What is the medical treatment of choice for elderly females with urinary incontinence?

Medical Treatment of Choice for Elderly Females with Urinary Incontinence

The medical treatment of choice for elderly females with urinary incontinence depends on the type of incontinence, with first-line treatments being non-pharmacological: pelvic floor muscle training for stress incontinence, bladder training for urgency incontinence, and a combination of both for mixed incontinence. 1, 2

Types of Urinary Incontinence in Elderly Women

Urinary incontinence affects approximately 75% of elderly women (aged 75+ years) and is categorized into different types:

• Stress incontinence: Involuntary urine leakage with increased abdominal pressure (coughing, sneezing)
• Urgency incontinence: Sudden compelling urge to void with involuntary leakage
• Mixed incontinence: Combination of stress and urgency components
• Overflow incontinence: Leakage due to bladder overdistention

Treatment Algorithm Based on Incontinence Type

1. Stress Urinary Incontinence

• First-line: Pelvic floor muscle training (PFMT) (strong recommendation, high-quality evidence) 1

  • Supervised PFMT can result in up to 70% improvement in symptoms 2
  • Should be evaluated after 8-12 weeks of supervised training
  • PFMT with biofeedback using vaginal EMG shows superior results compared to PFMT alone 2

• Avoid: Systemic pharmacologic therapy (strong recommendation, low-quality evidence) 1

2. Urgency Urinary Incontinence

• First-line: Bladder training (strong recommendation, moderate-quality evidence) 1

  • Behavioral therapy that includes extending time between voiding
  • Offering bathroom access every 2 hours during day, every 4 hours at night 2

• Second-line: Pharmacologic treatment if bladder training unsuccessful (strong recommendation, high-quality evidence) 1

  • Anticholinergic medications (e.g., solifenacin, tolterodine)
    • Solifenacin 5mg reduces incontinence episodes by 1.5 per 24 hours 3
    • Solifenacin 10mg reduces incontinence episodes by 1.8 per 24 hours 3
  • Choice based on tolerability, adverse effect profile, ease of use, and cost 1
  • Caution: Anticholinergics have more side effects in elderly patients

3. Mixed Urinary Incontinence

• First-line: Combination of PFMT with bladder training (strong recommendation, moderate-quality evidence) 1
• Second-line: Consider pharmacologic treatment if urgency component predominates and is not controlled with behavioral therapy

Additional Interventions for All Types

Lifestyle Modifications

• Weight loss and exercise for obese women (strong recommendation, moderate-quality evidence) 1, 2

  • Number needed to benefit: 4 2

• Adequate hygiene and skin care

  • Frequent cleaning with mild soap and water 2
  • Barrier creams to protect skin from irritation 2
  • Immediate changing of wet clothing 2

• Fluid management

  • Reduce fluid intake at night to decrease nocturnal incontinence 2
  • Maintain adequate daytime hydration

Management of Contributing Factors

• Treat urinary tract infections promptly 2
• Evaluate and manage functional/cognitive impairment that may affect toileting ability
• Review medications that may worsen incontinence (diuretics, sedatives)

Comparative Effectiveness of Treatments

For urgency incontinence, behavioral treatment has shown superior effectiveness compared to drug treatment:

• Behavioral treatment: 80.7% reduction in incontinence episodes
• Drug treatment: 68.5% reduction in incontinence episodes
• Placebo: 39.4% reduction 4

Patient satisfaction is also higher with behavioral treatments, with only 14% wanting to change treatments versus 75.5% in medication groups 4.

Common Pitfalls and Caveats

1. Failure to identify the specific type of incontinence before initiating treatment
2. Premature use of medications before trying behavioral interventions
3. Inadequate duration of behavioral therapy (minimum 8-12 weeks needed)
4. Overlooking contributing factors like UTIs, medications, or functional limitations
5. Using absorbent products as the sole management strategy rather than as an adjunct to specific treatments
6. Assuming incontinence is a normal part of aging and therefore untreatable 5

Special Considerations for Elderly Women

• Supervised PFMT programs are more effective than unsupervised or leaflet-based care 6
• Annual screening for urinary incontinence is recommended for women of all ages 2
• Avoid permanent catheterization whenever possible due to infection risk 2
• Consider intermittent catheterization if post-void residual volume is >100 ml 2

The goal of treatment should be to reduce incontinence episodes by at least 50%, which is considered clinically successful treatment 1, 2. With appropriate assessment and targeted treatment, the majority of elderly women with urinary incontinence can achieve significant improvement in symptoms and quality of life.