Treatment of Urinary Incontinence in Elderly Women
Begin with behavioral interventions as first-line therapy: pelvic floor muscle training for stress incontinence, bladder training for urgency incontinence, or both combined for mixed incontinence—these are more effective than medications and have no adverse effects. 1
Step 1: Identify the Type of Incontinence
The treatment algorithm depends entirely on correctly classifying the incontinence subtype through targeted history:
- Stress incontinence: Leakage occurs with coughing, sneezing, laughing, or physical exertion due to urethral sphincter failure 1
- Urgency incontinence: Leakage accompanied by sudden, compelling urge to void 1
- Mixed incontinence: Combination of both patterns (common in elderly women) 1
Document voiding patterns using a frequency-volume chart for 3-7 days to objectively measure daytime frequency, nighttime frequency, voided volumes, and incontinence episodes. 2
Step 2: Screen for Reversible Causes Before Starting Treatment
Elderly women commonly have treatable conditions masquerading as primary bladder dysfunction. Evaluate for:
- Urinary tract infection (may present atypically with confusion or functional decline rather than dysuria) 1, 2, 3
- Uncontrolled diabetes causing polyuria 1
- Medications causing urinary symptoms (diuretics, sedatives, antidepressants) 1, 4
- Fecal impaction 1
- Excessive fluid intake or caffeine consumption 2, 4
- Restricted mobility and cognitive impairment 1, 2
Critical pitfall: Elderly patients with UTI may not report classic dysuria symptoms—look for new-onset confusion or functional decline. 2
Step 3: First-Line Treatment Based on Incontinence Type
For Stress Incontinence:
Pelvic floor muscle training (PFMT) is the first-line treatment with strong recommendation and high-quality evidence. 1, 2, 5
- Supervised program of repeated voluntary pelvic floor muscle contractions (Kegel exercises) 1, 5
- Reduces incontinence episodes by mean of 10.5 episodes per week 2
- Avoid systemic pharmacologic therapy for stress incontinence—it is not effective 1
For Urgency Incontinence:
Bladder training is the first-line treatment with strong recommendation and moderate-quality evidence. 1, 2, 5
- Behavioral therapy involving scheduled voiding with progressively extended intervals between voids 1, 5
- Reduces frequency and urgency episodes by mean of 5 episodes per week 2
- Behavioral treatment achieves 80.7% reduction in incontinence episodes 6
For Mixed Incontinence:
Combine pelvic floor muscle training with bladder training as first-line therapy. 1, 2, 5
- This combination shows odds ratio of 4.15 (95% CI: 2.70-6.37) for improvement in continence rates 2
Step 4: Address Obesity if Present
Weight loss and exercise are strongly recommended for obese women with any type of incontinence. 1, 5
- Particularly effective for stress incontinence 5
- Strong recommendation with moderate-quality evidence 1
Step 5: Consider Vaginal Estrogen for Postmenopausal Women
Vaginal estrogen formulations (not transdermal patches) improve stress incontinence and prevent recurrent UTIs in postmenopausal women. 2, 3
- Avoid transdermal estrogen patches—they worsen urinary incontinence 2
Step 6: Pharmacologic Therapy Only After Behavioral Interventions Fail
Reserve medications exclusively for urgency incontinence, and only after bladder training has been unsuccessful. 1, 2, 5
Medication Options for Urgency Incontinence:
- Tolterodine (preferred): Causes fewer adverse effects than oxybutynin while providing equivalent efficacy 2
- Oxybutynin: Effective but higher side effect burden 6
- Mirabegron (beta-3 agonist): Alternative option 2
Base medication choice on tolerability, adverse effect profile, ease of use, and cost. 1
Common Medication Side Effects:
- Dry mouth, constipation, heartburn, urinary retention 5
- Higher discontinuation rates compared to behavioral therapies 5
- Long-term safety data generally unavailable 5
Drug treatment achieves 68.5% reduction in incontinence episodes compared to 80.7% with behavioral treatment, making behavioral interventions superior. 6
Step 7: Monitor Treatment Response Objectively
- Continue frequency-volume charts to track improvement objectively rather than relying solely on patient report 2
- Clinically successful treatment is defined as ≥50% reduction in incontinence episodes 1, 2
- Reassess at 4-6 weeks to determine if behavioral interventions are effective before escalating to pharmacologic therapy 2
Critical Pitfalls to Avoid
- Never start medications before attempting behavioral interventions—behavioral therapies are more effective, have no adverse effects, cost less, and don't limit future treatment options 2, 5
- Don't provide inadequate PFMT instruction—proper technique and supervision are essential for success 5
- Don't overlook atypical UTI presentations in elderly patients who may present with confusion rather than dysuria 2
- Don't fail to address modifiable risk factors like obesity, constipation, and excessive fluid intake 5
When to Refer for Specialist Treatment
If conservative measures fail after adequate trial (4-6 weeks of behavioral therapy, followed by medication trial if appropriate), consider referral for: