Bladder weakness (urinary incontinence) in older age

People with urinary incontinence (i.e. bladder weakness) experience accidental, uncontrolled passing of urine. In other words, they are no longer in control of when they pee. This condition has a range of possible causes.

Bladder weakness is very common, in particular among people of older age. However, many people feel too embarrassed to mention the problem to their doctor. Many effective treatments are available for bladder weakness.

There are various types of urinary incontinence with a range of causes. The most common types are stress urinary incontinence (SUI) and overactive bladder. A mixed form of both types – known as mixed incontinence – is also common. Overflow incontinence, extra-urethral incontinence and neurogenic incontinence are less common types.

Stress urinary incontinence

With stress urinary incontinence (SUI) or stress incontinence, any increased pressure on the bladder (usually due to coughing, sneezing, running or skipping) causes accidental leakage of urine. In particularly severe cases, accidental bladder leakage may also occur without any pressure (e.g. when sitting or lying down). SUI is caused by a weakness in the pelvic floor muscles and/or damage to the urethral sphincter muscle, which opens and closes the bladder. This type of bladder weakness occurs in particular during pregnancy and in women who have previously given birth. This type is rare in men and usually only occurs following surgery on the prostate gland.

Overactive bladder

Overactive bladder (OAB) occurs in older people in particular and is characterized by an intense urge to urinate that cannot be delayed. There are two sub-types, i.e. OAB-wet, in which there is leakage of urine, and OAB-dry, in which the person still makes it to the toilet before passing urine. There are many possible causes of overactive bladder, including frequent bacterial bladder infections, a local estrogen deficiency after the menopause, an enlarged prostate, bladder tumors, nervous system disorders such as multiple sclerosis, or damage to the spinal cord. If a cause cannot be identified, this is known as “idiopathic” overactive bladder. In this case, the cause is related to tiny structural changes in the bladder that can only be experimentally verified.

Overflow incontinence

With overflow incontinence, the bladder simply “overflows” when full. This may be caused by weak bladder muscles or a blockage in the urethra (the tube through which urine leaves the body). A weakness in the bladder muscles can be caused by nerve damage due to conditions such as diabetes. The urethra may become blocked or constricted as a result of tumors, urinary stones or a benign enlargement of the prostate.

Extra-urethral incontinence

With extra-urethral (fistular) incontinence, urine leaks through abnormal channels rather than the urethra. These channels occur if someone is born with a ureter that doesn’t connect properly with the bladder or malformations of the urethra, or because they develop urinary fistulas. Fistulas are small channels or pathways that may develop in the body, e.g. between the bladder and the vagina. A continuous trickling of urine out of the body is typical of this type of incontinence.

Neurogenic incontinence

People with neurogenic incontinence have either no sensation or only a partial sensation of their bladder being full due to nerve damage. One sub-type of neurogenic incontinence is reflex incontinence. This results in involuntary passing of urine at regular intervals.

Bladder weakness usually occurs due to the interaction of several risk factors, including:

• older age
• need for care
• impaired physical and cognitive abilities, e.g. due to Alzheimer’s disease
• overweight and obesity
• diabetes
• neurological conditions such as multiple sclerosis and Parkinson’s disease
• taking certain medications, e.g. diuretics

In addition, frequent coughing due to chronic lung diseases or as a result of smoking can increase the risk of developing stress urinary incontinence.

In women, the main risk factor for bladder weakness is (multiple) vaginal births, as these can damage the pelvic floor. In men, having prostate surgery is a particular risk factor for developing bladder weakness.

Over 200 million people worldwide suffer from urinary incontinence. In Germany, it is estimated that the figure is 6 million people. Older people are most commonly affected – up to 61 percent of people aged over 60 have bladder weakness. Urinary incontinence affects up to 80 percent of residents in care facilities.

Up to the age of 75, urinary incontinence affects twice as many women as men. However, the number of men with bladder weakness increases with age, so that this difference between the sexes gradually disappears among those of advanced age.

In women over 60, mixed incontinence is the most frequent type, followed by stress incontinence, overactive bladder and other types. Overactive bladder is the most common type among men, affecting up to 80 percent of men with urinary incontinence. However, stress urinary incontinence is rare in men.

Not all types of urinary incontinence can be prevented. However, there are some effective and simple measures that can help with stress urinary incontinence in particular.

Pelvic floor training

Strengthening the pelvic floor muscles with targeted pelvic floor exercises is the most effective method of preventing bladder weakness – in particular in women following a birth or in people with connective tissue damage. Certain types of exercise, such as cycling, swimming and yoga, also strengthen the pelvic floor.

A healthy lifestyle

Being overweight, constipation and chronic coughing should all be avoided because they put pressure on the pelvic floor. This can be done by getting enough exercise, eating plenty of fiber and following a healthy diet and by avoiding smoking. Staying well hydrated is also important. When people don’t drink enough fluids, the urine can become very concentrated, which in turn irritates the bladder muscle.

The most suitable point of contact for people with bladder weakness is a urologist or a gynecologist. They will be able to determine the type and cause of the bladder weakness in each case and identify an appropriate treatment. However, people with bladder weakness can also begin by talking to their family doctor.

The doctor will begin with a discussion of the patient’s case history and symptoms. This is followed by a physical examination of the external genitals and the rectum. The patient’s urine is usually also tested and an ultrasound scan of the bladder and the urethra is performed. Further, more specific tests may be performed at a later stage by a specialist. These include, for example, the pad test, a cystoscopy and measurements of bladder function known as urodynamic testing.

Pad test

This test determines the volume of urine that is leaked. The patient is usually provided with an incontinence pad (that has been weighed) to soak up the urine. The patient drinks 500 milliliters of tea before following an “exercise program”, which includes walking and climbing stairs. The incontinence pad is then weighed to determine how much urine has leaked from the body during this period.

Cystoscopy (bladder examination)

Doctors use a cystoscopy to determine whether any abnormal changes to the bladder could be causing urinary incontinence. The pelvic floor muscles and the urethral sphincter muscle may also be examined.

Urodynamic testing

Urodynamic testing may be used to measure and assess the bladder emptying process, bladder control and pressure in the bladder during urination. This type of testing allows doctors to determine the severity of the patient’s bladder weakness. However, urodynamic testing is only necessary if other tests are insufficient or if the doctor is considering surgery. In this case, it can help with planning of the surgery. In urodynamic testing, a narrow catheter is inserted into the bladder and another is inserted into the rectum. While this may feel uncomfortable, it doesn’t cause any pain.

Treatment methods for bladder weakness include methods such as behavioral therapies and pelvic floor training, as well as various medications and surgical procedures. Bladder weakness can usually be treated effectively and, in some cases, can even be cured.

For older people with overactive bladder, stress incontinence and mixed incontinence, the main approach to treatment is behavioral therapy in the form of toilet habit re-training, as this is not associated with any side effects. This involves defining a personalized schedule for emptying the bladder, timed voiding (going to the toilet at set intervals regardless of urge) and bladder re-training.

There are also many other treatment options based on the cause of the urinary incontinence:

Pelvic floor exercises

With mild to moderate stress urinary incontinence, regular training of the muscles in the pelvic floor is usually effective and has no side effects. For this reason, it is the number one treatment of choice and is best done under the guidance of a physiotherapist. Supplementary medication may be beneficial. However, it is not always effective and may have side effects.

Additional measures can serve to support this treatment:

• electrical stimulation
• biofeedback
• pessaries or incontinence tampons
• in post-menopausal women, estrogen-containing ointments or suppositories, which are inserted into the vagina (local estrogen therapy)

If these treatments are not adequate, doctors can also surgically restore the functioning of the pelvic floor and bladder. Several surgical procedures are available for this purpose.

Overactive bladder

Pelvic floor training is also beneficial in the case of overactive bladder and, as with stress incontinence, this type of treatment can be supported with various additional measures, such as local estrogen therapy. However, pessaries or incontinence tampons are not used in this case. A wide range of medications is also available, which differ in their effectiveness and tolerability from patient to patient.

If conservative measures and medications fail to prove effective, patients have the option of having a botulinum toxin injection into the bladder muscle to manage an overactive bladder.

Mixed incontinence

In the case of mixed incontinence, the predominant incontinence type is initially treated with the measures described above.

Overflow incontinence

Overflow incontinence is often caused by other conditions, such as benign prostate enlargement. For this reason, the primary focus is on treating the underlying illness. A catheter may also be used as a supplementary or temporary treatment.

Extra-urethral incontinence

This type of incontinence can be due to fistulas in the bladder region. By surgically removing these abnormal channels, the natural excretion pathway through the ureter can usually be restored.

You will find more information about bladder weakness and contact details for advice centers on the website of the German Continence Society.

The German Society of Urology has published a brochure about urinary incontinence, which provides clear and understandable information about the different types of urinary incontinence and treatment options: “Was tun bei Harninkontinenz?” (in German).

If you need to find a urologist close to where you live, you can use the urologist search (“Urologensuche”) tool provided on the urology portal of the German Society of Urology.