Incontinence, faecal and urinary
Red flags
- Acute urinary retention with overflow - palpable bladder, dribbling; the commonest reversible cause missed on a ward round
- Cauda equina syndrome - urinary retention or incontinence + saddle anaesthesia + bilateral leg symptoms + loss of anal tone -> urgent MRI, same day
- New neurological signs with incontinence - cord compression, stroke, MS, normal pressure hydrocephalus
- Visible haematuria, or non-visible haematuria with irritative symptoms - bladder cancer until excluded
- New faecal incontinence with rectal bleeding, weight loss or altered bowel habit - colorectal malignancy
- Faecal incontinence with overflow diarrhoea in an immobile older person - faecal impaction; do not treat as gastroenteritis
- Fistula - continuous leakage day and night, post-pelvic surgery/radiotherapy/obstetric injury
- Incontinence + fever + loin pain or delirium - upper tract infection or urosepsis
- Sudden onset over days - always a precipitant: drug, infection, retention, impaction, delirium, immobility, glycosuria
- Pressure injury or excoriated perineum - skin failure is already occurring
Differential by mechanism
Urinary - by mechanism
| Type | Mechanism | Clinical signature |
|---|---|---|
| Urge (overactive bladder) | Detrusor overactivity | *The commonest cause in older adults*. Sudden urgency, leakage on the way to the toilet, nocturia, frequency, "key-in-the-door" |
| Stress | Urethral sphincter/pelvic floor incompetence | Leak on cough, laugh, lift. Commonest in younger and parous women; in men almost always post-prostatectomy |
| Mixed | Both | Very common in older women - treat the more bothersome component first |
| Overflow | Detrusor underactivity and/or bladder outlet obstruction | Poor stream, hesitancy, incomplete emptying, dribbling, palpable bladder, high residual |
| Functional | Cannot reach or use the toilet in time | Normal bladder. Immobility, arthritis, delirium, dementia, restraint, no call bell, no accessible toilet |
| Continuous | Fistula, ectopic ureter, patulous urethra | Constant wetness, day and night |
- Detrusor hyperactivity with impaired contractility (DHIC) - the classic geriatric trap: urgency AND a high residual together; anticholinergics precipitate retention
Causes of detrusor overactivity
- Idiopathic (most), stroke, dementia, Parkinson disease, MS, spinal cord lesion (loss of cortical inhibition)
- Local irritation: infection, stones, tumour, atrophic vaginitis, indwelling catheter
Causes of outlet obstruction
- BPH, prostate cancer, urethral stricture (men); pelvic organ prolapse (women); constipation
Faecal incontinence - by mechanism
- Overflow around faecal impaction - *the commonest cause in frail and hospitalised older adults*
- Sphincter/structural injury - obstetric tear, anal surgery (fistulotomy, haemorrhoidectomy), rectal prolapse
- Neurological - pudendal neuropathy, diabetic autonomic neuropathy, cauda equina, cord lesion, dementia (loss of social continence)
- Diarrhoea of any cause - a normal sphincter cannot contain liquid stool (infection, IBD, coeliac, bile acid malabsorption, laxatives, metformin, magnesium)
- Reduced rectal compliance/capacity - radiation proctitis, IBD, resection
- Functional - immobility, cognitive impairment, poor toilet access
Reversible contributors - DIAPPERS
- Delirium, Infection (symptomatic), Atrophic vaginitis, Pharmaceuticals, Psychological (depression), Excess urine output (diuretics, hyperglycaemia, hypercalcaemia, heart failure, fluid overload), Restricted mobility, Stool impaction
Drugs to blame
- Diuretics (volume), alpha blockers (stress incontinence in women), anticholinergics and opioids (retention/constipation), ACE inhibitors (cough -> stress), calcium channel blockers (oedema -> nocturnal diuresis; constipation), sedatives and alcohol (functional), cholinesterase inhibitors (urgency), SGLT2 inhibitors (osmotic diuresis), lithium (polyuria)
Focused history
- *Ask - patients do not volunteer it.* Median delay to reporting is years; most assume it is normal ageing
- Which pattern?
- "Do you leak when you cough, laugh or lift?" -> stress
- "Do you get a sudden urge you cannot defer?" -> urge
- "Do you feel you empty completely? Is the stream poor?" -> overflow/obstruction
- "Could you get to the toilet in time if you wanted to?" -> functional
- Onset and tempo - sudden onset = look for a precipitant, not a new chronic diagnosis
- Volume, frequency, pad use and pad weight, nocturia, nocturnal enuresis
- Fluid habits - total volume, caffeine, alcohol, artificially sweetened drinks, evening intake, self-imposed fluid restriction
- Bowels - constipation, straining, impaction, laxative use, stool form (Bristol), faecal urgency vs passive soiling
- Passive soiling with no awareness = internal sphincter/neuropathy; urge soiling = external sphincter/rectal capacity
- Obstetric history - parity, forceps, third/fourth-degree tear, birth weight
- Surgical/radiotherapy history - prostatectomy, TURP, hysterectomy, prolapse repair, anal surgery, pelvic radiotherapy
- Neurological - stroke, Parkinson disease, MS, back pain, diabetes, cord symptoms, gait change
- Full medication review, including over-the-counter and recently changed drugs
- Functional and social: mobility, transfers, dexterity (buttons, zips), vision, cognition, toilet access at night, carer availability, use of a commode
- Impact: social withdrawal, sexual function, mood, carer strain
- *Incontinence is a leading precipitant of residential care admission and a marker of carer breaking point - ask explicitly*
- Goals - what would count as improvement for this person? Dryness, fewer pads, or a manageable routine?
Focused examination
- Abdomen - palpable/percussible bladder, masses, scars
- Neurological - gait, cognition (4AT/MoCA), focal signs, lower limb power/tone/reflexes, perineal sensation (S2-S4), anal tone, anal wink, bulbocavernosus reflex
- Rectal examination - mandatory in both sexes
- Faecal loading or impaction (may be soft, not hard - impaction does not require rock-hard stool)
- Resting tone (internal sphincter) and squeeze (external sphincter)
- Prostate size and consistency; rectal mass, blood, prolapse
- Women: pelvic examination
- Atrophic vaginitis - pale, dry, friable mucosa
- Prolapse (cystocele, rectocele, uterine) - ask her to cough/strain
- Cough stress test with a comfortably full bladder - visible leak confirms stress incontinence
- Pelvic floor squeeze strength
- Skin - excoriation, incontinence-associated dermatitis, candidiasis, pressure injury
- Legs - oedema (a reservoir that mobilises at night -> nocturia)
- Function, in situ - watch the patient walk to the toilet, undress and sit down; a 20-second observation changes the diagnosis more often than urodynamics
- Check the environment: distance to toilet, lighting, rails, height, walking aid within reach, clothing
Investigation strategy
Bedside - do these before anything else
- Post-void residual by bladder ultrasound - the single most useful test
- >100-150 mL is significant; >300 mL indicates retention
- Distinguishes overflow from urge and stops you giving an anticholinergic to someone in retention
- Urinalysis - to exclude haematuria, glycosuria, proteinuria
- *A positive nitrite/leucocyte dipstick in an asymptomatic older person is bacteriuria, not a cause of incontinence* - do not treat
- Bladder diary for 3 days - volumes, times, leaks, pad changes, fluid intake
- The highest-yield "investigation" in the whole assessment; distinguishes polyuria, nocturnal polyuria and small-capacity bladder
- Cognitive and functional screen
Bloods
- UEC, calcium, glucose/HbA1c; B12 if neuropathy suspected; PSA only after discussion, in men where it will change management
Imaging and specialist tests - selective, not routine
- Renal tract ultrasound if: high residual, recurrent infection, haematuria, renal impairment, suspected obstruction
- Urodynamics - not routine; before surgery for incontinence, after failed treatment, or when the pattern is unclear or neurogenic
- Cystoscopy - visible haematuria, persistent non-visible haematuria with irritative symptoms, suspected fistula or bladder lesion
- MRI spine - urgently if cord or cauda equina signs
- Faecal incontinence: anorectal manometry, endoanal ultrasound, defaecating proctography after conservative measures fail; colonoscopy if red flags or diarrhoea
- Coeliac serology, faecal calprotectin, stool culture where diarrhoea is the driver
Management
Reverse the reversible, then treat by type. Conservative measures precede drugs in every category.
1. Reverse the reversible - in everyone, first
- Treat constipation and disimpact (this alone resolves a large proportion of both urinary and faecal incontinence)
- Relieve retention - catheterise, then find the cause
- Review and deprescribe the drug list above
- Treat symptomatic infection, hyperglycaemia, hypercalcaemia, heart failure
- Topical vaginal oestrogen for atrophic vaginitis (low dose, safe, effective; systemic HRT does NOT help and may worsen incontinence)
- Optimise mobility, footwear, lighting, toilet access; commode or urinal at the bedside
2. Urge incontinence / overactive bladder
- Conservative first - continue even if drugs are started
- Bladder retraining with timed voiding and gradually increasing intervals
- Pelvic floor muscle training with urge suppression technique (stop, squeeze, distract, then walk)
- Caffeine and alcohol reduction; correct both excessive and insufficient fluid intake
- Weight loss; treat constipation
- Drugs - modest benefit; expect ~1 fewer leak per day
- Mirabegron (beta-3 agonist) is preferred in older adults - no anticholinergic burden; monitor BP
- Antimuscarinics: solifenacin, darifenacin if needed
- *Avoid oxybutynin in older people* - crosses the blood-brain barrier, worsens cognition, and adds to anticholinergic load
- Contraindicated in narrow-angle glaucoma; avoid with a high residual
- Review at 4-6 weeks; stop if no benefit - do not continue indefinitely
- Refractory: intradetrusor onabotulinumtoxinA (counsel about self-catheterisation), percutaneous tibial nerve stimulation, sacral neuromodulation
3. Stress incontinence
- Supervised pelvic floor muscle training for at least 3 months - first line, and effective (cure or improvement in ~60-70%)
- Weight loss, treat chronic cough, stop smoking
- Continence pessary or vaginal support device
- Duloxetine - second line, poorly tolerated, not PBS-subsidised for this indication in Australia
- Surgery: midurethral sling, colposuspension, bulking agents; artificial urinary sphincter for post-prostatectomy incontinence
4. Overflow / retention
- Catheterise to decompress, then treat the cause
- Intermittent self-catheterisation is preferred to an indwelling catheter wherever feasible
- Men: alpha blocker (tamsulosin, prazosin) +/- 5-alpha reductase inhibitor; consider TURP
- Detrusor underactivity: timed and double voiding; bethanechol is ineffective - do not use**
5. Functional incontinence
- Prompted and timed voiding on a schedule; "toileting before the urge"
- Occupational therapy: toilet height and rails, clothing with elastic waists and Velcro, commode, urinal, lighting, path clearing
- Treat the mobility problem - the bladder may be normal
6. Faecal incontinence
- Disimpact and then maintain regular emptying - macrogol titrated to a soft formed stool, plus a planned daily evacuation
- Firm the stool if loose: loperamide titrated (start very low - 0.5-1 mg), soluble fibre (psyllium)
- Regular post-prandial toileting to exploit the gastrocolic reflex
- Pelvic floor exercises +/- biofeedback for sphincter weakness
- Rectal irrigation / suppositories / enemas for neurogenic bowel
- Surgical: sphincter repair, sacral neuromodulation (good evidence), rarely stoma
- Barrier creams and skin protection; anal plugs in selected patients
7. Containment and dignity - for everyone, whatever the cause
- Correct product for the type and volume - continence nurse advisor referral
- Barrier cream, prompt changes, skin surveillance - prevent incontinence-associated dermatitis and pressure injury
- *Indwelling catheter is a last resort*: intractable retention, non-healing sacral wound, palliative comfort, patient preference after counselling
- Catheters cause infection, bypassing, trauma, stones and delirium; they do not treat incontinence
- National Continence Helpline, Continence Aids Payment Scheme, NDIS/My Aged Care funding for products
- Address carer burden explicitly - this symptom, more than most, determines whether a person can stay at home
Traps
- *Treating asymptomatic bacteriuria. A positive urine culture in an older person with chronic incontinence explains nothing and the antibiotic causes harm (C. difficile*, resistance, delirium)
- *Starting an anticholinergic without measuring the post-void residual* - precipitates retention, especially in DHIC and in men
- *Oxybutynin in an older person* - cognitive decline and anticholinergic load; and it is often prescribed to someone already on donepezil, directly opposing it
- *Missing faecal impaction presenting as diarrhoea* - the patient is charted as having loose stools and given loperamide
- Missing overflow - "he's incontinent" when he is in chronic retention with a bladder to the umbilicus
- Missing cauda equina - new incontinence with back pain is a same-day MRI, not a continence referral
- Accepting "it's just my age" - both the patient's and the clinician's version of this
- Advising fluid restriction - concentrated urine irritates the bladder, causes constipation, delirium and falls
- Inserting a catheter for convenience - "for accurate fluid balance" or to protect the sheets
- Forgetting the toilet is 20 metres away - a functional problem treated with drugs
- Treating urinary incontinence and ignoring the bowels - constipation is the single most treatable contributor to both
- Not asking men about post-prostatectomy leakage, and not asking women about prolapse or obstetric injury
- Treating the "mixed" patient's stress component when urge is what wakes her six times a night - ask which bothers her most
Talk track
1. Frame it as a geriatric syndrome, not a bladder disease
- "Incontinence in an older person is usually multifactorial - bladder, bowel, mobility, cognition and drugs all contribute, so I assess all five rather than looking for a single cause."
2. Reverse the reversible first
- "Before I classify the incontinence I look for the reversible contributors - delirium, symptomatic infection, atrophic vaginitis, drugs, excess urine output, restricted mobility and stool impaction - because those are where most of the benefit is."
3. Classify by type, and prove it at the bedside
- "I separate urge, stress, overflow and functional incontinence on the history, and I measure a post-void residual in everyone - that single measurement stops me giving an antimuscarinic to a patient in retention."
4. Conservative before pharmacological
- "For urge incontinence I would start with bladder retraining and pelvic floor training. If I do use a drug, I would choose mirabegron rather than oxybutynin in an older person because of anticholinergic cognitive burden, and I would review it at six weeks and stop it if it isn't working."
5. Do not treat the urine culture
- "I would not send or treat a urine culture on the basis of incontinence alone - asymptomatic bacteriuria is very common in this group and treating it causes harm without improving continence."
6. Name the stakes
- "Incontinence drives skin breakdown, falls, social isolation and carer exhaustion, and it is one of the commonest reasons an older person can no longer be cared for at home - so even where I cannot cure it, containment and carer support are an active part of the plan.
🔒
7 more sections, plus exam facts
Premium unlocks every note across every specialty, and the full exam fact library behind it.
Get premium access