Urinary Incontinence — Overview

•    Very common in older adults

•    Associated with:

o    Falls

o    Depression

o    Institutionalisation

•    Key types: urge, stress, overflow, functional (sometimes separately discussed)

Urge Incontinence

Mechanism

•    Detrusor overactivity → involuntary bladder contractions

•    Common triggers: running water, cold exposure, urgency

Causes

•    Idiopathic (most common)

•    Neurological disease:

o    Stroke

o    Parkinson’s disease

o    Multiple sclerosis

Management

•    First-line: bladder retraining (timed voiding, delayed voiding techniques)

•    Reduce caffeine, alcohol

•    Antimuscarinics (e.g., oxybutynin, tolterodine, solifenacin)

o    Avoid in frail elderly → risk of confusion, falls, constipation, dry mouth

•    Beta-3 agonists (e.g., mirabegron): alternative if antimuscarinics not tolerated

Stress Incontinence

Mechanism

•    Pelvic floor muscle weakness or urethral sphincter incompetence

•    Leakage with ↑ intra-abdominal pressure: coughing, laughing, lifting

Causes

•    Postpartum

•    Postmenopausal (oestrogen deficiency)

•    Obesity

Management

•    First-line: pelvic floor muscle training (at least 3 months)

•    Lifestyle modifications (weight loss, smoking cessation)

•    Pessary (in pelvic organ prolapse)

•    Pharmacotherapy:

o    Duloxetine (serotonin-noradrenaline reuptake inhibitor)

    Second-line option; increases urethral sphincter tone

    Side effects: nausea, insomnia

•    Surgery: mid-urethral sling, colposuspension

Overflow Incontinence

Mechanism

•    Bladder overdistension due to impaired emptying

•    Leads to continuous dribbling ± palpable bladder

Causes

•    Obstructive:

o    Benign prostatic hyperplasia (BPH)

o    Urethral stricture

o    Pelvic mass

•    Neuropathic (detrusor underactivity):

o    Diabetes mellitus (autonomic neuropathy)

o    Spinal cord lesions (e.g., MS, cauda equina)

Management

•    Immediate: catheterisation to relieve retention

•    Treat underlying cause (e.g., alpha-blockers for BPH, surgery if needed)

•    Intermittent self-catheterisation for chronic cases

Functional Incontinence

Concept

•    Inability to reach toilet in time due to:

o    Cognitive impairment (e.g., dementia)

o    Mobility issues

o    Environmental barriers

Management

•    Address mobility aids, improve toilet access

•    Scheduled toileting assistance

•    Continence products as supportive measure

Extra Revision Pearls

•    Post-void residual volume:

o    100 mL suggests incomplete emptying (overflow component)

•    Antimuscarinics caution:

o    Avoid in narrow-angle glaucoma

o    Avoid in elderly with cognitive impairment

•    Conservative measures first-line for all types whenever possible

•    Urodynamic studies:

o    Usually reserved if diagnosis uncertain or before surgical interventions