Urinary incontinence is common, treatable, and mostly not discussed

Estimates vary with definition, but around a third to a half of community-dwelling women over sixty-five report some urinary incontinence, and roughly 10 to 20 per cent of men. Rates in residential care are far higher.

The consequences extend well beyond inconvenience. Incontinence is independently associated with falls and fractures — largely from rushing to the toilet, often at night in poor light. It causes skin breakdown. It drives social withdrawal, since people stop going anywhere without a known toilet. It is a strong predictor of admission to residential care, frequently the specific tipping point for a family providing care at home. And it is associated with depression at rates well above the general population.

Surveys consistently find that people wait several years before mentioning it, and that many never do. A substantial fraction believe it is a normal part of ageing. It is not.

The types, which need different treatment

Stress incontinence — leakage on coughing, sneezing, laughing, lifting or exercising. Caused by weakness of the pelvic floor and urethral sphincter. Predominantly in women, associated with childbirth and with menopause, and in men most commonly after prostate surgery.

Urgency incontinence — a sudden compelling need to urinate with leakage before reaching a toilet, usually with frequency and nocturia. Part of overactive bladder syndrome, caused by involuntary detrusor contraction.

Mixed incontinence — both, and the commonest picture in older women.

Overflow incontinence — continuous dribbling from a bladder that does not empty, most often from prostatic obstruction in men, and sometimes from an underactive detrusor or neurological disease.

Functional incontinence — the bladder works, but the person cannot reach a toilet in time because of mobility problems, cognitive impairment, or an inaccessible bathroom. This is common and often the easiest to fix, sometimes with a commode and better lighting rather than anything medical.

What works

Pelvic floor muscle training is first-line for stress and mixed incontinence and has good evidence. Effect sizes are substantial when the training is supervised by a specialist physiotherapist and the programme is sustained. Unsupervised leaflet-based instruction performs considerably worse, largely because a significant proportion of people contract the wrong muscles when instructed only in writing.

It works in older women. Age is not a contraindication, and the assumption that it is too late is a common reason it is not offered.

Bladder training is first-line for urgency incontinence — gradually extending the interval between voids, with urge suppression techniques, over several weeks. Effective and under-prescribed.

Weight loss, where relevant, has a well-demonstrated effect on stress incontinence.

Fluid management, which needs care. Reducing intake concentrates urine and irritates the bladder, worsening urgency — a self-defeating strategy that many people adopt. Better to redistribute: adequate total intake, weighted toward earlier in the day.

Topical vaginal oestrogen for postmenopausal women improves urogenital atrophy and both urgency and recurrent urinary infections. Systemic absorption is minimal, and it is considerably safer than systemic hormone therapy — a point often misunderstood by patients and, occasionally, by clinicians.

Medication, with age-specific caution

Antimuscarinics — oxybutynin, tolterodine, solifenacin — are effective for overactive bladder and are anticholinergic. Oxybutynin in particular crosses the blood-brain barrier readily, and cumulative anticholinergic burden is associated with cognitive impairment and, in cohort studies, with dementia risk. It appears on lists of drugs to avoid in older adults.

Mirabegron, a beta-3 agonist, works by a different mechanism and lacks anticholinergic effects, which makes it a more appropriate first choice in older patients despite the cost. It can raise blood pressure and needs monitoring.

For refractory overactive bladder, intravesical botulinum toxin and sacral neuromodulation are effective options that are considerably under-referred.

For men specifically

Male incontinence is usually secondary to prostatic obstruction or to treatment for it. Lower urinary tract symptoms — hesitancy, poor stream, incomplete emptying, nocturia — warrant assessment, including a check that the bladder is emptying, because chronic retention can damage the kidneys silently.

Alpha blockers and 5-alpha reductase inhibitors are the usual medical treatments; surgical options exist for those who need them. Post-prostatectomy incontinence responds to pelvic floor training and, in persistent cases, to sling or artificial sphincter surgery.

Raising it

Because clinicians frequently do not ask, the burden falls on the patient. Two questions get the conversation started: "Do you ever leak urine?" and "Does your bladder affect what you do?"

A three-day bladder diary — times, volumes, leakage episodes, what you drank — is the single most useful thing to bring to that appointment, and it takes the conversation immediately past the awkward opening. Continence services exist in most health systems and can be accessed by referral, and often by self-referral.

Pads manage the symptom. They are not treatment, and accepting them as the end of the conversation is how a treatable condition becomes a permanent one.