Urinary Incontinence in the Aging Female

Etiology, Pathophysiology and Treatment Options

Alex Gomelsky; Roger R Dmochowski

Disclosures

Aging Health. 2011;7(1):79-88. 

In This Article

Abstract and Introduction

Abstract

Not only does the prevalence of incontinence increase with age, but the incidence does as well, in no small part due to the greater recognition of its signs and symptoms and the significant negative impact on quality of life. Elderly women differ from their younger counterparts by the presence of several physiologic changes in the urinary tract, as well as the presence of concomitant morbidity and polypharmacy. While the elderly have the same treatment options as younger women, they may experience a greater incidence of adverse events due to urologic and nonurologic factors. The objective of this article is to elucidate the unique changes in the elderly population and summarize the treatment options.

Introduction

The Fourth International Consultation on Incontinence recently redefined the signs, symptoms, urodynamic observations and conditions associated with lower urinary tract symptoms and urodynamic studies.[1] The symptoms of lower urinary tract symptoms were categorized into several distinct types of incontinence. Stress urinary incontinence (SUI) is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Urgency urinary incontinence (UUI) is the complaint of involuntary leakage accompanied or immediately preceded by urgency. Mixed urinary incontinence (MUI) refers to the complaint of involuntary leakage associated with urgency and also with effort, exertion, sneezing and coughing. Nocturnal enuresis is any involuntary loss of urine during sleep. Postmicturition dribble and continuous urinary leakage denotes other symptomatic forms of incontinence. Overactive bladder (OAB) is characterized by the storage symptoms of urgency with or without urgency incontinence, usually with frequency and nocturia. Continuous incontinence may develop as a byproduct of a postsurgical vesicovaginal fistula or mesh erosion into the bladder or urethra following pubovaginal sling or mesh-augmented pelvic prolapse repair.

Urinary incontinence is a major problem in the elderly population and several emerging trends deserve particular mention. First, there is abundant evidence that the population is rapidly aging. A report by the US Census Bureau noted that, while the total US population has increased twofold in the past century, the population of Americans aged 60 years and older has increased tenfold.[101] In the year 2000, the estimate approached 35 million individuals. The number of Americans over age 80 years in particular, is expected to increase by almost 70% between the years 2000 and 2030. Second, incontinence is increasingly common in the aging population. An analysis of over 3100 responses to a medical questionnaire showed that the estimated incidence of incontinence increased steadily with age.[2] By age 59 years, 30% of individuals were estimated to have had one or more episodes of incontinence in general and 18% had incontinence episodes as defined by the International Continence Society. The Australian Longitudinal Study of Women's Health (ALSWH) recently reported the 10-year longitudinal evaluation of the continence status of women aged 70–75 years in 1996 and who completed four health surveys over the next 10 years.[3] Over this time, 14.6% (95% CI: 13.9–15.3%) of the women in the study who had previously reported leaking urine 'rarely' or 'never' developed incontinence, and 27.2% (95% CI: 26.2–28.3%) of women participating in Survey 4 in 2005 reported leaking urine 'sometimes' or 'often' in the survey, with women being twice as likely to report incontinence in Survey 4 as they were 6 years earlier. Longitudinal models demonstrated the association between incontinence and dementia, dissatisfaction with physical ability, falls to the ground, BMI, constipation, urinary tract infection (UTI), history of prolapse and prolapse repair.

The prevalence of different types of incontinence is also considerable. A US study of 5204 adults who participated in a validated telephone survey revealed that OAB with UUI in women increased more than ninefold, from 2.0% in those 18–24 years of age to 19.1% among those 65–74 years of age.[4] A marked increase was observed after 44 years of age. Likewise, the prevalence of SUI has been reported to be as high as 40% in women aged 70 years and older, with a third of these women classifying their incontinence as severe.[5,6] The most common type of incontinence may also change with increasing age. When the prevalence rates of different types of incontinence were stratified by frequency and age, 55% of women under 60 years of age were found to have pure SUI, while 20 and 25% had UUI and MUI, respectively.[7] In comparison, SUI accounted for only 30% of incontinence cases in women aged 60 years and older, while UUI and MUI each accounted for 35% of cases in this age group. Incontinence may also make a significant impact on a woman's quality of life (QoL). In a national sample of over 3400 women from the National Survey of Self-Care and Aging, urinary incontinence was positively and independently associated with poor self-rated health.[8] This relationship remained significant after adjustments for comorbidity and frailty. When cross-sectional data from a population-based cohort of over 2100 middle-aged or older women were analyzed, more than 28% reported weekly incontinence.[9] SUI, UUI and MUI were reported in 37, 31 and 21% of the cohort, respectively. MUI was associated with a greater impact on QoL than either SUI or UUI, independent of age, race, health or incontinence severity.

Finally, the costs of managing urinary incontinence in the elderly are substantial and continue to rise. For individuals 65 years of age and older these costs were estimated to be US$8.2 billion in 1984 and $16.4 billion in 1993.[10] The 1995 societal cost of incontinence for individuals aged 65 years and older was $26.3 billion, or $3565 per individual with urinary incontinence. The total cost of urinary incontinence and OAB was $19.5 billion and $12.6 billion, respectively, in the year 2000.[11] With urinary incontinence, $14.2 billion was borne by community residents and $5.3 billion by institutional residents. With OAB, $9.1 and $3.5 billion was incurred by community and institutional residents, respectively. Analysis of Medicare claims for 1992, 1995 and 1998 confirmed that the costs of urinary incontinence among older women nearly doubled between 1992 and 1998 in nominal dollars, from $128 million to $234 million.[12] This increase was due almost entirely to increased out-patient costs, which increased from $25.4 million or 9.1% of total costs in 1992 to $329 million or 27.3% of total costs in 2000 in this group.[13] The cost of in-patient services increased only slightly during the reporting period.

While it is clear that urinary incontinence in the elderly is a prevalent, bothersome and costly problem, it is often dismissed as a normal part of aging by patients, caregivers and physicians. Most now believe that the increasing prevalence of incontinence is strongly associated with additional comorbidities and functional impairments that accompany growing older, rather than age itself.[14] The purpose of this article is to elucidate the unique physiological adaptations in the elderly female and to review the outcomes of treatment in this population.

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