Urinary incontinence (UI) is a prevalent in geriatric patients.(1) Among women older than 70 years, UI is frequently associated with impairments in physical function and cognition(2), and with skeletal muscle weakness(3).  In the context of these functional impairments, UI is considered as a multi-factorial geriatric syndrome that may represent a distinct clinical phenotype of UI that we refer to as the geriatric incontinence syndrome.  It is plausible that this novel phenotype may account for the refractory nature of UI among older women.  However, the clinical characteristics of the geriatric incontinence syndrome have yet not been to be elucidated because it lacks a clinical diagnosis.  Consequently, we lack understanding of the efficacy of common UI treatment approaches for this highly impacted and under-recognized group of older incontinent women.  We present prospectively collected data primarily aimed to robustly characterize the pelvic floor function, physical performance and strength, and cognitive function of older women with the moderate-to-severe urinary incontinence to provide the foundation to clinically characterize the geriatric incontinence syndrome.

We conducted a prospective cohort study of community-dwelling women older than 70 years with moderate-to-severe UI symptoms. Potential participants were eligible if age was older than 70 years and they had a diagnosis of UI  determined by the presence of ICD-10 diagnosis codes [R32 (unspecified UI), N39.81 (functional UI), N39.41 (urge UI), N39.46 (mixed UI), or N39.3 (stress UI) in their electronic medical record within 6 months of the query. Women were excluded if they had prior surgical intervention for UI or hysterectomy within the past 12 months, diagnosis of pelvic organ prolapse beyond the hymenal ring, urogenital fistula, neurogenic overactive bladder (associated with a diagnosis of Multiple Sclerosis, Stroke within past 12 months), incomplete bladder emptying/urinary retention with PVR > 150 ml (measured by bladder scan), required assisted device (4 point cane, walker) for ambulation all or most of the time, wheelchair bound, were currently undergoing treatment for significant cognitive impairment or dementia, deemed medically unsafe to exercise (severe cardiopulmonary disease), or if they were determined otherwise ineligible by the principal investigator.  Introductory letters were mailed in bulk. Screening calls were made for those who self-selected to participate to confirm eligibility.    Informed consent was obtained at the baseline visit.   All participants completed validated questionnaires regarding their overall health, UI symptom type and severity, a 3-day bladder diary, pelvic floor function, and perceived assessment of exercise, physical performance, and mobility. Participants underwent subjective and objective assessment of their physical performance, balance, lower extremity strength, skeletal muscle mass, and cognition.    Physical performance was determined using the Short Physical Performance Battery score (SPPB), whereas normal physical performance was defined as (SPPB > 9) and poor physical performance defined as (SPPB ≤ 9). Participants were first compared based on UI severity; moderate being <2 UI episodes/day and severe being ≥2 UI episodes/day. Test of difference between groups utilized Student’s T-test or Chi-square for continuous and categorical measures, respectively, except for number of deliveries (vaginal and total) that relied on Wilcoxon rank sum non-parametric test due to non-symmetric distribution.

71 women completed in person screening.  10 women did not return their baseline bladder diary and were excluded leaving 61 women to be included in this analysis.  19 women had moderate UI with <2 UI episodes/day and 42 had severe UI with ≥2 UI episodes/day. Mean±SD age was 77.1±5.8 years, 51 women were white and 10 were black.  Median (IQR) parity was 2(2, 3).  Women with more severe UI had larger BMI, 32 ± 13.3 kg/m2 vs 27.3 ± 5.7 kg/m2, p=0.06.  There were no significant differences in total number of medications used with mean of 6.7 ± 3.5. Depression was uncommon, found in only 6 (9.8%) women.  Constipation was present in 20% of women based on Bristol Stool chart.  Daytime voiding frequency was normal in both groups and the majority had nocturia with mean±SD of 2.6 ± 1.5 voiding episodes/night. There were no differences in pelvic floor strength, endurance, or efficiency based on UI severity with mean Brink grade of 3 ±1, mean contraction endurance of 4.5 ± 1.9 seconds, and mean number of repetitions at maximum power of 9.1 ± 1.8.  

Nearly all (98.4%) of women reported their UI as a barrier to exercise. Among women with severe UI, Pepper Center Assessment of Disability scores were significantly greater at 1.8 ± 0.6 compared to women with moderate UI at 1.5 ± 0.6, p=0.03.  Mean mobility assessment scores were also significantly lower among women with severe UI, 57.0 ± 9.3 vs 62.6 ± 10.4, p=0.04.  Objectively, a greater proportion of women with severe UI had worse physical performance with SPPB ≤ 9 in 82.8% vs 54.8% among women with normal physical performance (SPPB > 9), p=0.02. This was driven by slower chair-stand pace among women with severe UI with significantly lower SPPB- subscale mean score of 2.3 ± 1.4 compared to 3.3 ± 0.9 among women with moderate UI, p=0.007. Gait speed was also significantly slower among older women with severe UI at 0.8 ± 0.2 m/s compared to 1 ± 0.2 m/s, p=0.03. In considering markers of sarcopenia, there were no significant differences in risk factors of sarcopenia. Mild cognitive impairment was common with mean MoCA score of 24.6 ± 3 for the entire cohort with no significant differences based on UI severity or physical performance.

Older women with severe UI (≥2 UI episodes/day) have larger BMI, greater perceived physical disability and mobility impairment. Objectively, they had poor physical performance, slower chair stand pace, and slower gait speed.

We present novel and clinically important prospective data describing a potentially new phenotype of UI, the geriatric incontinence syndrome.  This syndrome may be clinically characterized in women older than 70 years with severe UI, mobility disability and physical function impairment. Further prospective studies are needed to assess the efficacy of evidenced-based UI treatments in women with the geriatric incontinence syndrome to determine its impact on clinical practice.

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Huang AJ, Brown JS, Thom DH, Fink HA, Yaffe K. Urinary incontinence in older community-dwelling women: the role of cognitive and physical function decline. Obstet Gynecol. 2007;109(4):909-16.
Parker-Autry, C., Houston, D. K., Rushing, J., Richter, H. E., Subak, L., Kanaya, A. M., & Kritchevsky, S. B. (2017). Characterizing the Functional Decline of Older Women With Incident Urinary Incontinence. Obstetrics and gynecology, 130(5), 1025–1032. https://doi.org/10.1097/AOG.0000000000002322