14.3 Urinary Incontinence & Pressure Injuries in Older Adults

ABIM Internal Medicine Exam

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15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

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20 Chapter 19: Ophthalmology (1% of Exam)

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21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

14.3 Urinary Incontinence & Pressure Injuries in Older Adults

Key Takeaways Explain This Topic AI

Incontinence in the elderly and pressure injuries are separately enumerated blueprint subsections under Geriatric Syndromes.

Reversible contributors summarized by the DIAPPERS mnemonic must be addressed before drug therapy for incontinence.

Post-void residual measurement distinguishes overflow incontinence, in which antimuscarinics cause retention.

Pressure injury stage is assigned by the deepest tissue visible, and a wound obscured by eschar or slough is unstageable.

Stable dry eschar on an ischemic heel should not be debrided because it functions as a biological cover.

Last updated: August 2026

1. Urinary Incontinence in Older Adults

Urinary incontinence affects >50% of nursing home residents and 30-40% of community-dwelling older adults. It is a major precipitant of caregiver burnout, institutionalization, pressure ulcers, and fall-related fractures from nighttime rushing to the commode.

Initial Diagnostic Workup

History & Voiding Diary: Timing, frequency, volume of leakage, precipitating triggers (cough, sneeze, sudden urge), fluid intake, and caffeine/alcohol use.

Targeted Physical Examination: Pelvic exam in women (atrophic vaginitis, pelvic organ prolapse, urethral caruncle), prostate exam in men, lower extremity edema, neurological exam (perineal sensation, bulbocavernosus reflex, lower extremity motor tone).

Urinalysis: Essential to rule out active urinary tract infection, microscopic hematuria (mandates urology referral for cystoscopy/imaging), and glycosuria.

Post-Void Residual (PVR) Volume: Measured via ultrasound bladder scanner or straight catheterization immediately (<5-10 min) after voluntary voiding.

Normal PVR: < 50 to 100 mL .

Elevated PVR: > 200 to 300 mL (indicates urinary retention / overflow incontinence).

The 4 Major Incontinence Syndromes

Incontinence Subtype Pathophysiology & Etiology Clinical Presentation & PVR First-Line Non-Pharm & Pharmacologic Management

Stress Incontinence Urethral hypermobility (weakness of pelvic floor muscles and endopelvic fascia) or intrinsic sphincter deficiency (trauma, prior radical prostatectomy in men) Involuntary urine leakage with sudden increases in intra-abdominal pressure ( coughing, sneezing, laughing, bending, lifting ).; PVR is Normal (<50-100 mL) 1. Pelvic Floor Muscle Training (Kegel exercises) : 3 sets of 10-15 contractions daily for >=3 months (First-line).; 2. Vaginal Pessaries or continence rings.; 3. Topical Vaginal Estrogen if atrophic vaginitis is present.; 4. Mid-urethral sling surgery (gold standard for refractory cases).; (Note: Systemic pharmacotherapy like pseudoephedrine or duloxetine is rarely used in elderly due to side effects).

Urgency Incontinence (Overactive Bladder) Detrusor muscle overactivity (involuntary, uninhibited detrusor contractions during bladder filling phase; idiopathic, stroke, Parkinson disease, spinal cord injury) Sudden, overwhelming, uncontrollable urge to void followed immediately by moderate-to-large volume leakage; frequency (>8 times/day) and nocturia .; PVR is Normal (<50-100 mL) 1. Bladder Training / Timed Voiding (voiding on a fixed schedule, gradually expanding intervals) + fluid/caffeine restriction.; 2. Beta-3 Adrenergic Agonists (Mirabegron 25-50 mg daily, Vibegron 75 mg daily) : First-line pharmacotherapy in older adults; activates detrusor beta-3 receptors causing bladder relaxation during filling; does NOT cause anticholinergic side effects or cognitive decline (monitor BP with Mirabegron).; 3. Anticholinergics (Tolterodine, Trospium, Solifenacin) : Avoid in older adults with cognitive impairment.; 4. Intra-detrusor OnabotulinumtoxinA injections or sacral neuromodulation for refractory OAB.

Overflow Incontinence Bladder outlet obstruction (Benign Prostatic Hyperplasia [BPH], urethral stricture, severe cystocele) OR Detrusor underactivity / acontractility (diabetic autonomic neuropathy, severe B12 deficiency, spinal cord injury) Continuous or frequent involuntary dribbling, hesitancy, weak urinary stream, straining to void, sensation of incomplete bladder emptying.; PVR is Markedly Elevated (> 200-300 mL) 1. Relieve Outflow Obstruction: ; - Alpha-1 Blockers: Tamsulosin 0.4 mg daily , Alfuzosin, Silodosin (relax bladder neck/prostatic smooth muscle).; - 5-Alpha Reductase Inhibitors: Finasteride 5 mg daily , Dutasteride (reduce prostate volume; requires 6-12 months).; - Surgical transurethral resection of prostate (TURP).; 2. Detrusor Hypocontractility: Clean Intermittent Catheterization (CIC).; CRITICAL CONTRAINDICATION: Strictly avoid anticholinergics and opioids , which precipitate complete urinary retention.

Functional Incontinence Intact lower urinary tract anatomy and innervation; inability to reach the toilet in time due to physical immobility (severe arthritis, stroke hemiparesis, Parkinson disease), sensory loss, or severe cognitive impairment / dementia (apraxia, agnosia) Predictable, normal voiding mechanics, but leakage occurs due to environmental barriers, delayed physical transit, or inability to recognize bladder fullness. 1. Scheduled / Prompted Voiding (prompting to toilet every 2 to 3 hours).; 2. Environmental Modifications: Bedside commode, unobstructed well-lit pathway to bathroom, urinal within reach.; 3. Clothing Modifications: Velcro closures, elastic waistbands.; 4. Physical therapy for transfer and gait speed training.

2. Pressure Injuries (Pressure Ulcers): Staging & Management

Pressure injuries are localized areas of damage to the skin and underlying soft tissue, typically over bony prominences (sacrum, greater trochanter, ischial tuberosity, calcaneus/heel, occiput), resulting from prolonged pressure exceeding capillary closing pressure (~32 mmHg), combined with shear and friction forces.

National Pressure Injury Advisory Panel (NPIAP) Staging System

NPIAP Stage Anatomical Depth & Tissue Characteristics Key Visual & Clinical Features Specific Wound Management & Dressings

Stage 1 Intact skin with localized non-blanchable erythema Area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In darkly pigmented skin, redness may not be visible; look for localized purplish discoloration, edema, or induration. Pressure redistribution; barrier creams (zinc oxide/petrolatum); transparent film or hydrocolloid dressing to reduce friction.

Stage 2 Partial-thickness skin loss with exposed viable dermis Shallow, open ulcer with a viable, pink or red, moist wound bed without slough, granulation tissue, or eschar. Also includes intact or ruptured serum-filled blisters . (Does not include skin tears, moisture-associated skin damage [MASD], or tape burns). Maintain moist wound bed: Hydrocolloid or foam dressings ; gentle non-cytotoxic wound cleansing (0.9% normal saline).

Stage 3 Full-thickness skin loss Subcutaneous adipose (fat) tissue is visible ; granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are NOT exposed. Debridement of devitalized tissue; Alginate or hydrofiber dressings for heavily exudative wounds; foam dressings for moderate exudate; cavity packing.

Stage 4 Full-thickness skin and tissue loss Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough, eschar, epibole, undermining, and tunneling are frequently present. Depth varies by anatomical location (shallow on bridge of nose/ear; deep on sacrum/heel). High risk of osteomyelitis. Surgical sharp debridement; wound packing; negative pressure wound therapy (wound VAC); evaluate for osteomyelitis with probe-to-bone test and MRI; systemic antibiotics only if systemic sepsis or confirmed osteomyelitis.

Unstageable Full-thickness skin and tissue loss obscured by slough or eschar Extent of tissue damage cannot be confirmed because the wound bed is completely covered by slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black) . Debridement (sharp, enzymatic, autolytic) is required to expose the base and establish stage.; CRITICAL EXCEPTION: Stable, dry, intact, non-erythematous, non-fluctuant eschar on the heel (calcaneus) must NOT be debrided. It serves as the body's natural biological cover.

Deep Tissue Pressure Injury (DTPI) Persistent, non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin Epidermal separation revealing a dark wound bed or blood-filled blister . Results from intense pressure and shear at the bone-muscle interface; often rapidly evolves to expose deep tissue loss. Immediate pressure offloading; non-adhesive protective dressing; monitor closely for rapid ulcer evolution. Do NOT aggressively debride early intact DTPI.

Comprehensive Prevention and Wound Healing Protocols

Risk Assessment: Use the Braden Scale (evaluates Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear; score < 18 indicates elevated risk).

Pressure Redistribution:

In bed: Reposition at least every 2 hours using a 30-degree lateral tilt (avoiding direct pressure on greater trochanters and sacrum); use high-specification dynamic alternating-pressure or multi-layer foam mattresses.

In chair: Reposition every 15-30 minutes; limit unassisted sitting in chair to <2 hours at a time.

Heels: Completely elevate/offload heels off the bed surface (" floating heels " with pillows placed lengthwise under mid-calves or specialized heel-suspension boots).

Moisture Management: Prompt cleansing after incontinence episodes; apply dimethicone- or zinc oxide-based barrier ointments; avoid diapers when possible to prevent moisture-associated dermatitis and skin maceration.

Nutritional Optimization: Target 1.25 to 1.5 grams of protein/kg body weight/day and 30-35 kcal/kg/day; oral nutritional protein supplements (e.g., high-protein drinks with arginine and zinc) accelerate healing of Stage 3 and 4 pressure injuries.