Stress urinary incontinence in active elderly women.

Abstract: Urinary incontinence in the elderly is a significant health problem fraught with isolation, depression, and an increased risk of institutionalization and medical complications. Stress urinary incontinence (SUI), the complaint of involuntary loss of urine during effort or exertion or during sneezing or coughing, is the most common type of urinary incontinence. SUI can seriously degrade the quality of life for many active seniors, and has become an economic challenge for society. With the rapid increase in the active elderly worldwide, SUI is becoming a significant global problem. However, since only a fraction of women with SUI have consulted a physician, the clinical extent and public health impact of SUI are probably underestimated. The mounting social, medical, and economic problem of SUI in active elderly women as a rapidly growing segment of the population worldwide is reviewed. We evaluate the age-related changes of the lower urinary tract, examine risk factors, and suggest different treatment options shown to be effective in reducing SUI in this population.

Key Words: elderly, quality of life, stress urinary incontinence, urinary incontinence

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Urinary incontinence (UI) is a growing medical, social, and economic problem for the elderly worldwide. Transient or chronic UI affects more than one third of community-dwelling elders and more than half in nursing homes. (1,2) Stress urinary incontinence (SUI), defined by the International Continence Society as the complaint of involuntary loss of urine during effort or exertion or during sneezing or coughing, (3) is the most common type of UI. SUI is caused by insufficient urethral closure. It is different from urge urinary incontinence (UUI), the complaint of involuntary urine loss associated with or immediately preceded by a strong and urgent desire to void, which may be caused by uncontrolled bladder contractions. (3) SUI and UUI may occur in pure forms or may coexist as mixed urinary incontinence (MUI).

According to a recent National Institutes of Health Aging Institute report, the world's elderly population (defined as 65 years or older) is growing by 795,000 individuals every month. By 2050, more than 20% of the US population will be 65 years and older. (4,5) With the rapid increase in the elderly population worldwide, particularly in the United States, UI is becoming an increasingly significant global problem. (6)

Although the percentage of elderly people residing in US nursing homes has remained fairly constant at approximately 5%, assisted living in elderly residential settings represents one of the fastest-growing trends. (7) The majority of the elderly between 65 and 85 years have no difficulties in performing activities of daily living, and half of them are living with a spouse. (7) In the past 25 years, women living in assisted living centers as well as the community have become more physically active and economically independent; many are even returning to the workforce. (4) This active lifestyle among the elderly makes it more critical than ever for these women to obtain an accurate diagnosis and effective treatment for their condition.

In this report, we discuss the prevalence of SUI and its impact on the quality of life in active elderly women, examine the pathophysiology and causes of SUI, and discuss some of the treatment options shown to be effective in this population.

Scope and Impact of Stress Urinary Incontinence

Prevalence

Due to differences in definitions and methodologies, there is substantial variability in the estimates of incidence and prevalence of UI in the elderly. UI may be transient in up to one third of community-dwelling elderly and up to 50% of inpatients, depending on a variety of risk factors. (8) In a survey of 5,701 community-dwelling women aged 50 to 69 years, 16% of women reported monthly incontinence. (9) In contrast, in another recent study of 2,763 active elderly women (mean age, 67 [+ or -] 7 years), 65% of the women reported weekly incontinence. (10) Among noninstitutionalized elderly women ([greater than or equal to]60 years), the Medical Epidemiologic and Social Aspects of Aging (MESA) survey revealed a 38% prevalence of UI. (11) Of the women with incontinence, 34% reported losing urine at least once per week, and another 16% lost urine on the average of 300 to 365 days. (12)

In elderly women, UUI is often reported to be the dominant type of incontinence. However, this has been disputed in several recent studies that identified SUI to be the dominant type not only in younger women but also in the active elderly. (13-17) In a study of 1,955 community-dwelling senior citizens aged 60 or older in Washtenaw County, Michigan, 27% of women with incontinence reported SUI and 56% reported MUI. (18) In a US study of 2,025 women aged 64 years and older, the prevalence of UUI was found to be 36.3% and SUI was 40.3%. (15)

Although more than one third of the active community-dwelling women over age 65 have some form of UI, the impact may be significantly underestimated, since physicians do not commonly ask elderly patients about UI and elderly patients seldom initiate discussions about their UI. (19) American women with SUI accept their symptoms on average of 41 months (18 months for MUI) before they consult their primary care physician. (20) The elderly are less likely than younger patients to initiate the discussion about incontinence. (19)

Physical and quality-of-life effects

UI is associated with a constellation of physical and behavioral problems that can seriously degrade quality of life for the elderly. (21) The disorder is fraught with embarrassment, stigmatization, social isolation, depression, a high risk of institutionalization, (22,23) and a considerable burden on caregivers. (24) In a study of elderly patients (mean age, 79 years), more than 75% believed that incontinence was inconvenient, embarrassing, or distressing, and 37% believed that it significantly interfered with their daily lives. (25) In some patients with incontinence, the decrease in quality of life can be as severe as that of many chronic disease states. (26)

Although studies have suggested that UUI is associated with a greater quality-of-life impairment than SUI, (27-29) SUI is nevertheless associated with a significant social and emotional burden in the elderly. In one study of 605 women in the United States with symptoms of SUI, more than three fourths of the women reported their symptoms to be bothersome, with approximately 29% reporting their symptoms to be moderately to severely bothersome. (30)

Although many women with SUI are highly bothered by their symptoms, only 1 of 3 to 4 seek help from her physician. When severely affected, approximately 43% of the women consult a healthcare provider. Reasons for not seeking help are social embarrassment, fear of surgery, belief that SUI is a natural part of aging or childbearing, and lack of information and/or knowledge about the condition and its management. (31)

Costs

In 2003, the estimated total economic cost of incontinence in the United States was $12.02 billion, with $9.17 and $2.85 billion incurred in the community and institutions, respectively. Costs for elderly women and men with incontinence living in the community totaled $7.37 and $1.79 billion, respectively. (32) Although direct costs have been studied most rigorously, indirect costs, such as productivity loss due to morbidity or disability, can also be associated with SUI.

Direct costs include out-of-pocket expenses paid by patients for personal care items (eg, pads, diapers) and related costs (eg, laundry), as well as costs to the health care system, mainly due to incontinence surgery and outpatient consultation. Costs for inpatient care are the largest component of total treatment cost for patients with SUI, followed by out-patient services. (33) In the United States, annual UI-related costs for patients (mean age, 52 years) undergoing surgery for SUI were approximately 10 times higher than annual costs in patients who did not undergo surgery for SUI ($3,620 versus $350). (33) UI increases the risk of hospitalization by more than 30% and is believed to be a significant factor for institutionalization among the elderly; about half of patient admissions to nursing facilities in the United States have listed a diagnosis of incontinence. (34) One study reported that UI doubled the risk of admissions to nursing homes, independent of age and the presence of other diseases. (35) However, it may be difficult to identify the main reason for nursing home admission in an elderly patient with multiple diseases.

Pathophysiology and Causes of Stress Urinary Incontinence

Basic pathophysiology

Stress urinary incontinence is usually the result of either hypermobility of the bladder neck/proximal urethra or intrinsic sphincter deficiency. In many women, SUI is caused by a combination of both. Due to weakening of the extrinsic support of the proximal urethra, the bladder neck and/or urethra descends outside the intra-abdominal (pelvic) cavity during stress activities (exercising, coughing, sneezing). As a consequence, the urethra cannot be sufficiently compressed and the increased abdominal pressure overrides urethral closure forces resulting in urine leakage. In patients with intrinsic sphincter deficiency, the intrinsic urethral sphincter mechanism and/or its nerve supply are damaged and therefore cannot maintain an adequate urethral tone when stress activities increase abdominal pressure.

Age-related changes in lower urinary tract function

Although UI is not an inevitable consequence of getting older, age-related physiologic changes of the lower urinary tract may alter the micturition habits and predispose women to UI. In the older woman, decreased circadian production of arginine vasopressin and atrial natriuretic hormone may raise nocturnal urine output (36) and contribute to UI.

Bladder and urethra

The female genital and urinary tracts have a common embryologic origin and hold estrogen and progesterone receptors. Declining hormone levels after menopause decrease the number of intermediate and superficial cells in the epithelium of the bladder and urethra. (37) As a consequence, afferent receptors in the bladder may be more exposed, increasing the risk of bladder irritability and UUI, whereas mucosal and submucosal cushions of the urethral lumen may weaken with age, (38-41) increasing the risk of SUI.

The quality of elastic and collagen connective tissue degrades with age, decreasing the bladder capacity and leading to more frequent voiding. Also, because there are fewer muscle cells as a person ages, the reduced strength of the bladder muscle increases the risk of incomplete bladder emptying and UI. (38-41)

In elderly women with or without UI, the detrusor muscle may become overactive without any neuronal loss. These spontaneous bladder muscle contractions result in urgency to empty the bladder even at low bladder volumes, resulting in UUI. Urgency is the most common voiding symptom in the elderly (42); however, elderly women are generally less able to suppress these early detrusor contractions. Although detrusor hyperactivity associated with impaired bladder muscle contractility is common in the frail elderly, (43,44) the existence of SUI caused by urethral sphincter instability and paradox relaxation in the absence of detrusor contraction has been questioned. (45) However, the number of muscle cells in the striated urethral sphincter decline with age and increase the risk of urethral closure weakness. (38-41)

Vagina

Atrophic vaginitis and urethritis may be the result of a lower sex hormone level. Together with an age-related immunodeficiency, the risk of recurring lower urinary tract infections are likely to cause UUI and possibly SUI. (45,46)

Muscles and ligaments

Age-related weakening of pelvic floor muscles and ligaments supporting the bladder and proximal urethra may be responsible for bladder neck hypermobility (causing SUI) or pelvic organ prolapse, (6,47) increasing the risk of UI or urinary retention.

Risk Factors for Stress Urinary Incontinence

Several risk factors have been associated with SUI, but disagreement exists because most studies have used retrospective designs that do not consider SUI as a complex condition with a fluctuating nature and a multifactor etiology. (48) Differences in study design, populations studied, and definition of terms may make it difficult to draw firm conclusions. (13,49)

Parity and pelvic trauma during vaginal delivery are established risk factors for SUI. Overall, 30% of women have SUI within 5 years after their first vaginal delivery. (50) However, the impact in elderly multiparous women is difficult to identify because of confounding factors such as age, obesity, chronic lung disease, smoking, and medications. (51) In a cohort of 150 nulliparous elderly women (nuns living in a convent; average age, 68 years), 30% had SUI, indicating that parity is only one of the factors predisposing incontinence in elderly women. (52)

Another established risk factor for SUI in women is obesity. Several epidemiologic studies have demonstrated that higher body mass index is independently associated with the presence of SUI, but the effect of conservative weight loss has not been conclusively established.

Any condition or medication that affects lower urinary tract function can predispose an older individual to SUI. Cardiorespiratory deterioration in the form of congestive heart failure, chronic obstructive lung disease, and chronic cough are examples of significant risk factors. (53) Other risk factors are surgery, radiotherapy, trauma, and the use of [alpha]-blocking medications. (54) A complete summary of risk factors for SUI is presented in Table 1. (105-122)

Diagnostic Evaluation 

A preliminary diagnosis of UI can be made on the basis of the patient history, physical examination, urinalysis, bladder diary, cough stress test, and, if needed, assessment of postvoid residual urine (PVR) volume (Table 2). (123) The history should focus on types of incontinence symptoms, patterns of voiding, quality of life, coexisting medical conditions, and precipitating factors. In the older woman, PVR is considered significant if the amount of urine remaining in the bladder after a voiding exceeds 100 to 150 mL. Large residuals associated with cystoceles are rare, since patients with cystoceles tend to empty their bladders completely. However, a large residual is usually the cause of the cystocele rather than the result. PVR should be assessed by catheterization or ultrasound; abdominal palpation is unreliable. Neurologic examinations may be added, but these tests should be interpreted carefully since an absent sacral reflex does not imply a neurogenic lesion, and its presence does not exclude a partial lesion. (55) Patients with a history suggesting neurologic disease should have a screening neurologic examination to detect previously unrecognized conditions that may require further evaluation.

Special emphasis should be directed to potentially reversible risk factors, especially in elderly patients (Table 3). (75) Although there is insufficient evidence from controlled trials that treating risk factors associated with UI results in improvement, both the Agency for Health Care Policy and Research and the Scientific Committee of the International Consultation on Incontinence recommend clinicians screen for risk factors and focus on addressing those that are potentially modifiable. (56)

Since urodynamic equipment is not usually available in the primary care setting, and because there is a surprisingly low correlation between the presenting symptoms and the pathophysiologic mechanism, (17,57,58) the management of UI is often initiated without urodynamics. Urodynamic testing is generally reserved for complicated cases, after treatment failure, or before invasive, irreversible, or highly specific treatment. Controversy exists about the use of urodynamics in patients with urge symptoms. Some suggest urodynamics in all patients with urge symptoms, (59) whereas others reserve such studies for patients with persistent symptoms or before considering continence surgery. (57,60)

Management of Stress Urinary Incontinence

The multifactorial nature of incontinence in older persons requires a search for all possible causes and precipitants beyond a focus on specific genitourinary diagnosis including mental and physical status, comorbidity, medications, and environment. (61) Both assessment and treatment must be individually tailored because factors outside the urinary tract often affect the diagnosis as well as the efficacy and feasibility of treatment. (8) However, because conservative interventions are both safe and effective, it is generally recommended, even in the absence of a precise diagnosis, that the first treatment choice should be the least invasive option with the lowest risk for adverse events. (56)

A summary of the therapeutic options for the treatment of women with SUI is presented in Table 4. With varying degrees of scientific evidence, all of these options have been shown to reduce or eliminate SUI. However, compliance issues and side effects may be significant. Absorbent pads do not treat the disorder and may cause discomfort, embarrassment, and rashes.

Treatments

Pelvic floor muscle training and exercise

Behavioral training with pelvic floor muscle training (PFMT) is a well-established, conservative intervention for SUI. It has been shown to be effective for reducing incontinence in cognitively intact women, particularly older women. (62) The objective of PFMT is to increase the support of the lower urinary tract and promote urethral closure by voluntary contraction of periurethral muscles. Pelvic floor muscle control can be taught using several methods, including biofeedback, feedback based on vaginal or anal palpation, and electrical stimulation. Once patients learn to properly contract and relax the pelvic floor muscles, a program of daily practice and exercise is prescribed to increase muscle strength and enhance skill level. Although exercise alone can improve urethral support and continence status, results are generally better when patients learn to use their muscles actively to prevent urine loss during situations of physical exertion. This involves developing the habit of consciously contracting pelvic floor muscles before and during coughing, sneezing, and any other activities that have previously caused urine loss. This skill has been referred to as the stress strategy, counter-bracing, or the Knack.

Exercising and using pelvic floor muscles requires the active participation of a motivated patient. It is often challenging to remember to use muscles strategically in daily life, as well as to persist over time in a regular exercise regimen to maintain strength. This reliance on patient behavior change represents the major limitation of this treatment approach. Dropout rates suggest that it is difficult for many women to sustain their exercise program over time. (63,64) In addition, most women do not achieve total continence. In fact, only 10 to 25% of elderly community-dwelling women become fully continent using this treatment. (65)

Weighted vaginal cones

Weighted vaginal cones have been used to facilitate pelvic floor muscle control and teach sustained muscle tone. Cones are tampon-sized devices that are typically inserted twice a day for 15 minutes per session. As the woman succeeds in holding the cone, she is progressed to heavier cones as tolerated. In one study, participants receiving vaginal cones were more likely to be subjectively cured compared with control subjects, but there were no differences in objective outcomes such as leakage episodes, pad test, or pelvic floor strength. (66) One function of cones might be to help women increase awareness of the pelvic floor and develop the habit of holding or spontaneously using their muscles to avoid urine loss.

Electrical stimulation

Another method of strengthening the pelvic floor muscles is electrical stimulation of the pelvic floor using low-voltage vaginal or anal probes. This appears to help women identify the proper muscle groups and produce a passive exercise of pelvic floor muscles that has led to mixed results in women with SUI. Several controlled trials have noted a large placebo effect. A recent uncontrolled study from Norway involving 3,198 women found that home-managed electrical stimulation therapy resulted in cure or significant improvement in 29% according to patient assessment, or 33% according to physician assessment. (67)

Bladder training 

In bladder training, patients gradually increase the time interval between voids, using progressive voiding schedules during a training period of at least 3 weeks. Originally developed for the treatment of UUI and frequent urination, it may be useful for reducing SUI in some women. (68) Elser et al (69) compared the effects of PFMT, bladder training, or both on urodynamic parameters in 204 elderly women with genuine SUI and found that these behavioral treatments had no effect on the commonly measured urodynamic parameters. However, bladder training together with pelvic muscle exercise with biofeedback (and combinations of these) had the greatest effect on reducing incontinent episodes than either therapy alone, regardless of urodynamic diagnosis. (70) In this study, patients with SUI had even greater improvement in life impact than those with UUI. The authors underscored the importance of a structured intervention program with education, counseling, and frequent patient contact, using these therapies.

It is also useful to ensure that the bladder is completely empty after each void to maximize the patient's functional bladder capacity. Double or triple voiding may be practiced by standing up after voiding and sitting down again for a second or third attempt to void. This can be especially beneficial in patients with residual urine volumes secondary to advanced pelvic organ prolapse. Bladder neck support with a pessary can also be helpful for this group of patients.

Surgery

Surgical intervention is typically recommended only after conservative approaches have failed. Surgical procedures to treat SUI are designed to correct urethral closure deficiencies and to improve support of the urethrovesical junction. (56) More than 200 different procedures have been described. Traditionally, those performed most frequently have been open retropubic colposuspension, laparoscopic colposuspension, anterior vaginal repair, and suburethral sling procedure. Based on a recent Cochrane review, open retropubic colposuspension seems to be the most effective treatment modality for SUI, especially in the long term. (71) Within the first year of treatment, the overall continence rate is approximately 85 to 90%. After 5 years, approximately 70% patients can expect to be dry. Newer minimal access procedures such as tension-free vaginal tape, a Prolene sling positioned under the mid-urethra, provides cure rates similar to those after open abdominal retropubic suspension, but long-term results are awaited. (72) Periurethral injections, the injection of bulking agents into the urethral submucosa, have also been used to create artificial urethral cushions, (73) although results from the first randomized, double-blinded trial showed that periurethral fat injections were no more efficacious than placebo. (74)

Although surgery is generally considered the most curative, immediate, and permanent treatment for SUI, published success rates vary and are based largely on data derived from nonrandomized, uncontrolled studies. (75,76) Among elderly patients, there is an overall increased risk of surgical failure largely due to associated comorbid conditions such as hypertension and cardiac disease (77); risk from anesthesia is also greatly increased. (78) Other potential adverse outcomes of surgery include perioperative complications (eg, infection, hemorrhage, pain, and urinary retention), de novo urgency and UI, voiding difficulties, recurrent or new pelvic organ prolapse, and need for repeat continence surgery. (56)

Pharmacotherapy 

The pharmacologic treatment of SUI aims to increase urethral closure forces by increasing tone in the urethral smooth muscle or by improving the tone of the striated muscles in the urethra and pelvic floor. Although several medications have been used off-label to treat SUI, the results have been largely disappointing, in part because of inconsistent treatment efficacy but also because of adverse reactions. The use of many of these pharmacologic agents is based more on tradition than on evidence.

Hormone replacement therapy, mostly in the form of estrogens, has been used for many years to treat SUI in postmenopausal women. Estrogen, because of its trophic effects on the urethral epithelium, subepithelial vascular plexus, and connective tissue, (79) was considered a prime candidate for SUI therapy, but results of clinical trials have been disappointing. Recently, Al-Badr et al (80) examined five major databases for literature on the effectiveness of estrogens, with or without progestins, in treating SUI. Although symptomatic or clinical improvement was reported in nonrandomized studies, randomized trials did not document a benefit of estrogen therapy, with or without progestins, among postmenopausal women with SUI. (80) There is also evidence that postmenopausal hormone therapy may increase the risk of development of UI. (81,82) In light of recent studies revealing that long-term estrogen use increases the risk of stroke, heart attack, and breast and ovarian cancer, (83-85) estrogen and progestins have become a less attractive treatment modality for SUI.

Medications with [alpha]-adrenergic agonist properties have been the mainstay of pharmacotherapy for SUI. Examples of these agents used off-label are the nonsubtype-selective agonists ephedrine, pseudoephedrine, norephedrine (synonymous with phenylpropanolamine or PPA), and norfenefrine, as well as the subtype-selective [alpha]1-adrenergic receptor agonists midodrine and methoxamine. These agents stimulate urethral smooth muscle contraction during bladder filling and voiding, continuously increasing the urethral closure. (86) Ephedrine and norephedrine have been found to be effective in SUI in some clinical trials (87) and have also been used in combination with estrogens and other nonsurgical treatments, such as pelvic floor exercises and electrical stimulation. (88,89) However, the clinical usefulness of direct, peripherally acting subtypeselective agonists may be limited by systemic side effects (90,91) and the risk of urinary retention. (92) Because of the risk of hemorrhagic stroke in women, PPA was withdrawn from the US market by the FDA in 2000. (93,94)

Anticholinergic (antimuscarinic) agents, including tolterodine and oxybutynin, are indicated for the treatment of bladder overactivity and are sometimes prescribed off-label for SUI. Anticholinergic agents decrease the tendency of the bladder to contract inappropriately by blocking acetylcholine binding at its peripheral (muscarinic) receptor on the bladder smooth muscle (95); however, an anticholinergic effect on the urethral muscles has not been documented. Pharmacotherapy of SUI with tolterodine has not proven to be any more effective than placebo. (96) There have been no controlled trials with oxybutynin in the treatment of SUI.

Recent studies have demonstrated that serotonin (5-HT) and norepinephrine neurotransmitters play an important role in the micturition cycle, and new pharmacologic opportunities to treat SUI are currently being investigated. (97,98) Specifically, pharmacotherapies aimed at increasing neural activity to the striated urethral sphincter, or rhabdosphincter, may show promise in reducing the incidence of SUI episodes. (99) The motor neurons innervating the rhabdosphincter exhibit unique neuroanatomic and neurochemical characteristics that offer possible therapeutic targets for pharmacologic intervention in the treatment of SUI.

In an animal model, duloxetine, a dual 5-HT and norepinephrine reuptake inhibitor, enhances external urethral sphincter activity and increases bladder capacity by suppressing parasympathetic activity and enhancing sympathetic and somatic activity in the lower urinary tract. (99) In placebo-controlled phase 2 and phase 3 studies, duloxetine (80 mg/d) was associated with significant decreases in incontinence episode frequency (IEF) that paralleled improvements in the Patient Global Impression of Improvement rating and the Incontinence Quality of Life (I-QOL) score. (100-103) The median decreases in IEF ranged from 50 to 64% for duloxetine in comparison to 27 to 41% for placebo; these changes were associated with significant increases in voiding intervals (15 to 24 minutes), indicating the incontinence improvement did not result from more frequent emptying of the bladder as a behavior learned during the trial. (100-103) In a subgroup analysis of these patients comparing efficacy between individuals 45 to 65 years and over 65 years, the decrease in IEF for patients 65 years of age or older was slightly diminished for both the duloxetine and placebo groups, but the treatment difference was maintained. (104)

Conclusion

Stress urinary incontinence among the active elderly is a medical, social, and economic problem worldwide, but despite the refinement in diagnoses and treatment options, many elderly women do not seek treatment. SUI is usually influenced by several contributing factors and best responds to treatment of multiple aspects. Recent advances in understanding how the central nervous system controls lower urinary tract function have opened new avenues for treatment of SUI. With greater education, refinements in diagnosis, and new treatment options available, continence and greater independence in living may be achieved in the many active elderly patients with SUI.

A doctor can bury his mistakes but an architect can only advise his
clients to plant vines.
--Frank Lloyd Wright

Table 1. Risk factors for stress urinary incontinence in elderly
women (a)

Risk factor             Comments/supporting literature

Age                     Independent risk of age is not clear. Prevalence
                          of SUI appears to increase up to fifth decade;
                          prevalence of UUI increases almost in linear
                          fashion, especially after
                          menopause. (19,105-108)
Familial disposition    Women, whose mother and/or older sisters have
                          UI, have an increased risk for SUI and MUI
                          and more severe symptoms. (108)
Race                    SUI more prevalent in white than Hispanic and
                          black women. (10,109)
Pregnancy, mode of      SUI risk increases with prolonged second-stage
  delivery, and parity    labor, episiotomy, and instrumental delivery.
                          Women with incontinence and no remission after
                          first pregnancy and delivery have 92% risk of
                          SUI and 60% risk of UUI 5 years
                          later. (10,50,52,54,110)
Menopause/lack of       Impact on SUI and UUI is controversial. A
  estrogen                meta-analysis has reported that estrogen
                          replacement might reduce UUI. (10,83)
Obesity/body mass       SUI and UUI risk is related to a chronic strain
  index increase          on the pelvic floor. (10,111)
Constipation            Though SUI is more prevalent in women with
                          constipation, the relation is controversial.
                          Stress on the pelvic floor is postulated
                          mechanism. (112,113)
Pelvic organ prolapse   SUI and pelvic organ prolapse often coexist;
                          with protrusion > 1 cm distal of the hymen,
                          urinary retention should be considered. (3)
Pelvic surgery/         Hysterectomy may increase long-term
  hysterectomy            risk. (54,114)
Chronic obstructive     Smoking can cause chronic cough and has
  lung disease            anti-estrogenic effect; repeated and
                          irreversible increased abdominal pressure due
                          to coughing, emphysema. (113,115,116)
Neurologic disorders    Transient ischemic attack, stroke, Parkinson
                          disease, multiple sclerosis, dementia, and
                          diabetic neuropathy may be responsible for SUI
                          or urinary retention. (53,113,117-121)
Impaired mobility,      Can cause functional UI, but other types of UI
  impaired daily          should be ruled out. (9,106,122)
  living activities
Prior radiation         Different tissue damages causing UI. (54)

(a) SUI, stress urinary incontinence; UUI, urge urinary incontinence;
MUI, mixed urinary incontinence.

Table 2. Key aspects of diagnostic evaluation in elderly women (a)

Diagnostic tool

Patient history           Clarifies type, severity, and bothersomeness
                            of urinary incontinence. A voiding diary may
                            be added to clarify history and change
                            improper drinking or voiding habits but is
                            often not necessary if a thorough history is
                            obtained.
Gynecologic examination   May reveal pelvic mass, mucosal atrophy, or
                            genital prolapse.
Rectal examination        May reveal constipation and anal/rectal
                            tumors.
Urinalysis                Will rule out contributing factors such as
                            pyuria (infection), hematuria (infection,
                            stones or cancer), proteinuria (renal
                            disease), and glycosuria (diabetes).
Cough stress test         Office staff can be trained to perform a
                            simple cough stress test. When the patient
                            feels as if she can void, she can be brought
                            to the restroom and prepped to obtain a
                            clean urine specimen for urinalysis. While
                            standing near the commode with paper towels
                            on the floor, she should be asked to cough
                            forcefully once. A positive stress test is
                            indicated by leakage simultaneous with
                            coughing. Some women will have cough induced
                            detrusor instability and will initiate
                            voiding after the cough; this is not a
                            positive cough stress test. The cough test
                            can be repeated in the supine position
                            during the pelvic examination. Leakage in
                            the supine position with a relatively empty
                            bladder may indicate more severe SUI and/or
                            ISD.
Postvoid residual volume  Indications for a postvoid residual volume in
                            an elderly woman are history of diabetes or
                            neurologic disorders such as multiple
                            sclerosis or spinal cord injury, history of
                            recurrent urinary tract infections, symptoms
                            of voiding difficulty in addition to stress
                            urinary incontinence, or a large pelvic
                            organ prolapse such as a cystocele on
                            physical examination.

(a) SUI, stress urinary incontinence; ISD, intrinsic sphincter
deficiency.

Table 3. Management of reversible conditions that cause or contribute to
urinary incontinence in elderly women

Condition                   Management

Excess fluid intake         Reduction in intake of especially diuretic
                              fluids (eg, caffeinated beverages)
Urinary tract infection     Antimicrobial therapy
Atrophic vaginitis/         Oral or topical estrogen (estrogenic use is
  urethritis                  increasingly challenged)
Stool impaction             Disimpaction, stool softeners, bulk-forming
                              agents, and laxatives if necessary,
                              high-fiber intake, adequate mobility and
                              fluid intake
Metabolic (hyperglycemia,   Better control of diabetes mellitus
  hypercalcemia)
                            Therapy for hypercalcemia depends on
                              underlying cause.
Venous insufficiency with   Support stocking, leg elevation, sodium
  edema                       restriction, diuretic therapy
Chronic congestive          Medical therapy
  heart failure
Chronic or intermittent     Intensify, if possible, treatment of cold,
  cough or sneezes            asthma, or allergy
Chronic illness, injury,    Regular toileting, use of toilet
  or restraint that           substitutes, environmental alterations
  interferes with mobility    (eg, bedside commode, urinal)
Psychologic                 Remove restraints if possible. Appropriate
                              pharmacologic and/or nonpharmacologic
                              treatment
Delirium                    Diagnosis and treatment of underlying
                              cause(s) of acute confusional state
Medications                 Suspend or modify use of diuretics, alpha
                              blockers and angiotensin-converting enzyme
                              inhibitors (the latter of which can
                              exacerbate cough)

Table 3 is adapted from AHCPR Publication No. 96-0686, 1996. (123)

Table 4. Treatment options for women with stress urinary
incontinence (a)

Treatment               Examples                  Comments

Lifestyle modification  Limiting fluid intake     Patients may not be
  (limit risk factors)    (including caffeine),     willing to adopt
                          stopping smoking,         behavioral changes
                          reducing weight,          or modify lifestyle.
                          double and triple         Limited efficacy in
                          voiding                   patients with severe
                                                    SUI. Require
                                                    adherence over time.
Pelvic floor muscle     Pelvic floor muscle       The treatment regimen
  training/Kegel          training with or          must be intense and
  exercises               without vaginal           repeated often to
                          weights/cones             maintain continued
                                                    benefit. Compliance
                                                    with the regimen
                                                    tends to decrease
                                                    over time.
Bladder training        Requires the patient      Generally used in
                          to void at regular        UUI, but has been
                          and progressively         applied in older
                          longer intervals of       women with SUI.
                          up to 3 hours during      Cure rates are
                          a training period of      variable and
                          at least 3 weeks.         long-term effect
                                                    is unknown.
Electrical stimulation  Stimulation of the        Efficacy for SUI is
                          pelvic floor using a      controversial and
                          wide variety of           placebo-controlled
                          current types,            studies are
                          frequencies,              warranted.
                          intensities, and
                          electrode placements.
Continence surgery      Burch retropubic          Acute risks are
                          colposuspension,          urinary retention,
                          anterior colporrhaphy,    wound infection,
                          suburethral sling         urinary tract
                          procedures (eg,           infection, surgical
                          tension-free vaginal      injury, bleeding,
                          tape)                     time lost from work
                                                    or other activities,
                                                    and expense. Long-
                                                    term complications
                                                    such as painful
                                                    urination,
                                                    development of UUI,
                                                    reoccurrence of SUI,
                                                    and pelvic organ
                                                    prolapse, may
                                                    develop.
                                                  Long-term efficacy of
                                                    Burch tends to
                                                    diminish over time
                                                    with 27% of women
                                                    having a positive
                                                    stress test, 25%
                                                    having a positive
                                                    24-hour pad test,
                                                    and 73% reporting
                                                    stress or urge
                                                    incontinence 5 to 10
                                                    years after surgery.
                                                    However, the
                                                    majority of reported
                                                    success rates after
                                                    surgery is not based
                                                    on randomized,
                                                    controlled trials
                                                    analyzed with ITT
                                                    statistics. (75)
Devices                 Vaginal or urethral       Problems vary by
                          devices to support        device and may
                          the bladder neck or       include patient
                          act as occlusive or       inconvenience, low
                          obstructive               compliance,
                          mechanisms                migration into
                                                    vagina, and urinary
                                                    tract infections.
Pharmacologic therapy   [alpha]-adrenergic        No drug therapy is
                          agonists (eg,             widely indicated
                          pseudoephedrine,          for SUI because of
                          midodrine), estrogens     lack of efficacy and
                          (eg, conjugated           significant side
                          estrogens, estradiol),    effects. Clenbuterol
                          tricyclic                 is indicated in
                          antidepressants (eg,      Japan, midodrine in
                          imipramine, doxepin)      Portugal, and
                                                    phenylpropanolamine
                                                    in Finland.

(a) SUI, stress urinary incontinence; UUI, urge urinary incontinence;
ITT, intention-to-treat.

Acknowledgment

The authors express appreciation to Christopher Dant, PhD, Stanford University, for assistance in the preparation of the manuscript.

Accepted August 27, 2004.

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RELATED ARTICLE: Key Points

* Stress urinary incontinence (SUI) among the active elderly is a medical, social, and economic problem worldwide, but despite the refinement in diagnoses and treatment options, many elderly women do not seek treatment.

* Stress urinary incontinence is usually influenced by several contributing factors and best responds to treatment of multiple aspects.

* Recent advances in understanding how the central nervous system controls lower urinary tract function have opened new avenues for treatment of SUI.

* With greater education, refinements in diagnosis, and new treatment options available, continence and greater independence in living may be achieved in the many active elderly patients with SUI.

Lars Viktrup, MD, PHD Stephanie Koke, MS, Kathryn L. Burgio, PHD, and Joseph G. Ouslander, MD

From Lilly Research Laboratories, Indianapolis, IN; Department of Family Medicine of Indiana University School of Medicine; the University of Alabama at Birmingham School of Medicine and Birmingham VA Medical Center, Birmingham, AL; and the Division of Geriatric Medicine and Gerontology, Wesley Woods Center of Emory University, Atlanta, GA.

Kathryn L. Burgio and Joseph G. Ouslander have served on advisory boards for and have consulting agreements with Eli Lilly and Company and Boehringer Ingelheim. Lars Viktrup and Stephanie Koke are both full-time employees of Eli Lilly and Company and hold stock and/or stock options in the company.

Reprint requests to Dr. Joseph G. Ouslander, Wesley Woods Center of Emory University, 1841 Clifton Road NE, Atlanta, GA 30329. Email: [e-mail]