What is the best approach to treating urinary incontinence in older women with a urinary tract infection (UTI)?

Treatment of Urinary Incontinence in Older Women with UTI

Treat the acute UTI first with appropriate antibiotics, then address the underlying urinary incontinence with behavioral interventions as first-line therapy, recognizing that UTI itself is a risk factor for incontinence in this population.

Immediate Management: Treat the Acute UTI

The presence of a UTI requires prompt antimicrobial treatment before addressing the incontinence, as the infection may be contributing to or exacerbating the incontinence symptoms 1.

Antibiotic Selection for Older Women

• Obtain urine culture before initiating treatment to guide therapy and confirm the diagnosis 2
• Empiric treatment options (adjust based on local resistance patterns) 2:
  • Trimethoprim-sulfamethoxazole (160/800 mg twice daily) if local E. coli resistance is <20%
  • Ciprofloxacin 250 mg twice daily (use cautiously due to increasing resistance and adverse effects in elderly)
  • Nitrofurantoin 100 mg twice daily (effective even with mild-moderate renal impairment) 3

Treatment Duration

• 3-day course is sufficient and preferred for uncomplicated UTI in older women 4
• A 3-day course of ciprofloxacin 250 mg twice daily achieved 98% bacterial eradication versus 93% with 7-day treatment, with significantly fewer adverse events in the shorter course 4
• Short-course treatment (3-6 days) is as effective as longer courses for uncomplicated UTIs in elderly women 5

Common Pitfall: Avoid treating asymptomatic bacteriuria, which is present in 15-50% of elderly women and does not require antibiotics 2. Only treat if the patient has acute urinary symptoms (dysuria, urgency, frequency) or systemic signs of infection.

Subsequent Management: Address the Urinary Incontinence

Once the acute UTI is treated, determine the type of incontinence and initiate appropriate therapy.

First-Line Behavioral Interventions (Start Immediately After UTI Treatment)

For Stress Incontinence:

• Pelvic floor muscle training (Kegel exercises) is the first-line treatment with strong recommendation and high-quality evidence 1

For Urgency Incontinence:

• Bladder training is the first-line treatment with strong recommendation and moderate-quality evidence 1
• This involves behavioral therapy that includes extending the time between voiding 1

For Mixed Incontinence (common in older women):

• Combine pelvic floor muscle training with bladder training as first-line therapy 1

Additional Behavioral Modifications

• Adequate hydration (1.5-2L daily), timed voiding schedules, and pelvic floor exercises 2
• Weight loss and exercise for obese women with UI (strong recommendation, moderate-quality evidence) 1

Pharmacologic Treatment (Second-Line)

Only consider pharmacologic therapy if behavioral interventions fail:

• For urgency incontinence: Pharmacologic treatment is recommended only after unsuccessful bladder training 1
• Base medication choice on tolerability, adverse effect profile, ease of use, and cost 1
• Avoid systemic pharmacologic therapy for stress incontinence (strong recommendation against) 1

Critical Consideration in Elderly: Use anticholinergic medications cautiously due to anticholinergic burden in elderly patients, which can cause cognitive impairment, constipation, and dry mouth 2.

Prevention of Recurrent UTIs (If Applicable)

Since UTI is a risk factor for incontinence 1, preventing recurrent UTIs is essential:

Non-Antimicrobial Prevention (Preferred First-Line)

• Vaginal estrogen replacement is strongly recommended for postmenopausal women to prevent recurrent UTIs 2
• Atrophic vaginitis due to estrogen deficiency is a major risk factor for UTIs in elderly women 2
• Methenamine hippurate is strongly recommended for women without urinary tract abnormalities 2
• Cranberry products (minimum 36 mg/day proanthocyanidin A) may reduce recurrent UTIs 1

Antimicrobial Prophylaxis (Only After Non-Antimicrobial Interventions Fail)

• Continuous daily antibiotic prophylaxis for 6-12 months can be offered for recurrent UTIs 1
• Options include: trimethoprim-sulfamethoxazole, nitrofurantoin, or trimethoprim 1
• Post-coital antimicrobial prophylaxis is an alternative strategy 1

Key Clinical Pitfalls to Avoid

• Do not attribute all urinary symptoms to UTI in elderly women—many have chronic urinary symptoms from incontinence, overactive bladder, or other conditions 2
• Do not treat asymptomatic bacteriuria with antibiotics, as it does not improve outcomes and contributes to antibiotic resistance 2
• Do not rely solely on urine dipstick tests in elderly women, as specificity ranges from only 20-70% 2
• Negative nitrite and leukocyte esterase strongly suggest absence of UTI, and absence of pyuria is particularly useful to exclude urinary source 2