Urinary Incontinence in Older Adults

 

OVERVIEW

UI is extremely prevalent among older adults. Throughout the world, prevalence rates are estimated at between 25% and 45% (Abrams et al., 2018; Batmani et al., 2021). Approximately 43% of noninstitutionalized U.S. older adults and 70% of U.S. nursing home residents have experienced urinary leakage (Gorina et al., 2014). UI has significant physical, psychosocial, and economic consequences, and negatively affects the quality of life of those with the condition and their CGs (Moon et al., 2021; Pizzol et al., 2021; Talley et al., 2021). Nurses play a key role in the assessment and management of UI.

 

BACKGROUND

A. Definitions

  1. UI, one of the most common geriatric syndromes, is defined as the complaint of any involuntary urine loss (Abrams et al., 2018). Although more common among older populations, UI is not an inevitable outcome of aging.
    • Transient UI is characterized by the new onset of potentially reversible causes of UI; it has also been called new-onset, nosocomial, and hospital-acquired (Davis et al., 2020; Dowling-Castronovo, 2014).

B. Types of established UI

  1. Stress UI is defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure; it is more common among women, but occurs in men after a prostatectomy (Abrams et al., 2018; D’Ancona et al., 2019).
  2. Urge UI is characterized by an involuntary urine loss associated with a strong desire to void. An individual may complain of urinary urgency, with or without UI (Abrams et al., 2018; D’Ancona et al., 2019).
  3. Mixed UI is defined as a combination of stress UI and urge UI (Abrams et al., 2018; D’Ancona et al., 2019).
  4. Overflow UI is an involuntary loss of urine associated with overdistention of the bladder and may be caused by an underactive detrusor muscle or outlet obstruction leading to overdistention of the bladder and overflow of urine (Abrams et al., 2018; D’Ancona et al., 2019).
  5. Functional UI is caused by nongenitourinary factors such as cognitive or physical impairments that result in an inability of the individual to be independent in voiding, but may be continent with support of CGs (Abrams et al., 2018; D’Ancona et al., 2019).

C. Epidemiology

  1. UI is extremely prevalent among older adults. Throughout the world, prevalence rates are estimated at between 25% and 45% (Abrams et al., 2018; Batmani et al., 2021).
  2. Approximately 43% of noninstitutionalized U.S. older adults and 70% of U.S. nursing home residents have experienced urinary leakage (Gorina, 2014).

PARAMETERS OF ASSESSMENT

A. Document the presence or absence of UI for all patients (Abrams et al., 2018; Tran & Puckett, 2022).

B. Document the presence or absence of an indwelling urinary catheter (John et al., 2018).

C. For patients with UI, the nurse collaborates with interprofessional team members to:

  1. Determine whether the UI is transient, established (stress/urge/mixed/overflow/functional), or both, and document (Abrams et al., 2018; D’Ancona et al., 2019) using the mnemonic TOILETED (see Box 24.1)
  2. Identify and document the possible etiologies of the UI (Abrams et al., 2018) and contributing factors for UI (see Box 24.2; Davis et al., 2020; Gibson et al., 2021)

NURSING CARE STRATEGIES

A. General principles that apply to prevention and management of all forms of UI

  1. Identify and treat causes of transient UI (Tran & Puckett, 2022).
  2. Develop an individualized plan of care using data obtained from the history and physical examination, and in collaboration with other team members.
  3. Implement toileting programs as needed (Gibson et al., 2018; Thomas et al., 2019).
  4. Avoid medications that may contribute to UI (Gibson et al., 2021).
  5. Avoid indwelling urinary catheters whenever possible to avoid the risk of CAUTI (John et al., 2018).
  6. Monitor fluid intake and maintain an appropriate hydration schedule (Gibson, 2021).
  7. Prevent skin breakdown by providing immediate cleansing after an incontinent episode and using barrier ointments (Davis & Wyman, 2021).
  8. Pilot-test absorbent products to best meet the preferences needs of patient, staff, CGs, and the institution (Davis & Wyman, 2021).
  9. Manage constipation (Gibson, 2021).

B. Specific strategies

  1. Stress UI
    • Teach fluid management strategies and PFMEs (Cho & Kim, 2021; Gibson, 2021).
    • Encourage daily practice of PFME (Gibson, 2021).
    • Consider referral to other team members if pharmacological or surgical therapies are warranted (Tran & Puckett, 2022).
  2. Urge UI and OAB
    • Implement bladder training (Gibson, 2021).
    • If patient is cognitively intact and motivated, provide information on urge inhibition (Gibson, 2021).
    • Teach PFMEs to be used in conjunction with bladder training and instruct on urge inhibition strategies (Gibson, 2021).
    • Collaborate with prescribing team members if pharmacological therapy is warranted (Gibson, 2021; Tran & Puckett, 2022).
    • Initiate referrals for those patients who do not respond to the aforementioned strategies (Tran & Puckett, 2022).
  3. Overflow UI
    • Allow sufficient time for voiding (Abrams et al., 2018).
    • Discuss with interprofessional team the need for determining a PVR (see Box 24.3; Diokno et al., 2014; Gibson, 2021; Shenot, 2023).
    • If catheterization is necessary, sterile intermittent catheterization is preferred over indwelling urinary catheterization (Centers for Disease Control and Prevention, 2023).
    • Initiate referrals to other team members for patients requiring pharmacological or surgical intervention (Tran & Puckett, 2022).
  4. Functional UI
    • Provide individualized scheduled toileting, timed voiding, or prompted voiding (Gibson, 2021; Gibson et al., 2018).
    • Provide adequate fluid intake (Gibson, 2021).
    • Modify environment to maximize independence with continence and provide person-centered care (Wijk et al., 2018).
    • Refer for exercise training as appropriate (Gibson et al., 2021)

EVALUATION OF EXPECTED OUTCOMES

A. Patients will:

  1. Have fewer or no episodes of UI or complications associated with UI

B. Nurses will:

  1. Document assessment of continence status; if UI is identified, document type of UI
  2. Use interprofessional expertise and interventions to assess and manage UI
  3. Include management of UI in discharge planning needs and refer as needed

C. Institutions will:

  1. Set achievable goals for preventing, reducing, and resolving transient UI
  2. Require assessment and documentation policies for continence status
  3. Provide access to evidence-based guidelines for evaluation and management of UI
  4. Instruct staff to receive administrative support and ongoing education regarding assessment and management of UI

FOLLOW-UP MONITORING OF CONDITION

A. Provide patient/CG discharge education and referral to specialists, as needed.

B. Identify areas for improvement and enlist interprofessional collaboration in devising strategies for improvement.

RELEVANT PRACTICE GUIDELINES

A. International Continence Society: 6th International Consultation on Incontinence. Abrams, P., Cardozo, L., Wagg, A., & Wein, A. (Eds.). (2017). Incontinence 6th Edition. International Continence Society. 

ABBREVIATIONS

CAUTI        catheter-associated urinary tract infection

CG             caregiver

OAB           overactive bladder

PFME         pelvic floor muscle exercises

PVR            postvoid residual

UI               urinary incontinence

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 24, Davis, N.J. & Dowling-Castronovo, A. (2025) Urinary Incontinence

 

REFERENCES

Abrams, P., Andersson, K. E., Apostolidis, A., Birder, L., Bliss, D., Brubaker, L., Cardozo, L., Castro-Diaz, D., O’Connell, P. R., Cottenden, A., Cotterill, N., de Ridder, D., Dmochowski, R., Dumoulin, C., Fader, M., Fry, C., Goldman, H., Hanno, P., Homma, Y., Khullar, V.; & Members of the Committees. (2018). 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourology and Urodynamics, 37(7), 2271–2272. https://doi.org/10.1002/nau.23551. Evidence Level I.

Albertson, M. (2018). Decreasing urinary incontinence in home healthcare. Home Healthcare Now,36(4), 232–237. https://doi.org/10.1097/NHH.0000000000000670. Evidence Level IV.

Batmani, S., Jalali, R., Mohammadi, M., & Bokaee, S. (2021). Prevalence and factors related to urinary incontinence in older adults’ women worldwide: A comprehensive systematic review and meta-analysis of observational studies. BMC Geriatrics, 21(1), 212. https://doi.org/10.1186/s12877-021-02135-8. Evidence Level I.

Centers for Disease Control and Prevention. (2023). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other urinary system infection [USI]) events. Retrieved from https://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf. Evidence Level VI.

Cho, S. T., & Kim, K. H. (2021). Pelvic floor muscle exercise and training for coping with urinary incontinence. Journal of Exercise Rehabilitation, 17(6), 379–387. https://doi.org/10.12965/jer.2142666.333. Evidence Level II.

Cortes, G. A., & Flores, J. L. (2022). Physiology, urination. In StatPearls. StatPearls Publishing. www.statpearls.com/articlelibrary/viewarticle/43110/. Evidence Level IV.

Cunich, M., Barakat-Johnson, M., Lai, M., Arora, S., Church, J., Basjarahil, S., Campbell, J. L., Disher, G., Geering, S., Ko, N., Leahy, C., Leong, T., McClure, E., O’Grady, M., Walsh, J., White, K., & Coyer, F. (2022). The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: A systematic review. International Journal of Nursing Studies, 129, 104216. https://doi.org/10.1016/j.ijnurstu.2022.104216. Evidence Level I.

D’Ancona, C, Haylen, B., Oelke, M., Abranches-Monteiro, L., Arnold, E., Goldman, H., Hamid, R., Homma, Y., Marcelissen, T., Rademakers, K. Schizas, A., Singla, A., Soto, I., Tse, V., de Wachter, S., Herschorn, S. On behalf of the Standardisation Steering Committee ICS and the ICS Working Group on Terminology for Male Lower Urinary Tract & Pelvic Floor Symptoms and Dysfunction. (2019). The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourology and Urodynamics, 38(2): 433–477. https://doi.org/10.1002/nau.23897. Evidence Level VI.

Datar, M., Pan, L. C., McKinney, J. L., Goss, T. F., & Pulliam, S. J. (2022). Healthcare resource use and cost burden of urinary incontinence to United States payers. Neurourology and Urodynamics, 41(7), 1553–1562. https://doi.org/10.1002/nau.24989. Evidence Level III.

Davis, N. J., & Wyman, J. F. (2020). Managing urinary incontinence. The American Journal of Nursing, 120(2), 55–60. https://doi.org/10.1097/01.NAJ.0000654340.42201.54. Evidence Level III.

Davis, N. J., Wyman, J. F., Gubitosa, S., & Pretty, L. (2020). Urinary incontinence in older adults. The American Journal of Nursing, 120(1), 57–62. https://doi.org/10.1097/01.NAJ.0000652124.58511.24. Evidence Level III.

Diokno, A. C., Laijness, M. J., & Griebling, T. L. (2014). Urinary incontinence: Evaluation and diagnosis. In T. L. Griebling (Ed.), Geriatric urology (pp. 127−140). Springer Publishing Company. Evidence Level V.

Dowling-Castronovo, A. (2014). Regaining control [Doctoral dissertation]. Retrieved from http://dx.doi.org/doi:10.7282/T3057D5P.Evidence Level IV.

Egbujie, B. A., Northwood, M., Turcotte, L. A., McArthur, C., Berg, K., Heckman, G. A., Wagg, A. S., &Hirdes, J. P. (2022). Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study. Neurourology and Urodynamics, 41(8), 1749–1763. https://doi.org/10.1002/nau.25018. Evidence Level III.

Fantl, A., Newman, D. K., Colling, J., DeLancey, J. O., Keeys, C., & Loughery, R. (1996). Urinary incontinence in adults: Acute and chronic management (Report No. Publication No. 92–0047). Agency for Health Care Policy and Research. Evidence Level I.

Gibson, W. (2021). Management of incontinence in the frail elderly. Obstetrics, Gynaecology & Reproductive Medicine, 31(3), 63–71. https://doi.org/10.1016/j.ogrm.2021.01.003. Evidence Level IV.

Gibson, J. M. E., Thomas, L. H., Harrison, J. J., Watkins, C. L., &the ICONS Project Team and the ICONS Patient, P. and C. I. G. (2018). Stroke survivors’ and carers’ experiences of a systematic voiding programme to treat urinary incontinence after stroke. Journal of Clinical Nursing, 27(9/10), 2041–2051. https://doi.org/10.1111/jocn.14346. Evidence Level IV.

Gibson, W., Johnson, T., Kirschner-Hermanns, R., Kuchel, G., Markland, A., Orme, S., Ostaszkiewicz, J., Szonyi, G., Wyman, J., &Wagg, A. (2021). Incontinence in frail elderly persons: Report of the 6th International Consultation on Incontinence. Neurourology and Urodynamics, 40(1), 38–54. https://doi.org/10.1002/nau.24549. Evidence Level I.

Gorina Y., Schappert, S., & Bercovitz, A. (2014). Prevalence of incontinence among older Americans. National Center for Health Statistics Vital and Health Statistics 3(36). https://www.ncbi.nlm.nih.gov/pubmed/24964267. Evidence Level IV.

Harlow, B. L., Bavendam, T. G., Palmer, M. H., Brubaker, L., Burgio, K. L., Lukacz, E. S., Miller, J. M., Mueller, E. R., Newman, D. K., Rickey, L. M., Sutcliffe, S., & Simons-Morton, D. (2018). The prevention of lower urinary tract symptoms (PLUS) Research Consortium: A transdisciplinary approach toward promoting bladder health and preventing lower urinary tract symptoms in women across the life course. Journal of Women’s Health, 27(3), 283–289. https://doi.org/10.1089/jwh.2017.6566.Evidence Level VI.

Hooper, G., Moynihan, L., Leegant, A., Long, J. B., Atnip, S., Bradley, M., Clemons, J. L. (2022). Vaginal pessary use and management for pelvic organ prolapse. Urologic Nursing, 42(6), 277–290. https://doi.org/10.7257/2168-4626.2022.42.6.277. Evidence Level I.

Huang, P., Luo, K., Wang, C., Guo, D., Wang, S., Jiang, Y., Huang, W., Zhang, W., Ding, M., & Wang, J. (2021). Urinary incontinence is associated with increased all-cause mortality in older nursing Home residents: A meta-analysis. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 53(5), 561–567. https://doi.org/10.1111/jnu.12671. Evidence Level I.

Jaekel, A. K., Rings, T. M., Schmitz, F., Knappe, F., Tschirhart, A., Winterhagen, F. I., Kirschner-Hermanns, R. K. M., & Knüpfer, S. C. (2023). Urinary and double incontinence in cognitively impaired patients: Impacts on those affected and their professional caregivers. Journal of Clinical Medicine,12(10), 3352. https://doi.org/10.3390/jcm12103352. Evidence Level II.

John, G., Primmaz, S., Crichton, S., & Wolfe, C. (2018). Urinary incontinence and indwelling urinary catheters as predictors of death after new-onset stroke: A report of the South London Stroke Register. Journal of Stroke and Cerebrovascular Diseases, 27(1), 118–124. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.08.018. Evidence Level III.

Khan, M. J., Omar, M. A., & Laniado, M. (2018). Diagnostic agreement of the 3 Incontinence Questionnaire to video-urodynamics findings in women with urinary incontinence: Department of Urology, Frimley Health NHS Foundation Trust Wexham Park Hospital Slough, Berkshire, United Kingdom. Central European Journal of Urology, 71(1), 84–91. https://doi.org/10.5173/ceju.2018.1622. Evidence Level III.

Kushner, D. S., & Johnson-Greene, D. (2018). Association of urinary incontinence with cognition, transfers and discharge destination in acute stroke inpatient rehabilitation. Journal of Stroke and Cerebrovascular Diseases The Official Journal of National Stroke Association, 27(10), 2677–2682. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.05.028. Evidence Level III.

López-Fando, L., Santiago, M., Ruiz, M., Varela, J. C., Luis, G. C., Bonillo, M. A., Padilla-Fernández, B., Castro-Díaz, D. M., Jiménez, M., Esteban, M., & Arlandis, S. (2022). Is the first day of the bladder diary enough for symptom assessment in women with lower urinary tract symptoms? Continence, 2, 1–5. https://doi.org/10.1016/j.cont.2022.100026. Evidence Level III.

Moon, S., Chung, H. S., Kim, Y. J., Kim, S. J., Kwon, O., Lee, Y. G., Yu, J. M., & Cho, S. T. (2021). The impact of urinary incontinence on falls: A systematic review and meta-analysis. PloS One, 16(5), e0251711. https://doi.org/10.1371/journal.pone.0251711. Evidence Level I.

Moreno-Martin, P., Jerez-Roig, J., Rierola-Fochs, S., Oliveira, V. R., Farrés-Godayol, P., Bezerra de Souza, D. L., Giné-Garriga, M., Booth, J., Skelton, D. A., & Minobes-Molina, E. (2022). Incidence and predictive factors of functional decline in older people living in nursing homes: A systematic review. Journal of the American Medical Directors Association, 23(11), 1815–1825.e9. https://doi.org/10.1016/j.jamda.2022.05.001. Evidence Level I.

National Association For Continence. (2022, October 16). Bladder diary – Track your bladder habbits! https://nafc.org/product/bladder-diary-free-download-from-nafc-track-your-bladder-habits/ Evidence Level VI.

Naumova, I., & Castelo-Branco, C. (2018). Current treatment options for postmenopausal vaginal atrophy. International Journal of Women’s Health, 10, 387–395. https://doi.org/10.2147/IJWH.S158913. Evidence Level III.

Newman D. K. (2019). Prompted voiding for individuals with urinary incontinence. Journal of Gerontological Nursing, 45(2), 14–26. https://doi.org/10.3928/00989134-20190111-03. Evidence Level IV.

Pizzol, D., Demurtas, J., Celotto, S., Maggi, S., Smith, L., Angiolelli, G., Trott, M., Yang, L., & Veronese, N. (2021). Urinary incontinence and quality of life: A systematic review and meta-analysis. Aging Clinical and Experimental Research, 33(1), 25–35. https://doi.org/10.1007/s40520-020-01712-y. Evidence Level I.

Robinson, M. O., & Linder, B. J. (2023). Evaluation and treatment of pelvic organ prolapse. Minerva Medica, 114(4), 516–528. https://doi.org/10.23736/S0026-4806.22.08396-3. Evidence Level IV.

Rosier, P. F. W. M., Kuo, H. C., De Gennaro, M., Gammie, A., Finazzi Agro, E., Kakizaki, H., Hashim, H., & Toozs-Hobson, P. (2019). International consultation on incontinence 2016; executive summary: Urodynamic testing. Neurourology and Urodynamics, 38(2), 545–552. https://doi.org/10.1002/nau.23903. Evidence Level VI.

Shenot, P. J. (2023, May 25). Urinary incontinence in adults – Genitourinary disorders. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/urinary-incontinence-in-adults. Evidence Level IV.

Talley, K. M. C., Davis, N. J., Peden-McAlpine, C., Martin, C. L., Weinfurter, E. V., & Wyman, J. F. (2021). Navigating through incontinence: A qualitative systematic review and meta-aggregation of the experiences of family caregivers. International Journal of Nursing Studies, 123, 104062. https://doi.org/10.1016/j.ijnurstu.2021.104062. Evidence Level I.

Thomas, L. H., Coupe, J., Cross, L. D., Tan, A. L., & Watkins, C. L. (2019). Interventions for treating urinary incontinence after stroke in adults. The Cochrane Database of Systematic Reviews, 2(2), CD004462. https://doi.org/10.1002/14651858.CD004462.pub4. Evidence Level I.

Todhunter-Brown, A., Hazelton, C., Campbell, P., Elders, A., Hagen, S., & McClurg, D. (2022). Conservative interventions for treating urinary incontinence in women: An Overview of Cochrane Systematic Reviews. The Cochrane Database of Systematic Reviews, 9(9), CD012337. https://doi.org/10.1002/14651858.CD012337.pub2. Evidence Level I.

Tran, L. N., & Puckett, Y. (2022). Urinary incontinence. In StatPearls. StatPearls Publishing. www.statpearls.com/articlelibrary/viewarticle/30850/. Evidence Level IV.

Wijk, H., Corazzini, K., Kjellberg, I. L., Kinnander, A., Alexiou, E., & Swedberg, K. (2018). Person-centered incontinence care in residential care facilities for older adults with cognitive decline: Feasibility and preliminary effects on quality of life and quality of care. Journal of Gerontological Nursing, 44(11), 10–19. https://doi.org/10.3928/00989134-20181010-04. Evidence Level III.

Wound, Ostomy, and Continence Nurses Society. (n.d.). The WOC community of opportunty. https://www.wocn.org

Yan, F., Xiao, L. D., Zhou, K., Li, Z., & Tang, S. (2022). Perceptions and help-seeking behaviours among community-dwelling older people with urinary incontinence: A systematic integrative review. Journal of Advanced Nursing, 78(6), 1574–1587. https://doi.org/10.1111/jan.15183. Evidence Level I.

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