Evaluation of the causes and severity of geriatric incontinence. A critical appraisal.

The evaluation of urinary incontinence in the elderly differs from that in younger patients because of altered or nonspecific disease presentation, the different spectrum of pathophysiology, greater variation between individuals and, in some cases or settings, variable treatment goals. Evaluation must be multifactorial and extend beyond the genitourinary system, because many age-related conditions and the drugs used to treat them can cause or exacerbate urinary incontinence. Voiding records are a reliable measure of severity, although studies of their validity are still lacking. History-taking requires more time in this age group. Stress incontinence symptoms remain very sensitive, whereas obstructive symptoms fall in predictive value. Clinical algorithms based on a combination of symptoms and simple bedside examination and maneuvers may prove most useful in specific settings such as nursing homes. The targeting and interpretation of the physical examination must also change because of age-related conditions (e.g., BPH, atrophic vaginitis) and prevalent comorbid diseases, especially neurologic ones. The Q-tip, elevation, and pessary tests for stress incontinence offer little diagnostic or therapeutic information in the elderly. Routine laboratory tests should be performed to exclude reversible causes of urinary incontinence, while interpretation of the urinalysis must consider the prevalence of asymptomatic bacteriuria. No radiographic studies are routinely needed; bead-chain cystourethrography and IVU in particular probably offer little additional information. Voiding cystourethrography, although little studied, offers dynamic data that may be helpful, especially in evaluating outlet obstruction. Bedside cystometry is simple but may be insensitive to the most prevalent type of detrusor instability in the institutionalized elderly. Finally, multichannel urodynamic study is safe and feasible even in frail elderly patients and should be considered when empiric therapy is risky or has failed, complicated comorbidity exists, or surgery is anticipated.