With advancing age, the lower urinary tract becomes an increasingly important source of medical and social concern. Incontinence, urinary tract infections (UTIs), bladder cancer, and bladder outlet obstruction (BOO) are all more prevalent in patients older than 65 years. Clinicians play an essential role in the screening, diagnosis, and treatment of these problems to preserve quality of life in elderly patients.
Urinary incontinence
The prevalence of urinary incontinence among both men and women older than 65 years is 15% to 30% and is greater than 50% in institutionalized patients.1-4 Despite this prevalence, incontinence often goes unrecognized, with only 25% to 50% of patients actively seeking treatment.4,5 Incontinence is associated with a number of adverse effects, including impairments in the ability to perform activities of daily living, a greater risk of falls, increased nighttime awakenings, skin ulceration, recurrent UTIs, social isolation, and depression.5,6
History and physical examination The history should address concurrent medical conditions, medications, 
relevant surgeries, obstetric history, sexual function, bowel habits, neurologic symptoms, mental status, and functional ability. Record any incontinence characteristics including onset, frequency, precipitating factors, and use of sanitary pads or other protective measures. Document history of previous incontinence treatment and the level of success. Ask patients about fluid intake and the presence of other lower urinary tract pathology such as recurrent UTIs, benign prostatic hyperplasia (BPH), and pelvic organ prolapse.
The physical examination should encompass abdominal, pelvic, genital, rectal, neurologic, and functional assessment and a calculation of body mass index. Other components include urinalysis, urine culture, voiding diaries, a cough test to assess for stress incontinence, and postvoid residual (PVR) volume measurement.1,3,4,7
Patients with clinically identified uncomplicated incontinence should undergo conservative management for 8 to 12 weeks before a treatment regimen is changed or referral to a specialist is considered.7 Recurrent incontinence; incontinence accompanied by hematuria, pain, abnormalities on physical examination, a PVR volume of 200 cc or greater; or a history of a recent GU procedure, pelvic irradiation, or radical pelvic surgery are indications for referral to a specialist (see “Diagnosis and treatment of urinary incontinence”).3,7
Stress incontinence Accounting for approximately half of all female urinary incontinence, stress incontinence 
peaks in prevalence in the fifth decade. It remains a concern in elderly women, however, since patients with sphincter dysfunction, insufficient pelvic floor support, urethral hypermobility, and neurogenic abnormalities are predisposed to this condition.2 Urine leakage then occurs with increased intra-abdominal pressure, such as occurs with sneezing, coughing, laughing, or exertion.1-4 Trauma, pelvic and prostate surgery, and pelvic irradiation are inciting causes in men.4,8 Encourage patients to monitor the type and amount of fluid intake, stop smoking, lose weight, and void on a scheduled basis.1,7 Pelvic floor muscle (Kegel) exercises and bladder training are first-line treatments for both sexes.3,4,7 Female patients may benefit from the use of vaginal pessaries for additional pelvic structure support.7
There are currently no FDA-approved medications for stress incontinence, although trials of duloxetine, a serotonin and norepinephrine reuptake inhibitor, have shown promise.1,6,9 Surgical options include artificial sphincter implantation, retropubic suspension, and sling procedures.3,7 Urethral bulking agents, such as periurethral collagen injections, are associated with a low incidence of mortality and can be useful treatment options for geriatric patients.3,4,7
Urge incontinence The predominant form of incontinence in women older than 75 years,1 urge incontinence is also common among men.4 In this condition, urine leakage is immediately preceded or accompanied by a sense of urgency. The cause may be idiopathic detrusor contractions or neurologic disease (including diabetic neuropathy, Parkinson's disease, stroke, or spinal cord injury). Fecal impaction, GU infection, pelvic irradiation, and BPH contribute to idiopathic hyperactivity of the detrusor.1,3,4