Urinary leakage, which refers to the involuntary loss of urine, is a significant issue with social, hygienic, and medical implications. It can affect women at all stages of life (especially when engaging in vigorous physical activity) but tends to become more of a problem with age. It can lead to depression, withdrawal, isolation, and a decline in overall quality of life.
The causes of urinary leakage in older adults are similar to those in younger individuals, but there are additional factors specific to the elderly population that require separate consideration. These include cognitive impairment leading to reduced awareness, mobility difficulties, challenges with undressing and dressing, and environmental factors.
Implementing scheduled urination, ensuring easy access to toilets, and using simple measures to simplify the undressing process (such as replacing buttons and zippers with adhesive tape) can help minimize episodes of urine leakage. Additionally, addressing urinary tract infections, treating vaginal dryness through local estrogen administration, making medication adjustments, managing conditions that increase urine output, and addressing constipation can decrease and even prevent urinary leakage in older women.
Overactive bladder is characterized by symptoms such as frequent urination, nocturia (urination at night), urgency, and urgency-related leakage. Involuntary contractions of the bladder result in a sense of urgency and an inability to hold back urine, with approximately 50% of cases also experiencing urinary leakage. It is important to note that this condition can lead to falls when rushing to the bathroom. While overactive bladder can occur at any stage of life, its frequency increases with age due to changes in bladder muscles and hormonal deficiencies, and it can affect both men and women. In older individuals, an overactive bladder is often accompanied by decreased bladder contractility during the emptying phase, leading to urine retention, which complicates drug treatment and may exacerbate voiding dysfunction. Furthermore, impaired bladder contractions and urine retention increase the risk of recurrent urinary tract infections and overflow incontinence, characterized by involuntary urine loss due to an underactive, enlarged, and full bladder.
To diagnose an overactive bladder, infections, and tumors must be ruled out. In most cases, the cause of the condition remains unknown, although approximately 10% of cases are attributed to nervous system disorders (such as stroke, multiple sclerosis, Parkinson's disease, or dementia).
Stress urinary leakage, which is not exclusive to older age but becomes more prevalent as individuals age, is typically caused by damage to the supporting tissue of the urethra and its prolapse, as well as dysfunction of the urethral closure mechanism. Due to urethral prolapse, increased intra-abdominal pressure fails to transfer to the sphincter mechanism, resulting in urine leakage during activities such as coughing, sneezing, laughing, and brisk walking.
Mixed urinary leakage is a common condition characterized by a combination of symptoms from stress urinary leakage and overactive bladder. The dominance of different types of urinary dysfunction varies among patients, necessitating individualized treatment approaches.
Treatment options for urgent urinary leakage include reducing fluid intake, avoiding coffee and caffeinated beverages, and limiting fluid consumption in the evening. Following a scheduled urination routine combined with bladder training to enhance control over urination events can reduce leakage incidents. Using vaginal estrogen preparations can alleviate dryness, local irritation, burning, frequency, and urgency, and even improve urgent urinary leakage, especially in older women with signs of estrogen deficiency. Pelvic floor physiotherapy, involving pelvic floor muscle exercises, biofeedback, and electrical stimulation, has proven effective in managing urgent leakage and enhancing the effectiveness of drug treatment.
Drug treatment for urinary leakage primarily involves the use of anticholinergic medications, which work by blocking muscarinic receptors to prevent detrusor muscle contraction and by blocking adrenergic receptors to promote bladder relaxation. Oxybutynin (Novitropan) is an example of an anticholinergic drug commonly used for this purpose. However, it can cause side effects such as dryness of the mouth and eyes, blurred vision, and cognitive impairment in elderly individuals. To minimize side effects and improve treatment effectiveness, modern drugs with immediate or extended-release formulations have been developed. Treatment precautions among the elderly population include the use of reduced doses, monitoring cognitive function, vigilance, and monitoring for worsening voiding difficulties and urine retention. It's worth noting that medications such as Tolterodine (Detrusitol SR), Trospium Chloride (Spasmex), Oxybutynin hydrochloride (Lyrinel), and solifenacin (Vesicare) are available in Israel but are not covered by the national health basket.
In cases where treatment does not yield satisfactory results, or where anticholinergic medications cause intolerable side effects or cannot be used owing to contraindications, alternative options can be considered. These include injecting botulinum toxin into the bladder muscle or, in resistant cases, implanting a sacral pacemaker. Augmentation of the urinary bladder using intestinal tissue is a surgical procedure performed in exceptional cases and is not a commonly recommended treatment for the elderly population.
Treatment for urinary leakage during exertion involves various approaches:
- Topical estrogen can be used to thicken the urethral mucosa, decreasing urinary leakage. This treatment is recommended in situations of estrogen deficiency and urinary leakage.
- Pelvic floor physiotherapy, particularly in the biofeedback phase, can strengthen the pelvic floor muscles and improve leakage during exertion.
- Duloxetine hydrochloride (Yentreve) is a drug option intended for moderate to severe cases of urinary leakage. It is often recommended in combination with pelvic floor physical therapy. Notably, this treatment is not covered by the national health basket.
- Dedicated pessaries can be used to prevent urinary leakage. These devices are inserted and removed by the patient but may cause discomfort, secretions, and ulcers.
- Periurethral injections performed in a clinical setting are another possibility. Advances in this area aim to reduce the body's reaction and prevent the dispersion of the injected substance over time. However, the effectiveness of injections is generally lower than that of surgical treatment, often requiring repeated injections. It is important to note that this treatment is not covered by the national health basket at this stage.
- Surgical treatment options for stress urinary leakage have significantly advanced over the past decade, particularly with the development of minimally invasive procedures using mid-urethral tapes to support the urethra. These surgeries offer improved possibilities for treating stress urinary leakage in elderly patients. The procedures are typically performed under local or regional anesthesia, require only short hospitalization, and in some cases can be performed with a day surgery setting.