What is the next step in managing an elderly female patient with intermittent urinary incontinence, intermittent fecal incontinence, and mild bilateral pelviectasis, with impaired renal function (eGFR 70, Creatinine 73)?

Management of Mild Bilateral Pelviectasis in an Elderly Female with Urinary and Fecal Incontinence

The mild bilateral pelviectasis is not clinically relevant in this case and requires no further imaging or intervention, as it has remained stable over time, the patient has no flank pain or hematuria, and her renal function is acceptable (eGFR 70). The primary focus should be on comprehensively evaluating and treating her urinary and fecal incontinence, which are the symptomatic issues affecting her quality of life.

Regarding the Pelviectasis Finding

• The stable mild bilateral pelviectasis with no flank pain, no hematuria, and preserved renal function (eGFR 70, Creatinine 73) does not warrant further imaging or urological referral. The initial ultrasound report itself recommended follow-up only if flank pain or hematuria were present, and the repeat study showed no progression. 1

• No additional imaging or intervention is needed for the pelviectasis at this time, as it represents an incidental finding without clinical significance in this context.

Priority: Address the Symptomatic Incontinence Issues

The patient's intermittent urinary and fecal incontinence are the clinically significant problems requiring systematic evaluation and management.

Step 1: Identify and Treat Reversible Causes

Begin by systematically evaluating for reversible causes of incontinence, as these account for the majority of cases in elderly women and must be addressed before proceeding to chronic management strategies. 1, 2, 3

Evaluate for:

• Urinary tract infection: Obtain urinalysis and urine culture, as UTI is a common reversible cause of incontinence in elderly women and may present with atypical symptoms. 1, 2, 4, 3

• Fecal impaction: Perform rectal examination, as this is a frequently overlooked reversible cause in elderly patients and can contribute to both urinary and fecal incontinence. 1, 2, 3

• Medication review: Conduct a careful review of all current medications, as polypharmacy is common in elderly patients and certain drugs can cause or worsen incontinence. 1, 3

• Metabolic causes: Check blood glucose and hemoglobin A1c to identify uncontrolled diabetes causing polyuria or neurogenic bladder. 1, 2, 3

• Pelvic examination: Assess for atrophic vaginitis, cystocele, prolapse, and vaginal candidiasis—all treatable causes of incontinence in elderly women. 1, 2, 3

• Cognitive and functional status: Screen for cognitive impairment and assess mobility, as these affect the patient's ability to implement self-care and may indicate functional incontinence. 1, 3

Step 2: Determine the Type of Urinary Incontinence

Once reversible causes are addressed, determine whether the incontinence is stress, urge, overflow, mixed, or functional type using a targeted history, voiding diary, physical examination, and measurement of post-void residual volume. 5, 6, 7, 8

• The ultrasound already documented complete bladder emptying with no significant post-void residual (90 cc pre-void with complete emptying), which makes overflow incontinence less likely. 3

• Use a patient questionnaire and voiding diary to characterize symptoms and their impact on quality of life. 8

Step 3: Initiate First-Line Behavioral Therapies

Behavioral interventions are the first-line treatment for urinary incontinence in elderly women and should be initiated before or alongside pharmacological therapy. 4, 5, 7

For Stress Incontinence:

• Pelvic floor muscle training (Kegel exercises) is the first-line treatment with strong evidence. 4

For Urge Incontinence:

• Bladder training is the first-line treatment with strong evidence. 4

For Mixed Incontinence:

• Combine pelvic floor muscle training with bladder training. 4

Additional Behavioral Modifications:

• Adequate hydration (1.5-2L daily), timed voiding schedules, and pelvic floor exercises. 4, 3

• Weight loss and exercise programs if the patient is obese, as obesity is a significant modifiable risk factor. 2, 4, 3

Step 4: Consider Vaginal Estrogen Therapy

For this postmenopausal woman, vaginal estrogen replacement is strongly recommended to address atrophic changes, improve incontinence symptoms, and prevent recurrent UTIs. 2, 4, 3

Step 5: Address Fecal Incontinence

• If fecal impaction is present, perform disimpaction and establish a bowel regimen to prevent recurrence. 3

• Evaluate for other causes of fecal incontinence, including neurogenic bowel from diabetes, pelvic floor dysfunction, or sphincter damage.

Step 6: Pharmacological Therapy (If Behavioral Measures Insufficient)

If behavioral therapies are insufficient after adequate trial, consider pharmacological treatment based on the type of incontinence identified. 5, 6

For Urge Incontinence:

• Anticholinergic medications or beta-3 agonists can be added, though elderly patients are more susceptible to adverse effects and require careful monitoring. 5, 6

For Stress Incontinence:

• Alpha-adrenergic drugs combined with estrogen therapy in women. 5

Common Pitfalls to Avoid

• Do not use adult absorbent products as the initial response to incontinence; they should only be used as adjunctive management after specific treatments are implemented. 5

• Do not assume incontinence is a normal part of aging; it is never normal and warrants evaluation and treatment. 6

• Do not initiate chronic indwelling catheterization for incontinence management unless there is clinically significant urinary retention, skin breakdown that cannot heal, or severe illness making it the most comfortable option. 5

• Elderly patients may not volunteer incontinence symptoms, so direct questioning is essential. 7