Ehab A. Elzayat, MD, Urology Fellow, Dalhousie University, Halifax, NS.
Ali Alzahrani, MD, Urology Fellow, Dalhousie University, Halifax, NS.
Jerzy B. Gajewski, MD, FRCSC, Professor of Urology and Pharmacology, Department of Urology, Dalhousie University, Halifax, NS.

Urinary incontinence is a common symptom among older adults that is often marginalized and not properly addressed. It is, however, often associated with potentially treatable conditions. Concurrent chronic medical problems add more challenges in this patient population. Comprehensive assessments and evaluations are necessary because of the multifactorial underlying pathology. The selection of the best treatment option is challenging. This article reviews the effect of age on lower urinary tract symptoms, mainly incontinence, and describes the evaluation and management of urinary incontinence in older men.
Key words: urinary incontinence, aging male, older adults, men’s health.

David R. Staskin, MD, Department of Urology, New York Presbyterian Hospital, Weill-Cornell Medical College, New York, NY, USA.
Edward Zoltan, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Alan J. Wein, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Older adults have a high prevalence of urinary incontinence. Among the older adult population, many nonurinary pathological, anatomical, physiological, and pharmacological factors may serve as comorbidities in the development of incontinence. The treating physician must appreciate potentially reversible pathologies. Older adults frequently are prescribed several drugs; therefore, it is important to consider drug-drug metabolic interactions. Age-associated changes may affect pharmacological actions of the drug. Antimuscarinic therapy has been proven efficacious and represents the first line of pharmacologic therapy for overactive bladder (OAB). The selection of an antimuscarinic agent for the management of an older individual presenting with OAB is limited by the natural condition of the aging body and by the side effects associated with antimuscarinics as a class and the specific agents themselves.
Key words: urinary incontinence, antimuscarinics, older adult, frail older adult, geriatrics.

Jayna M. Holroyd-Leduc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Clinician-Investigator, University Health Network, Toronto, ON.
Cara Tannenbaum, MD, FRCPC, MSc, Assistant Professor, Department of Medicine, University of Montreal; Director, Geriatric Incontinence Clinic, McGill University Health Centre; Director, Institut Universitaire de Geriatrie de Montreal, Montreal, QC.

Urinary incontinence is a prevalent condition among long-term care residents, particularly those with dementia. The costs and morbidity associated with urinary incontinence are significant. Urinary incontinence can be easily assessed within the long-term care setting. Several modifiable risk factors should be identified and addressed. Effective behavioural treatment options for incontinence exist and several treatment strategies can be used successfully for patients with dementia.

Key words: urinary incontinence, dementia, long-term care, diagnosis, management.

Sue O’Hara, RN, MScN, ACNP, GNC(C), Nurse Practitioner/Clinical Nurse Specialist, Specialized Geriatric Services, St. Josephs Health Care London, Parkwood Hospital, London, ON.; Michael J. Borrie, BSc, MB, ChB, FRCPC, Professor, Department of Medicine, Division of Geriatric Medicine, The University of Western Ontario, London, ON.

Urinary incontinence is a significant problem in older women. Prevalence rates vary from 4.5–44% in healthy older women and increase to 22–90% in patients in long-term care facilities. Canadian Continence Guidelines have recently been developed to assist patients and health care professionals in assessment, treatment and follow-up of urinary incontinence. Urinary incontinence can be treated successfully, improved or better managed in most patients. Treatment falls into four major categories: behavioural, pharmacologic, surgical and supportive measures. Education, the key to effectively addressing the needs of women with incontinence, is aimed at the patient and/or their caregiver, as well as health care professionals.
Key words: urinary incontinence, older women, assessment, treatment, Canadian Continence Guidelines.

Dr. Lynn Stothers, MD, MHSc, FRCSC, Assistant Professor of Surgery/Urology, Associate Member, Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC.

Dr. Howard Fenster, MD, FRCSC, Clinical Professor, Department of Surgery, Division of Urology, University of British Columbia, Vancouver, BC.

Definitions and Epidemiology
Urinary incontinence (UI), the involuntary loss of urine, is a common medical condition in the elderly. Over 1.5 million Canadians are currently afflicted with the condition, and the number is expected to increase significantly over the next 20 years as the baby boom population ages.¹ Chronic UI has far-reaching consequences for both the individuals affected and their caregivers. Physical complications include renal failure, urinary tract sepsis, renal calculi, hematuria, skin disease, falls and fractures and death relating to renal failure/urosepsis. Psychosocial impact can range from embarrassment and social isolation to depression and suicidal ideation. Less than 50% of those affected seek help for the condition, often due to embarrassment.

Classification
UI can be categorized according to the simple clinical classification presented in Table 1.

Sonya Lytwynec, RegN, BScN
Nurse Clinician,
Southwestern Ontario Regional Geriatric Program,
Continence Outreach

Urinary incontinence can be successfully treated in some individuals.¹ There are, however, many individuals who remain unresponsive to behavioural, medical or surgical treatment and continue to experience chronic urinary incontinence. These individuals can benefit from improved continence management, using incontinence products that enable them to maintain social acceptability, skin integrity and comfort.

The focus of this article is to identify the factors that influence product selection and describe the key features of products that may guide the health care professional in meeting the specialized needs of individuals and caregivers.

Incontinence products may be utilized in addition to other treatment modalities to promote comfort and security. For example, supplementing toileting protocols with the use of absorbent disposable diapers and moisture barriers may be effective in reducing the risk for skin breakdown.²

Selecting the most appropriate product can be a complex task.

Sonya Lytwynec RegN, BScN
Michael J Borrie BSc, MD, ChB, FRCPC
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Functional urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with functional incontinence are reviewed in this fifth and final article of a five part series on urinary incontinence. Functional incontinence is defined as the involuntary loss of urine associated with the inability to use the toilet because of impairments of cognitive or physical functioning, psychological unwillingness or environmental barriers.²

The existence of urinary incontinence has been estimated at 15% to 35% in community dwelling people over 60 years of age, with twice the prevalence in women compared to men. The prevalence increases to 53% in homebound individuals, and is reported at 30% in acute care hospitals and 40% to 60% in longterm care institutions.³ A study of incontinent people receiving home care services (mean age 74) reported that a total of 89% had at least one functional disability (cognition, mobility, transferring in and out of bed or chair, or undoing garments). The incontinence was moderate to severe in 41% of the patients, and 95% of the family caregivers viewed the incontinence as a problem.⁴

Functional incontinence should be a diagnoses of exclusion.

Michael J. Borrie, BSc, MB, ChB, FRCPC
Chair, Division of Geriatric Medicine, The University of Western Ontario

Prevalence studies of urinary incontinence in the elderly report widely-varying rates from 4.5-44% in healthy, elderly women to 4.6-24% in healthy, elderly men. The prevalence in institutionalized people ranges from 22-90%.¹

Choice of definition, wording of the questionnaire and study population contribute to this variability. The International Continence Society has defined incontinence as a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrated.² Based on the symptom complex, urinary incontinence is characterized as urge, stress, mixed, overflow, functional, or iatrogenic.

Urgency urinary incontinence is the most common type and is divided into sensory or motor urgency. Ambulatory or longer-term urodynamic studies have demonstrated involuntary detrusor contractions and calls into question the notion of sensory urgency. A new classification of overactive bladders has been proposed but has not yet been resolved.³ Detrusor instability is commonly associated with neurologic conditions such as stroke or Parkinson's Disease. It can also accompany prostatic obstruction.