Continence Management


Understanding a resident’s type of incontinence can assist in making treatment decisions.

This section contains information on recognising and treating the following types of incontinence:

Urge incontinence, also called overactive bladder, is associated with detrusor (bladder) muscle overactivity (involuntary bladder contractions). It is characterised by abrupt urgency, frequency and nocturia (urination at night). It may be age-related or have neurological causes or other causes such as bladder infection or urethral irritation. The resident can feel the urge to void but is unable to inhibit voiding long enough to reach the toilet. It is the most common cause of urinary incontinence in elderly persons.

Common causes

    Detrusor instability or detrusor hyperreflexia (detrusor contractions)
  • Acute or chronic urinary tract infection
  • Bladder stones or bladder cancer
  • Uterine prolapse, vaginal prolapse and tumors
  • Neurological disorders such as stroke, diabetes, Parkinson’s disease and multiple sclerosis
  • Anatomical muscle weakness: cystocele (herniation of bladder into vagina), rectocele (herniation of rectum into vagina), enterocele (herniation of small bowel into vagina)

General treatment

    Scheduled voiding
  • Pelvic floor muscle exercises (resident must be able to follow instructions and be willing to participate)
  • Absorbent products
  • Limit or eliminate caffeine, carbonated and alcoholic beverages, chocolate and citrus
  • Restrict fluid intake for 2 hours before sleeping
  • Biofeedback
  • Electrical stimulation

Stress incontinence is the loss of a small amount of urine with physical activity such as coughing, sneezing, laughing, climbing stairs or lifting. Urine leakage results from an increase in intra-abdominal pressure on a bladder that is not overdistended and is not the result of detrusor (bladder) contractions.

Stress incontinence is the second most common type of urinary incontinence in older women.

Common causes

  • Urethral hypermobility secondary to poor anatomic pelvic support (lax pelvic floor muscle tone due to childbirth, obesity)
  • Intrinsic sphincter deficiency (defect in urethra)

General treatment

  • Pelvic floor muscle exercises (resident must be able to follow instructions and be willing to participate)
  • Modify activity to decrease intra-abdominal pressure
  • Weight loss
  • Treat chronic cough and constipation
  • Instruct on voluntary contraction of pelvic muscle prior to any activity that increases abdominal pressure (cough, sneezing, lifting), a technique called “The Knack.”4
  • Topical oestrogen replacement therapy has shown to be helpful (doctor or practitioner consult required)

Drugs that can contribute to stress incontinence

  • Alpha adrenergic antagonists (blood pressure medications such as Aldomet®, Catapres® and Minipress)
  • Muscle relaxants (such as Chlorzoxazone, Methocarbamol, Baclofen)

Also known as chronic urinary retention, overflow incontinence is associated with leakage of small amounts of urine and occurs when the bladder has reached its maximum capacity and has become distended.

Symptoms include weak stream, dysuria (painful urination), nocturia, incomplete voiding, frequent or constant dribbling. A post void residual (PVR) of greater than 200 mls is characteristic of overflow incontinence although current research lacks consensus on what is a significant PVR for the elderly.

Urinary retention, due to obstruction, reduction of bladder contractions or weakened bladder muscles, is the cause of overflow incontinence. However urinary retention can also occur without incontinence. Acute urinary retention is accompanied by pain or abdominal discomfort and requires immediate treatment. Chronic urinary retention can be difficult to diagnose because there are often no symptoms of discomfort. Undetected urinary retention can lead to urinary tract infections, renal complications and overflow incontinence.

Common causes

  • Outlet obstruction
    • Prostate cancer
    • Benign prostatic hypertrophy (BPH)
    • Urethral stricture
    • Severe prolapse
  • Hypotonic bladder (detrusor muscle underactivity)
  • Neurogenic bladder (pelvic nerve damage from diabetes, spinal cord injury, surgery or radiation therapy)
  • Faecal impaction/constipation

Medications that can cause overflow incontinence

  • Amphetamines
  • Antihistamines (such as Diphenhydramine)
  • Calcium channel blockers
  • Benzodiazepines (used to treat anxiety)
  • Diuretics (such as Furosemide®)
  • Narcotics
  • Over-the-counter cold medicines
  • Phenothiazines
  • Phenytoin
  • Theophylline
  • Tricyclic antidepressants
  • Sedatives/anti-anxiety agents

General treatment

    Treat an enlarged prostate gland Treat faecal impaction or constipation Biofeedback (if the cause is functional and not due to a neuropathic cause) Treat obstruction of pelvic mass Use an indwelling catheter only as a last resort for voiding difficulties External (condom) catheters (if the outlet is obstructed, a straight or Foley catheter must be used) Absorbent products Caffeinated, carbonated and alcoholic beverages should be limited or eliminated Renal function should be monitored in chronic retention to monitor/prevent upper urinary tract damage

Pharmacological treatment (prescription required)

  • Ditropan, Ditropan XL (oxybutynin)
  • Alpha adrenergic blockers to decrease urethral resistance
    • Cardura® (doxazosin)
    • Hytrin® (terazonsin)
    • Flomax (tamsulosin)
    • Uroxatral (alfuzosin)

Many elderly people (especially women) will experience symptoms of both urge and stress incontinence, which is known in combination as mixed incontinence. It is often diagnosed when incontinence continues in spite of appropriate treatment.

Common causes

  • Hyperactivity of detrusor muscle (muscle surrounding the bladder)
  • Local bladder irritation or infection
  • Poor urethral support from pelvic floor structure
  • Incomplete closure of the urethra due to mucosal atrophy
  • Neuropathic detrusor instability

Medications that can contribute to mixed incontinence

  • Diuretics
  • Alpha adrenergic antagonists
  • Polysynaptic inhibitors
  • Acetylcholine-like agents
  • Anticholinesterases
  • Prostaglandin E-2 and alpha
  • Muscle relaxants

General treatment

  • Treat underlying condition (such as chronic cough, faecal impaction)
  • Pelvic floor muscle exercises (if resident can participate)
  • Bladder retraining
  • Modify activity to reduce intra-abdominal pressure
  • Absorbent products
  • Limit or eliminate caffeinated, carbonated and alcoholic beverages, chocolate and citrus
  • Electric stimulation and biofeedback have been shown to be beneficial

Pharmacological treatment (prescription required)

  • Oxybutynin (Ditropan® & Ditropan XL)*
  • Tolterodine (Detrol® & Detrol LA)*
  • Topical oestrogen
  • Oestrogen cream Estring® or FemRing®

Functional incontinence refers to incontinence that is secondary to urinary tract function.

Common causes

  • Physical weakness (including general weakness or poor eyesight)
  • Pain
  • Unfamiliar environment
  • Lack of privacy
  • Poor mobility/dexterity (e.g., poor eyesight, arthritis, stroke, contracture)
  • Cognitive issues (e.g., confusion, dementia, unwillingness to toilet)
  • Medications
  • Environmental impediments (e.g., poor lighting, toilets that are difficult to access, physical restraints)

Medications that can contribute to functional incontinence

  • Diuretics
  • Sedatives
  • Hypnotics
  • Analgesics
  • Narcotics

General treatment

  • Determine cognitive and physical ability
  • Address and eliminate the cause(s) of functional incontinence
  • Place call light within easy reach
  • Pain management
  • Physical therapy
  • Scheduled toileting
  • Absorbent products for episodic leakage
  • Treat chronic constipation or faecal impaction
  • Limit or eliminate alcohol, caffeine, carbonated beverages, chocolate and citrus
  • Place a commode near the resident’s bed for easier access to toileting

Transient incontinence refers to temporary or occasional incontinence that may be related to a variety of causes. Transient incontinence has the potential to be reversed or improved.

Common causes

  • Delirium
  • Infection (UTI)
  • Atrophic vaginitis or urethritis
  • Pharmaceuticals
  • Psychological disorders
  • Excess urine production
  • Restricted mobility
  • Stool impaction

Medications that can contribute to transient incontinence

  • Diuretics
  • Anticholinesterases
  • Acetylcholine-like agents
  • Alpha adrenergic antagonists
  • Polysynaptic inhibitors
  • Muscle relaxants

General treatment

  • Identify and treat the underlying cause
  • Pelvic floor muscle exercises (resident must be able to follow instructions and be willing to participate)
  • Scheduled toileting
  • Pain management
  • Physical therapy
  • Use absorbent products for episodic leakage
  • Treat chronic constipation or faecal impaction
  • Pharmacological treatments for the cause
  • Limit or eliminate alcohol, caffeine, carbonated beverages, chocolate and citrus

Faecal incontinence is the inability to control bowel movements. Severity can range from an occasional leakage of stool while passing gas to a complete loss of bowel control.

Common causes

  • Muscle damage (anal sphincters)
  • Nerve damage due to spinal cord injury, multiple sclerosis or diabetes
  • Rectal prolapse, rectocele, hemorrhoids, fissures or fistulas
  • Diarrhoea
    • Lactose intolerance
    • Malnutrition/malabsorption
    • Clostridium difficile (C. diff) infection
    • Irritable bowel syndrome (IBD)
    • Chronic infections
  • Rectal outlet obstruction
  • Anal/rectal surgical complications

General treatment

  • Attempt to attain GI regularity and stool consistency
  • Limit or eliminate foods that can contribute to incontinence, such as greasy foods, caffeine, alcohol, spicy foods, dairy products and cured or smoked meat
  • Implement a hydration program
  • Biofeedback has been shown to be very effective
  • Surgery

Pharmacological treatment (physician consultation required)

  • Antidiarrhoea (loperamide or diphenoxylate)
  • Laxatives (milk of magnesia)
  • Stool softeners (docusate)
  • Fibre (bulking agent)