Healthy living Bladder weakness (urinary incontinence) in older age

People with bladder weakness (urinary incontinence) accidentally pass urine without being able to control it. In other words, they are no longer able to control when they pass urine. This condition has a range of possible causes.

Urinary incontinence 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 urinary incontinence.

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, fistula-related incontinence and neurogenic incontinence are less common types.

Stress urinary incontinence

With stress urinary incontinence (SUI), 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 (for example, when sitting or lying down). SUI is caused by a weakness in the pelvic floor muscles and/or damage to the bladder sphincter, which controls the release of urine from the bladder. This type of urinary incontinence is particularly common during pregnancy and in women who have previously given birth. SUI is rare in men and usually only occurs following surgery on the prostate gland.

Overactive bladder

Overactive bladder (OAB) is particularly common in older people and is characterized by increased urinary urgency that cannot be suppressed. Involuntary urine leakage due to an overactive bladder is also known as urge incontinence. There are two sub-types, i.e. OAB-wet, in which there is leakage of urine, and OAB-dry, in which the person is able to reach the toilet in time. 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, neurological conditions 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 thought to be tiny changes in the bladder tissue that can only be verified in laboratory tests.

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 incontinence, also known as fistula-related incontinence, urine leaks through abnormal channels rather than the urethra. These abnormal channels may be present from birth, for example if a ureter does not connect properly to the bladder or if the urethra is malformed, or they may develop later as urinary fistulas. Fistulas are small channels or pathways that may develop in the body, for example, 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 may be unable to sense when their bladder is full, or may have only limited sensation of bladder fullness, due to nerve damage. For example, some neurological conditions can cause involuntary leakage of urine at regular intervals.

Urinary incontinence usually occurs due to the interaction of several risk factors, including:

• older age
• having care needs
• physical and cognitive impairments, for example caused by dementia
• excess weight and obesity
• diabetes
• neurological conditions, such as multiple sclerosis and Parkinson’s disease
• taking certain medications, such as diuretics (medication to promote urine production)

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 urinary incontinence is (multiple) vaginal births, as these can damage the pelvic floor. A hormone deficiency may also develop in the vagina after menopause, when taking the contraceptive pill or as a result of using a hormonal coil. The risk of urinary incontinence may increase as a result. In men, having prostate surgery is a particular risk factor for developing urinary incontinence.

Over 400 million people worldwide have urinary incontinence. In Germany, the figure is estimated at 10 million. Older people are particularly likely to be affected – up to 61 percent of people 60 have urinary incontinence. Up to 80 percent of residents in care facilities have urinary incontinence.

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

In women over 60, mixed incontinence is the most common 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 those who have 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 urinary incontinence – in particular in women after giving birth or in people with connective tissue weakness. Certain types of exercise, such as cycling, swimming and yoga, also strengthen the pelvic floor.

A healthy lifestyle

Excess weight, 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 urinary incontinence is a urologist or a gynecologist. They will be able to determine the type and cause of the urinary incontinence in each case and identify an appropriate treatment. However, people with urinary incontinence 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. Before starting, the patient drinks 500 milliliters of tea. This is followed by 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. This examination is done under local anesthetic and involves a tube with a camera being inserted into the bladder through the urethra. The camera transmits images from inside the bladder.

Urodynamic testing

Urodynamic testing may be used to assess the bladder emptying process and pressure in the bladder during urination. This type of testing allows doctors to determine the severity of the patient’s urinary incontinence. 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 surgical planning. In urodynamic testing, a thin tube called a catheter is inserted into the bladder and another is inserted into the rectum. While this may feel uncomfortable, it doesn’t normally cause any pain.

Treatment includes behavioral therapies and pelvic floor training, as well as various medications and surgical procedures. Urinary incontinence 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 treatment approach is behavioral therapy in the form of toilet habit retraining, 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 the urge) and bladder retraining. The objective is to avoid unwanted passing of urine by emptying the bladder in time.

There are also digital health applications (“DiGA”) to support patients with urinary incontinence. These include apps that are available on prescription. These apps provide information and exercise instructions, and can be used to document symptoms and record progress.

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

Stress urinary incontinence/mixed urinary incontinence

For mild to moderate stress urinary incontinence or mixed incontinence, regular pelvic floor muscle training is usually effective and has no side effects. For this reason, it is the first-line treatment 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 be used to support the treatment of stress urinary incontinence in some case, for example:

• Electrical stimulation: the muscles in the pelvic floor are stimulated electrically so that they contract.
• Biofeedback: a device provides the patient with information about the activity of the pelvic floor muscles.
• Pessaries or incontinence tampons for women: these medical aids can support the urethra or bladder, thus reducing urine leakage.
• In postmenopausal women or those with a hormone deficiency: estrogen-containing ointments or suppositories inserted into the vagina (local estrogen therapy) may relieve the symptoms of urinary incontinence.

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 show varying degrees of effectiveness and tolerability in individual patients.

These medications aims to relax the bladder muscles so that they contract less strongly. 
A botulinum toxin injection may be used if other measures and medications are ineffective. This is a nerve toxin that inhibits muscle activity. Botulinum toxin can be injected into the bladder muscles during a cystoscopy.

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, which is a tube to drain urine, may also be used as a supplementary or temporary treatment.

Extra-urethral incontinence

This type of incontinence can occur as a result of fistulas in the bladder region. By surgically removing these fistulas, the natural excretion pathway through the urethra can usually be restored.

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

The German Society of Urology (Deutsche Kontinenz Gesellschaft e.V.) has published a leaflet providing clear and understandable information about the different types of urinary incontinence and treatment options: “Harn- und Stuhlinkontinenz?” (“Bladder and bowel incontinence”, in German only).

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