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GERICLINICS

Reference · Urinary incontinence

Urinary incontinence in older adults

Assessing reversible causes, bladder training, pelvic floor muscle training, prompted voiding and safe use of bladder medicines for older people with urinary incontinence, mainly in women, summarised from the EAU 2026 guideline on female lower urinary tract symptoms and the WHO ICOPE guidelines.

Source
European Association of Urology (EAU) (2026) — EAU Guidelines on Non-neurogenic Female LUTS. Edition presented at the EAU Annual Congress, London 2026. Arnhem: EAU Guidelines Office; 2026.
Last updated
21 October 2026
Checked against source
21 October 2026
Clinical review
Needs clinical reviewNot yet reviewed by a clinician. Check against the source before relying on it.

Grades are shown as the source states them. EAU recommendations are rated strong or weak, with levels of evidence from 1a (meta-analysis of trials) to 4 (expert opinion). WHO grades recommendations as strong or conditional with evidence quality from high to very low.

Key recommendations

  • Incontinence affects about a third of older people and has many causes, so assess beyond the bladder: fluid intake, medicines, mobility, cognition and previous urological surgery, with cardiovascular, abdominal and neurological examination.

    3.2.1 Urinary incontinenceWorld Health Organization (WHO) 2017

  • Look for reversible causes: delirium, infection, atrophic vaginitis, medicines causing retention, depression, high urine output (for example from hyperglycaemia) and faecal impaction.

    3.2.1 Urinary incontinenceWorld Health Organization (WHO) 2017

  • Offer pelvic floor muscle training — supervised, as intensive as possible and for at least three months — as first-line treatment to women with stress or mixed incontinence, including older women.

    StrongChapter 4 (disease management): 4.2.4.a.3European Association of Urology (EAU) 2026

  • WHO likewise recommends pelvic floor muscle training, alone or combined with bladder control strategies and self-monitoring, for older women with stress, urge or mixed incontinence.

    Strong; moderate-quality evidenceRecommendation 8World Health Organization (WHO) 2017

  • Offer bladder training as first-line treatment for overactive bladder and urgency incontinence.

    StrongChapter 4 (disease management): 4.1.4.a.5European Association of Urology (EAU) 2026

  • Offer prompted voiding to people with cognitive impairment.

    StrongChapter 4 (disease management): 4.1.4.a.5European Association of Urology (EAU) 2026

  • Use long-term anticholinergic bladder drugs with caution in older women, especially those with or at risk of cognitive impairment, and assess total anticholinergic burden and comorbidity before starting.

    StrongChapter 4 (disease management): 4.1.4.b.3European Association of Urology (EAU) 2026

Diagnosis

  • Two useful questions: for urge incontinence, whether a strong, sudden urge makes the person leak before reaching the toilet; for stress incontinence, whether leaking comes with coughing, sneezing, lifting, walking or running.

    3.2.1 Urinary incontinenceWorld Health Organization (WHO) 2017

  • Take a full history including comorbidity, examine, use a validated symptom questionnaire that captures bother and quality of life, and ask for a bladder diary covering at least three days.

    StrongChapter 3 (diagnosis): 3.1–3.3European Association of Urology (EAU) 2026

  • In stress incontinence, include a standardised cough stress test, done standing because that is more sensitive than lying.

    StrongChapter 4 (disease management): 4.2.3.aEuropean Association of Urology (EAU) 2026

Investigations

  • Do a urinalysis at the first assessment and reassess after treating any infection. Do not treat asymptomatic bacteriuria in older people in the hope of improving incontinence.

    StrongChapter 3 (diagnosis): 3.4European Association of Urology (EAU) 2026

  • Measure post-void residual volume by ultrasound at the first assessment, and monitor it during any treatment that may cause or worsen voiding problems.

    StrongChapter 3 (diagnosis): 3.5European Association of Urology (EAU) 2026

  • Do not routinely perform urodynamics before first-line treatment of uncomplicated overactive bladder or stress incontinence, or image the urinary tract beyond measuring residual volume.

    StrongChapter 3 (diagnosis): 3.6 and 3.8European Association of Urology (EAU) 2026

Treatment

  • Encourage weight loss if overweight, help people stop smoking, advise that less caffeine may ease urgency and frequency (though not leakage), and review what and how much the person drinks.

    Strong (fluid review: weak)Chapter 4 (disease management): 4.1.4.a.4European Association of Urology (EAU) 2026

  • Bladder training means voiding to a schedule, starting every 2 hours and gradually lengthening the interval, for at least 6 weeks. A starting pelvic floor programme could be 3 sets of 10 strong contractions, 2–3 times a week; finding the right muscles and staying motivated are key.

    3.2.1 Urinary incontinenceWorld Health Organization (WHO) 2017

  • If conservative treatment fails for overactive bladder, offer an anticholinergic (extended-release where possible) or a beta-3 agonist (mirabegron or vibegron), which work as well with less dry mouth. If the first drug fails, change the dose or drug or combine with a beta-3 agonist; review early, and decide together with the patient.

    StrongChapter 4 (disease management): 4.1.4.b.1–2European Association of Urology (EAU) 2026

  • Offer vaginal oestrogen to women whose urinary symptoms come with genitourinary syndrome of menopause; vaginal oestrogen does not carry the thromboembolic, endometrial and breast risks of systemic treatment.

    WeakChapter 4 (disease management): 4.1.4.b.4European Association of Urology (EAU) 2026

  • For overactive bladder that does not respond, options include bladder wall injections of onabotulinumtoxinA (100 units) and posterior tibial nerve stimulation. Warn about the limited duration of response, urinary infection and the possible need for intermittent self-catheterisation after botulinum toxin.

    StrongChapter 4 (disease management): 4.1.4.a.5 and 4.1.4.c.1European Association of Urology (EAU) 2026

  • For stress incontinence where surgery is chosen, a midurethral sling is offered after a full discussion of risks and benefits; weigh the safety of pelvic floor training against the benefits and complications of surgery.

    StrongChapter 4 (disease management): 4.2.4European Association of Urology (EAU) 2026

  • Take a medication history from everyone, review any new medicine linked to new or worse symptoms, and address related conditions such as obesity and sleep apnoea.

    Strong (comorbidities: weak)Chapter 4 (disease management): 4.1.4.a.2European Association of Urology (EAU) 2026

Important geriatric considerations

  • Incontinence is linked with pressure ulcers, sepsis, kidney failure, urinary infection and higher mortality, as well as loss of self-esteem, social withdrawal and depression, and is a key driver of care dependency.

    3.2.1 Urinary incontinenceWorld Health Organization (WHO) 2017

  • In older people, urinary symptoms are associated with heart failure, chronic kidney disease, diabetes, COPD, neurological disease, cognitive impairment, sleep apnoea, depression and metabolic syndrome; changes in these conditions or their treatment can change the symptoms.

    Chapter 4 (disease management): 4.1.4.a.1European Association of Urology (EAU) 2026

  • The cognitive effect of anticholinergic medicines adds up and increases with time on them. Oxybutynin may worsen cognition in older women, whereas darifenacin, fesoterodine, solifenacin and trospium have not been shown to in short-term studies; mirabegron is effective and safe in older women.

    Levels of evidence 1b–2Chapter 4 (disease management): 4.1.4.b.3European Association of Urology (EAU) 2026

  • Adherence to anticholinergic bladder drugs is low; most people stop within the first three months.

    Level of evidence 2aChapter 4 (disease management): 4.1.4.b.1European Association of Urology (EAU) 2026

  • The evidence for prompted voiding comes from nursing homes, and it may be hard to deliver at home where it depends on family carers.

    Conditional; very low-quality evidence3.2.1 Urinary incontinence: rationaleWorld Health Organization (WHO) 2017

Drug doses

Not covered in this summary — see the original guideline.

When to refer

  • A non-specialist health worker can start the assessment, but a full evaluation is the responsibility of a doctor because causes in older people are multifactorial.

    3.2.1 Urinary incontinenceWorld Health Organization (WHO) 2017

  • Perform urodynamics only when the result could change the choice of invasive treatment or the diagnosis is uncertain.

    WeakChapter 3 (diagnosis): 3.6European Association of Urology (EAU) 2026

Red flags

  • Treatments for overactive bladder can cause urinary retention, so check residual volume when there are voiding symptoms and during treatment that may worsen emptying.

    StrongChapter 3 (diagnosis): 3.5; Chapter 4 (disease management): 4.1.4.c.1European Association of Urology (EAU) 2026

Recent updates

  • The 2026 EAU edition fully updated every section of its female LUTS guideline after a new literature search; the guideline grew out of the 2021 urinary incontinence guideline.

    Chapter 1.4 (publication history)European Association of Urology (EAU) 2026

References

Cited in this summary, followed by other guidelines on this topic.

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