What are the best practices for diagnosing and managing urinary incontinence in elderly patients?

Best practices for diagnosing urinary incontinence in elderly patients include taking a detailed clinical history to categorise the type of incontinence as stress, urgency, or mixed urinary incontinence, and identifying predisposing or precipitating factors and other diagnoses that may require referral or further investigation. A physical examination should include assessment of pelvic floor muscle function through digital examination before starting pelvic floor muscle training. Urine dipstick testing is recommended to detect blood, glucose, protein, leucocytes, and nitrites, with further urine culture and antibiotic sensitivity testing if infection is suspected. Measurement of post-void residual volume by bladder scan is preferred over catheterisation to assess voiding dysfunction or recurrent urinary tract infections. Bladder diaries covering at least 3 days are useful in the initial assessment to understand symptom patterns. Routine use of pad tests, cystoscopy, and imaging (other than bladder scan for residual urine) is not recommended in initial assessment. Referral to specialist services should be considered for complex cases such as persistent bladder or urethral pain, palpable bladder after voiding, neurological disease, or previous pelvic surgery.

Management should start with conservative measures such as supervised pelvic floor muscle training, tailored to the patient’s ability and confirmed by digital assessment. Medicines for overactive bladder may be offered with careful consideration of coexisting conditions, cognitive status, and potential adverse effects, especially in elderly patients. Anticholinergic medicines should be used cautiously, avoiding oxybutynin immediate release in older women at risk of cognitive or physical deterioration. Long-term indwelling catheters should be used only when necessary, with preference for suprapubic catheters over urethral catheters due to lower complication rates. Intravaginal and intraurethral devices are not recommended for routine management but may be used occasionally to prevent leakage during activities. Complementary therapies are not recommended. Ongoing assessment of treatment efficacy should include symptom and quality-of-life questionnaires.