Continence in Older People

Introduction

Urinary and faecal incontinence are common in older people but are never simply a normal, expected consequence of ageing to be managed passively with pads. Both always have an identifiable contributing cause or combination of causes, many of which are modifiable, and both carry a significant impact on dignity, skin integrity, social participation and risk of care home admission if left unassessed.¹

New incontinence is also one of the five classic frailty syndromes (alongside falls, delirium, immobility and increased susceptibility to medication side effects - see ²), meaning it should prompt the same systematic search for an underlying acute cause as any other atypical presentation of illness in an older person, not be accepted as a standalone endpoint diagnosis.

Reversible causes of transient urinary incontinence: DIAPPERS

New or worsening urinary incontinence, particularly of sudden onset, should prompt a search for a transient, reversible cause before assuming an established, chronic bladder problem.

Age-related changes in bladder function

Several physiological changes make continence more precarious with age. None of them cause incontinence on their own, but together they reduce the margin for error, so that an additional insult - a diuretic, an infection, reduced mobility, or an unfamiliar environment - readily tips a person into incontinence.

• Reduced bladder capacity and an earlier first sensation of needing to void
• Increased involuntary detrusor contractions, giving urgency and reduced warning time
• Reduced urethral closure pressure, particularly in postmenopausal women following oestrogen withdrawal, and in men after prostate surgery
• Increased post-void residual volume from less efficient detrusor emptying
• Loss of the normal nocturnal reduction in urine production, so more urine is made overnight, producing nocturia
• Prostatic enlargement in men, causing outflow obstruction, hesitancy, poor stream and eventually overflow

Types of urinary incontinence

Assessment

• History: onset, pattern (stress vs urgency features), frequency, volume, nocturia, and impact on quality of life
• Bladder diary over 3 days - recording fluid intake, voiding times and volumes, and episodes of leakage - is more informative than history alone and should be used routinely before starting treatment
• Medication review, screening for diuretics, sedatives, anticholinergics and alpha-blockers
• Mobility and cognitive assessment, since functional incontinence is common and easily missed if only the bladder itself is assessed
• Abdominal and rectal examination: palpable bladder (retention), faecal loading/impaction, and in men, prostate assessment
• Vaginal examination in women: prolapse, atrophic changes
• Urinalysis to exclude infection, glycosuria or haematuria
• Post-void residual volume (bladder scan) to identify incomplete emptying/overflow

Management of urinary incontinence: a stepped approach

Conservative measures (first-line for most patients)

• Pelvic floor muscle training, supervised for at least 3 months, first-line for stress incontinence and useful as an adjunct in mixed incontinence
• Bladder training, gradually increasing the interval between voids, first-line for urgency incontinence/overactive bladder
• Lifestyle modification: reducing caffeine and excess fluid intake (without causing dehydration), weight loss where relevant, and treating constipation
• Timed or prompted voiding, particularly useful where cognitive impairment limits the ability to use bladder training independently
• Optimising the environment: clear access to the toilet, appropriate clothing, and a commode or urinal where mobility is limiting - directly addressing functional incontinence

Pharmacological management

Used where conservative measures alone are insufficient, and matched to the type of incontinence.

Surgical and device options

Considered where conservative and pharmacological measures fail, individualised to fitness for intervention: for stress incontinence, options include colposuspension or mid-urethral sling procedures; for refractory overactive bladder, botulinum toxin bladder injection, sacral neuromodulation, or, rarely, augmentation cystoplasty.

Overflow incontinence

Managed by treating the underlying cause of retention - reviewing causative medication (anticholinergics, opioids), treating prostatic obstruction (alpha-blockers, 5-alpha-reductase inhibitors, or surgery), or intermittent/indwelling catheterisation where retention is established and other measures fail or are unsuitable.

Faecal incontinence

In older people, faecal incontinence is frequently related to overflow from chronic constipation with faecal impaction - a large rectal mass causing leakage of liquid stool around it, which can easily be mistaken for diarrhoea if a rectal examination is not performed.

• Rectal examination is essential in any older person with new faecal incontinence, to identify impaction before treating presumed diarrhoea
• Treat impaction first - typically with an escalating laxative regimen (osmotic then stimulant, or a combination), sometimes with manual evacuation where impaction is severe
• Address the underlying causes of constipation: low fibre or fluid intake, immobility, opioids and other constipating medication, hypothyroidism, hypercalcaemia
• Structured bowel care: regular toileting routine, adequate privacy and time, and dietary/fluid optimisation once impaction is cleared
• For faecal incontinence unrelated to overflow (e.g. sphincter dysfunction, neurological disease), specialist assessment including anorectal physiology testing may be needed

Catheters

Long-term indwelling urinary catheterisation is frequently used to manage incontinence when other measures seem to have failed, but it is rarely the right answer and carries substantial, often underestimated harm. It should be regarded as a last resort with specific indications, not a convenience measure.

Where drainage is genuinely needed, alternatives to a long-term urethral catheter should be considered first: intermittent self-catheterisation preserves bladder function and carries a substantially lower infection risk; a sheath (condom) catheter avoids urethral instrumentation in men with incontinence but no retention; and a suprapubic catheter is more comfortable and avoids urethral trauma where long-term drainage is unavoidable. Asymptomatic bacteriuria is near-universal in catheterised patients and should not be treated.

Skin care and product use

Continence products (pads, sheaths) have a legitimate role in managing established incontinence and protecting dignity and independence, but should be introduced alongside, not instead of, a proper assessment for reversible causes and appropriate treatment - reaching for a pad before assessing the underlying cause is a recognised, avoidable failure of care. Good skin care to prevent moisture-associated skin damage is important wherever products are used long-term.

Red flags

Prognosis

Incontinence with an identified and treated reversible cause often improves substantially or resolves. Even where a chronic underlying bladder or bowel problem persists, structured, stepped management - conservative measures first, escalating as needed - meaningfully improves symptoms, quality of life and dignity for most patients, and prevents the secondary complications (skin breakdown, social withdrawal, avoidable care home admission) that arise when incontinence is simply managed passively with pads rather than properly assessed.

The impact of untreated incontinence is easy to underestimate because patients rarely volunteer it. Many wait years before mentioning it, assuming it is an inevitable part of ageing or feeling too embarrassed to raise it, and in the meantime restrict their social activities, avoid leaving home, and become progressively isolated - with the depression and deconditioning that follow. Asking directly about continence during a routine review, rather than waiting for the patient to raise it, is therefore itself a meaningful intervention.