (due usually to denervation, for example, in diabetes) or bladder outlet obstruction (prostate hypertrophy in men and cystocele in women). Thus, not surprisingly, the pathogenesis of urinary incontinence is connected to the disrupted aging systems that contribute to frailty, body composition changes (atrophy of the bladder and pelvic floor muscle), and neurodegeneration (both central and peripheral nervous systems). Frailty is a strong risk factor for urinary incontinence. Indeed, older women are more likely to have mixed (urge+stress) incontinence than any pure form (Fig. 72-18). In analogy with the other geriatric syndromes, UI derives from a predisposing condition superimposed on a stressful, precipitating factor. Accordingly, treatment of UI should address both. The first line of treatment is bladder training associated with pelvic muscle exercise (Kegel exercises) that sometimes should be associated with electrical stimulation. Those with possible vaginal or uterine prolapse should be referred to a specialist. Urinary infections should be investigated and eventually treated. A long list of medications can precipitate urinary incontinence, including diuretics, antidepressants, sedative hypnotics, adrenergic agonists or blockers, anticholinergic, and calcium channel blockers. Whenever possible, these medications

should be discontinued. Until recently, it was believed that estrogen oral or local treatments improved the UI symptoms in postmenopausal women, but this notion is now controversial. Antimuscarinic drugs such as tolterodine, darifenacin, and fesoterodine are modestly effective for mixed incontinence, but they all can affect cognition and so must be used with caution and careful follow-up monitoring of cognitive status. In some cases, surgical treatment should be considered. Chronic catheterization has many adverse effects and should be limited to chronic urinary retention that cannot be managed in any other way. Bacteriuria always occurs and should be treated only if symptomatic.