Bladder & Bowel

Problems with bowel and bladder control become more common as we age; however, aging alone is not the primary cause of these problems. It is estimated that approximately 15% of individuals over 65 years of age, living at home, have problems with incontinence. The prevalence of bowel and bladder problems rises significantly when individuals are placed in residential settings.

Urinary Incontinence (UI)

Problems with bladder control often referred to as Urinary incontinence (UI) is a syndrome that can be caused by a combination of factors. Some of these factors occur in isolation while others occur in combination with each other. Age related changes can also contribute to problems with balder control. The American Geriatrics Society report that the prevalence of UI increases with age and affects women more than men (2:1) until age 80, after which men and women are equally affected. For people aged 65 years and over, 15% to 30% of individuals living in the community are incontinent and the prevalence for individuals in long-term care is at least 50%. Urinary incontinence can cause other medical problems, including cellulitis, pressure ulcers, urinary tract infections, falls with fractures, sleep deprivation, social withdrawal, depression, and sexual dysfunction. UI is not associated with increased mortality. UI impairs quality of life, affecting the older person's emotional well-being, social function, and general health. Incontinent persons often manage to maintain their activities, but with an increased burden of coping, embarrassment, and poor self-perception.

Urinary Incontinence (UI) and Caregiving

Caregiver burden is higher with incontinent older persons, which can contribute to decisions to institutionalize. According to the Utah Geriatrics Society, the estimated annual UI-related costs total more than $36 billion. For older persons in particular, continence requires mobility, manual dexterity, the cognitive ability to recognize and react to bladder filling, and the motivation to stay dry.

Risk Factors

Age-related changes in the lower urinary tract and are found in both continent and incontinent older persons. Why some older persons develop UI and others do not remains unclear. Any condition, medication, or factor that affects lower urinary tract function, volume status and urine excretion, or the ability to toilet can predispose a person to UI. Risk factors in community-dwelling older persons include advanced age, depression, transient ischemic attacks and stroke, congestive heart failure, fecal incontinence and constipation, obesity, chronic obstructive lung disease, chronic cough, diabetes mellitus, impaired mobility, and impaired activities of daily living. Among institutionalized older persons, UI is associated with impaired mobility, depression, stroke, diabetes mellitus, and Parkinson's disease; at least one third have multiple conditions. Although moderate to severe dementia is associated with UI, even severely demented persons remain continent if they have mobility for transfers. Thus, UI in demented persons may not be caused by dementia, but may be caused by multiple factors with treatable causes.

Clinical Types of Incontinence

Incontinence can be classified into diagnostic clinical types that are useful in planning evaluation and treatment.

1.  Transient Incontinence

Urinary incontinence that occurs as a result of treatable factors is called transient incontinence. Transient UI affects approximately one third of community-dwelling older persons and accounts for one half of the incontinence among hospitalized older persons. The causes of transient incontinence include: delirium, urinary infection, medications, some major psychiatric disorders stool impaction, restricted mobility, excessive fluid intake, diuretics, hyperglycemia, hypercalcemia, volume overload (congestive heart failure, venous insufficiency, hypothyroidism).

2.  Urge Incontinence

Urge UI is the most common type of UI in older persons. It is characterized by abrupt urgency and frequency. The volume of leakage may be small or large. The term overactive bladder refers to a condition with frequency, nocturia (the need to get up during the night to urinate), and urgency or urge UI, or both. Urge UI is associated with detrusor (bladder muscle) over activity (DO) that may be age-related, secondary to lesions in central inhibitory pathways (e.g., stroke, cervical stenosis), or due to local bladder irritation (infection, bladder stones, inflammation, tumors). Because DO is found in healthy, continent older persons, failure of lower urinary tract and functional compensatory mechanisms may play an important role in UI. Distinctions between detrusor hyperreflexia (DO associated with central nervous system lesions) and detrusor instability (DO without such lesions) are frequently blurred in the older persons. Less common causes of urge UI are interstitial cystitis (urge UI with otherwise unexplained pelvic pain) and spinal cord injury, which results in impaired detrusor compliance (excessive pressure response to filling) or detrusor-sphincter dyssynergia (concomitant detrusor and sphincter contraction), or both. DO may coexist with impaired detrusor contractility (detrusor hyperactivity with impaired contractility, or DHIC), with an elevated post void residual volume (PVR) in the absence of outlet obstruction. DHIC accounts for most established UI in frail older persons. Women can be misdiagnosed with stress UI if weak DHIC contractions are not detected, and men can be misdiagnosed with outlet obstruction because of the similarity of the symptoms (urgency, frequency, weak flow rate, and elevated residual urine). Persons with DHIC may be at increased risk for urinary retention if treated with bladder-relaxant drugs.

3.  Stress Incontinence

Stress UI, the second most common type of UI in older women, results from failure of the sphincter mechanism(s) to preserve outlet closure during bladder filling. Stress UI occurs coincident with increased intra-abdominal pressure, in the absence of a bladder contraction. Leakage is due to impaired pelvic supports or, less commonly, failure of urethral closure; the latter intrinsic sphincter deficiency occurs with trauma and scarring from anti-incontinence surgery in women and prostatectomy in men, or with severe urethral atrophy. Unlike the episodic leakage of genuine stress UI, this leakage is typically continual and can occur while the person is sitting or standing quietly. Stress maneuvers may trigger DO; with such stress-related urge UI, leakage occurs after a several-second delay following the stress maneuver.

4. Overflow Incontinence

Overflow UI results from detrusor (bladder muscle) underactivity, bladder outlet obstruction, or both. Leakage is small in volume but continual. The PVR is elevated, and symptoms include dribbling, weak urinary stream, intermittency, hesitancy, frequency, and nocturia. Associated urge and stress leakage may occur. Rarely, continual leakage is due to extra urethral incontinence (e.g., cystovaginal fistula). Outlet obstruction is the second most common cause of UI in older men; most obstructed men, however, are not incontinent. Causes include benign prostatic hyperplasia, prostate cancer, and urethral stricture. In women, obstruction is uncommon and usually due to previous anti-incontinence surgery or a large cystocele that kinks the urethra. Detrusor underactivity causing urinary retention and overflow UI occurs in only 5% to 10% of older persons. Intrinsic causes are replacement of detrusor smooth muscle by fibrosis and connective tissue (e.g., with chronic outlet obstruction). Neurologic causes include peripheral neuropathy (from diabetes mellitus, pernicious anemia, Parkinson's disease, alcoholism) or mechanical damage to the spinal detrusor afferents by disc herniation, spinal stenosis, or tumor.