Workup for Overflow Incontinence in Elderly Women
Begin by systematically identifying and treating reversible causes—urinary tract infection, fecal impaction, medications, urinary retention, and restricted mobility—before proceeding to more complex evaluation, as these account for the majority of overflow incontinence cases in elderly women. 1, 2
Initial Clinical Assessment
History and Physical Examination
- Document voiding patterns using a frequency-volume chart for 3-7 days to objectively measure daytime frequency, nighttime frequency, voided volumes, and incontinence episodes 3
- Assess for symptoms of incomplete bladder emptying: sensation of fullness after voiding, weak urinary stream, need to strain to void, and continuous dribbling 4, 5
- Evaluate functional status and mobility, as restricted mobility and cognitive impairment are critical risk factors that alter treatment approach in elderly women 1, 2, 3
- Perform pelvic examination to identify atrophic vaginitis, cystocele, prolapse, and vaginal candidiasis—all treatable causes of overflow incontinence in elderly women 1, 2
- Check for fecal impaction via rectal examination, as this is a frequently overlooked reversible cause in elderly patients 1, 2
Medication Review
- Review all medications for drugs that can cause or worsen urinary retention: anticholinergics, antihistamines, opioids, calcium channel blockers, and alpha-adrenergic agonists 1
Laboratory and Diagnostic Testing
Essential Tests
- Obtain urinalysis and urine culture to identify urinary tract infection, which is a common reversible cause of incontinence in elderly women 1, 6
- Measure post-void residual (PVR) urine volume using bladder ultrasound or catheterization; PVR >200 mL suggests significant retention and overflow incontinence 5, 7
- Screen for metabolic causes: check blood glucose and hemoglobin A1c to identify uncontrolled diabetes causing polyuria and neurogenic bladder 1, 2
Additional Evaluation When Indicated
- Consider renal function testing if chronic retention is suspected, as hydronephrosis can develop from prolonged high bladder pressures 8
- Refer for urodynamic testing if the diagnosis remains unclear after basic workup, or if surgical intervention is being considered 8, 7
Common Pitfalls to Avoid
Critical Reversible Causes Not to Miss
- Do not overlook atypical UTI presentations in elderly patients, who may present with confusion or functional decline rather than classic dysuria symptoms 2, 3
- Always check for fecal impaction, as it is frequently missed and easily treatable 1, 2
- Recognize that neurogenic bladder from diabetes is a specific risk factor for overflow incontinence in elderly women with diabetes, requiring evaluation of glycemic control 1
Evaluation Errors
- Do not rely solely on patient report of voiding patterns; objective documentation with voiding diaries is essential 3
- Do not assume all incontinence in elderly women is stress or urge type; overflow incontinence requires different management and can lead to serious complications if missed 4, 5
Treatment Approach After Workup
Address Reversible Causes First
- Treat acute UTI with appropriate antibiotics based on culture results before addressing underlying incontinence 6
- Disimpact if fecal impaction is present and establish bowel regimen to prevent recurrence 1
- Discontinue or substitute offending medications when possible 1
- Optimize diabetes control if polyuria or neurogenic bladder is contributing 1
Management of Persistent Overflow Incontinence
- Initiate clean intermittent catheterization as first-line therapy for neurogenic bladder causing overflow incontinence, though this increases risk of catheter-associated UTI 5
- Consider alpha-1-blockers for overflow incontinence if bladder outlet obstruction is present, though this is less common in women than men 9, 5
- Vaginal estrogen replacement is strongly recommended for postmenopausal women to improve atrophic changes and prevent recurrent UTIs 6, 2
- Reserve chronic indwelling catheterization only for cases with clinically significant urinary retention that cannot be managed otherwise, severe illness, or skin conditions that cannot heal due to incontinence 8