Incontinence in Older Adults: Causes and Types

How continence works

Staying dry and clean needs several things to work together: a bladder and bowel that store and empty properly, strong muscles and nerves, a brain that recognises the urge and decides when and where, the ability to reach and use a toilet in time, and the ability to undress and manage clothes. A problem in any link can lead to leakage. Ageing changes some of these links (the bladder holds less, the urge may come suddenly, nighttime urine production rises, muscles weaken), but these changes alone do not cause incontinence. Other treatable factors usually tip the balance.

Types of urinary incontinence

Stress incontinence. Leakage when pressure rises in the abdomen: coughing, sneezing, laughing, lifting, standing up. The pelvic floor muscles or the sphincter are too weak to hold. Common in women after childbirth and menopause, and in men after prostate surgery. See pelvic floor exercises for older adults.

Urge incontinence. A sudden, strong need to pass urine, with leakage before reaching the toilet. The bladder muscle contracts at the wrong time. Often accompanied by frequency and getting up at night. Can be linked to infection, caffeine, medicines, stroke, Parkinson's disease or dementia.

Overflow incontinence. The bladder never empties fully, so it overfills and dribbles. Causes include an enlarged prostate, constipation, nerve damage from diabetes, some medicines and urethral narrowing. Signs: weak stream, straining, a feeling of not emptying, frequent small leaks. It can lead to infection and kidney damage and needs medical assessment; see prostate problems and urinary symptoms in older men.

Functional incontinence. The bladder works, but the person cannot reach or use the toilet in time because of poor mobility, arthritis, weakness, poor eyesight, confusion, dementia, a distant toilet, difficult clothing or no help. A very common type in frail older adults, and one that families can often improve; see incontinence and dementia: routines and reassurance.

Mixed incontinence. A combination, often stress and urge, particularly in women.

Nocturnal enuresis and night-time leakage. Wetting during sleep, often linked to high night urine output, sleep apnoea, heart failure, certain medicines or an unreachable toilet; see managing incontinence at night.

Bowel incontinence

Leakage of stool or gas, or inability to hold when the urge comes. In older adults, a very common cause is constipation with impaction, where hard stool blocks the rectum and liquid stool leaks around it, which looks like diarrhoea. Other causes: weak anal sphincter muscles, nerve damage, diarrhoea from infection, medicines or laxatives, bowel disease, dementia and immobility. See bowel incontinence and constipation in later life.

Common contributors and treatable causes

Before accepting incontinence as permanent, doctors look for causes such as:

• Urinary tract infection: new urgency, burning, or sudden worsening of leakage; in older adults it may present as confusion or falls; see urinary tract infections in older adults: atypical signs.
• Constipation: pressing on the bladder and causing overflow in both bowel and bladder.
• Medicines: diuretics (water tablets), sedatives and sleeping tablets, some antidepressants, some blood pressure and heart medicines, muscle relaxants, anticholinergic drugs, opioid painkillers and alcohol. Do not stop or change any medicine yourself; tell the doctor, who may review. See medicine side effects families should watch for.
• Diabetes, with high sugar causing more urine, and nerve damage; see diabetes after 60: a home care guide.
• Prostate enlargement in men.
• Menopause-related changes in the tissues of the vagina and urethra, and pelvic organ prolapse in women.
• Stroke, Parkinson's disease, dementia, spinal problems and other nerve conditions.
• Reduced mobility, pain, arthritis, hip or knee problems, or being in bed.
• Poor eyesight or hearing, which make it hard to find the toilet or to recognise signals.
• Confusion or delirium, where the person cannot understand where to go; see delirium in older adults.
• Heart or kidney problems and swollen legs, which shift fluid into urine at night.
• Sleep apnoea, raising night urine production.
• Excess caffeine, alcohol or fizzy drinks, and obesity.
• Depression, where self-care and toilet routines slip.
• Environmental barriers: a toilet far away, steps, a dark route, a squat toilet that is hard to use; see night-time toilet trips and falls.
• Smoking and chronic cough.

The impact: more than wet clothes

Incontinence affects skin (rashes, infections, sores), sleep, falls (rushing to the toilet in the dark), mood, confidence and social life. People may stop drinking to avoid leaks, which causes dehydration, concentrated urine, more infections and constipation. Carers may feel exhausted and resentful. Recognising these effects helps the family approach the problem with practical and emotional support. See talking about incontinence with a parent without shame.

What families can do at home

1. Talk about it calmly and without blame, and offer to arrange a medical check. 2. Keep a simple diary for three days: times and amounts of drinks, toilet visits, leaks, urges, and any pain or symptoms. This helps the doctor and reveals patterns. 3. Make the toilet easy: clear path, good light, a toilet within a short distance, a raised seat, rails, a bedside commode or urinal at night, clothing that is easy to remove. See raised toilet seat guide, commode chair guide and urinals for men and women: bedside use. 4. Do not restrict fluids to stop leaks. Aim for regular drinks through the day unless a doctor has limited fluids for heart or kidney disease; see hydration for older adults. Reduce caffeine, fizzy drinks and alcohol, especially in the evening. 5. Prevent constipation with fibre, fluids, movement and a regular routine; see constipation in older adults. 6. Use timed toileting to reduce accidents; see bladder training and timed toileting. 7. Teach pelvic floor exercises where suitable; see pelvic floor exercises for older adults. 8. Choose products to suit the situation, as a safety net and not a substitute for assessment; see choosing incontinence products by situation. 9. Protect the skin: change promptly, cleanse gently, use a barrier cream; see incontinence-associated skin damage: prevention and care. 10. Keep calm and dignified when accidents happen; see dignity in intimate care: words, privacy and consent.

What the doctor may do

A good assessment includes a history, a medicine review, a physical and sometimes a pelvic or rectal examination, a urine test, a check for incomplete emptying (for example by ultrasound), blood tests for sugar and kidney function, and a bladder diary. Treatments may include treating infection or constipation, changing medicines, bladder training, pelvic floor therapy, local oestrogen for some women, medicines for an overactive bladder (with caution in older adults, as some affect memory and can worsen confusion), treatment of prostate problems, devices, catheters in selected cases, or surgery. Guidance such as the NICE guidelines on urinary incontinence and on lower urinary tract symptoms in men sets out the stepwise approach. See when to see a doctor about bladder or bowel changes.

Common myths

• "It is normal at my age." It is common, but not normal, and often treatable.
• "Drinking less will help." It usually makes things worse.
• "Pads fix it." Pads manage leakage but do not address the cause, and overuse can hide a treatable problem.
• "Nothing can be done for dementia." Routines and prompts help a lot; see incontinence and dementia: routines and reassurance.
• "Talking about it is shameful." Doctors and nurses treat it every day.

When to ask a professional

See a doctor for any new, worsening or distressing incontinence, particularly if there is pain, burning, blood in urine or stool, fever, a weak stream, inability to pass urine, sudden onset, leg weakness or numbness, or after a fall or stroke. A continence nurse, physiotherapist or urologist can help. Ask a pharmacist about medicines that may be contributing. Seek urgent help for inability to pass urine, severe lower abdominal pain, fever with confusion, or loss of bladder and bowel control with numbness around the groin or weakness in the legs, and call 112 if severe.