**9.1 Conservative management**

124 Urinary Incontinence

**- Persistent bothersome symptoms after adequate trials of behavioural or drug therapy** 

examination) we are able to distinguish between an acute cause or a chronic cause of incontinence, to detect the great majority of the transient causes, the main risks factors for incontinence and to recognize the clinical type of UI and its main symptoms. With this information would be possible to decide the plan of treatment and the follow-up of the older

If the basic step does not drive the physician to a conclusive diagnosis of UI type, or in cases that conservative management of the frail older patients has failed, more extensive or invasive diagnostic techniques should be planed individually. In some cases, could be necessary to practice several complementary techniques in order to discover the etiologic

The gold standard technique in diagnosis of established incontinence is Urodynamics, allowing demonstrate whether an underlying abnormality of storage or voiding is present. Nowadays, this technique is not appropriate for all older patients, and usually it is reserved for selected patients (Thirugnanasothy, 2010). Probably, the main recommendations for this technique in the frail elderly population, is the demonstration of a significant PVR and

Based on the results of these techniques, especially on Urodynamics, we can obtain definitive diagnosis of UI type and organize better the complete and multidimensional plan

In order to decide treatment scheme, we should establish a comprehensive individualized plan of treatment, based on: the patient's characteristics (comorbidity and level of disability); the type of incontinence (urgency, at cough, mixed, overflow); the impact of incontinence; the patient's preferences and level of co-operation; the need of help by others; and also true chances of adherence to treatment (Schröder et al, 2009; Abrams et al; 2010).

It is very important to underline that the main objectives of our intervention should be: firstly, to improve the QOL; secondly, the reduction of the severity / number of leakages; and finally, if possible, the recovery of continence. In fact, the individual scheme of treatment has to be very realistic and adapted to the characteristics of each frail patient,

mechanism of the incontinence and also the status of the upper urinary tract.

before planning a surgical procedure to repair urinary incontinence (Verdejo, 2011).

**9. Medical treatment of the urinary incontinence in the frail elderly** 

**- Surgery or irradiation involving the pelvic area** 

**- Marked pelvic prolapse on physical examination - Difficulty passing a 14-Fr straight urinary catheter** 

**- Abnormal prostate examination on digital rectal - Asymptomatic microscopic or macroscopic hematuria - Before a surgical procedure to repair urinary incontinence** 

**- Pelvic pain associated with incontinence** 

**- Post-void residual volume > 200 ml** 

patients with incontinence.

of treatment.

**- Two or more urinary tract infections in a one-year period - Incontinence with new-onset neurologic symptoms** 

Table 8. Main criteria to refer a frail elderly for specialty evaluation

Nowadays, the conservative treatment of UI is considered as the mainstay in its management (grade A of recommendation). There are several effective interventions such as: modification of fluid intake pattern; modification of drug treatments; type of clothes used; palliative aids; environmental manipulations; detection and correction of transient causes (especially delirium in the frailest population); and the use of behavioural procedures (Wyman et al, 2009; Imamura et al, 2010; Abrams et al, 2010; DuBeau et al, 2010).

Behavioural techniques have been demonstrated be an effective tool in the management of several types of incontinence in the elderly. The technique used depends on the individual's functional and cognitive state. In general, if the patient doesn't have cognitive impairment, pelvic floor muscle exercises and bladder training can be used successfully. For patients with cognitive impairment, the best alternative is prompted voiding (Level 1 of evidence) (Markland et al, 2011).

It is very important to highlight that all of these techniques have show to reduce the severity of urgency and stress incontinence (grade A of recommendation) (Burgio, 2009; Price et al, 2010). In cases of institutionalized older patients and cognitively impaired, scheduled and prompted voiding have demonstrated to reduce the number of leakages of urine and the severity of the incontinence. However, these techniques require many caregivers and staff in nursing home, so it is not always possible to use them in the disabled and frailest elderly patients (Thum & Wagg, 2009).
