Behavioral therapies form the mainstay of treatment for UI in most patients. Avoiding dietary components that increase bladder irritation and urinary urgency and frequency can be useful. This includes caffeine, alcohol, highly acidic foods, and carbonated beverages [41]. Fluid restriction is generally not helpful, and can worsen urinary urgency and frequency in some patients due to increased urinary concentration; however, limiting fluids after dinner can reduce nocturia. Timed or scheduled urination can be useful, particularly among those with urinary urgency and urgency UI. Timed voiding is often combined with learning to delay voiding by controlling urge symptoms; this behavioral technique is called ‘urge control’ [42].

Pelvic floor muscle exercises are useful for many patients with stress UI and urgency UI. Patients generally need targeted instruction, and may benefit from working with a physical therapist or nurse for individualized coaching. Such behavioral treatments typically require 3–4 visits to gain confidence in proper techniques and then a periodic review for reinforcement. Older adults using this type of behavioral therapy must be motivated to continue pelvic floor exercise, and understand how to use them at appropriate times. Pelvic floor muscle exercise has been shown to work well in both men and women , and can improve UI more than simple bladder training and timed voiding alone [43, 44].

Many people use devices such as condom catheters or absorbent pads and products to manage urinary leakage. There are a variety of intravaginal pessaries that can be used for management of stress urinary incontinence (see Chap. 13 Gynecology). Penile clamps for men, or urethral plugs and inserts for women can be used in cases with stress incontinence, particularly with physical exercise or other activities. In general, devices are considered options for management of symptoms rather than definitive treatment of UI.

Medications are widely used for treatment of UI in both younger and older patients but should be initiated only after a trial of behavioral therapy. Most medications are targeted at overactive bladder and are used to treat urinary urgency, frequency, and urgency UI. Most are antimuscarinic, anticholinergic agents which block muscarinic receptors in the bladder and reduce involuntary detrusor contractions. Side effects of this class of medications include urinary retention, constipation, dry mouth, dry eyes, headache, and confusion [45]. Newer agents include beta-3 agonists that also work to reduce bladder overactivity, but avoid the typical anticholinergic effects; side effects for this agent include hypertension, headache, nausea, dizziness, and tachycardia (including atrial fibrillation). The route of administration may be an important consideration, particularly in geriatric patients. Transdermal preparations applied as either a skin patch or gel may be useful in those with swallowing problems. Time-released medications may improve adherence and efficacy. Liquid preparations may also be useful in patients with swallowing difficulties or in those who require use of a feeding tube.

Studies examining use of antimuscarinics in cohorts of older patients have shown efficacy, safety, and tolerability [46, 47]. Using the lowest effective drug dose is recommended, and patients should be monitored carefully and continuously for drug interactions or other adverse effects. Discontinuation of medication due to side effects or limited perceived efficacy is common, and several different medications may need to be tried to find one that works best for an individual patient [48–50]. Cost is also a factor when considering medication therapy for elderly patients [51]. Insurance coverage is variable and may differ substantially between medications for a given payment plan.

Surgical therapy can be useful for treatment of UI in older adults, particularly if more conservative therapies such as behavioral options or medications have not been successful. In carefully selected patients surgical options improve outcomes for treatment of UI [52]. Age itself should not be the deciding factor of whether someone is a candidate for surgical intervention. Instead, overall health, comorbidity, and goals of care should be the guiding variables [53]. Development of less invasive surgery has increased surgical options for many older adults with UI and other lower urinary tract conditions [54].

Injection of bulking agents at the bladder neck to increase urethral outlet resistance is minimally invasive, and may be effective in elderly women with stress urinary incontinence [55]. A variety of materials have been used for this purpose. Results are generally good, and the procedure offers the advantage of being easily repeatable if needed. This type of therapy may be particularly useful in elderly women with stress UI who may not be good surgical candidates for more involved procedures.

Sling procedures include those that place grafts either under the mid-urethra or the bladder neck. Various graft materials are available including synthetic mesh, autologous fascia, and other biological grafts either from cadaver tissue donors or animal xenografts. Outcomes in carefully selected elderly women are generally good with complication rates similar to those in younger patients [56, 57]. However, other reports suggest that older women may have less overall clinical success with slings, and are at higher risk of complications [58, 59]. Sling procedures for treatment of male stress UI have also been developed, although outcome data specific to elderly men is limited. In men with stress UI, implantation of an artificial urinary sphincter is also an option. Good cognitive status and hand dexterity are needed to correctly operate the device after implantation. In select patients, this therapy can be extremely effective [60].

For patients with urinary urgency, frequency or urgency UI, neuromodulation and chemodenervation are minimally invasive surgical therapies that can help treat symptoms. Neuromodulation uses electrical stimulation of the nerves that control bladder contractility. Sacral neuromodulation is performed by implanting an electrode in the third sacral foramen (S3). This is connected to a programmable generator that provides impulses to the nerve. Success rates up to 83.3 % have been reported in selected elderly patients who underwent stimulator placement [61]. The most common complication is device infection or erosion that may require surgical removal. However, overall complication rates are similar in older and younger patients and age itself should not influence decisions for treatment with this therapy [62, 63]. Chemodenervation of the bladder detrusor muscle is also used for treatment of urgency UI and symptomatic urinary urgency and frequency. The most commonly used agent is onabotulinum toxin A. Studies have demonstrated clinical efficacy and safety even in elderly patients [64]. The main side effect of this treatment is urinary retention which may require clean intermittent catheterization at least temporarily in order to drain the bladder.

In highly select patients, urinary diversion may be considered for treatment of intractable UI. This could include reconstructive procedures with either creation of a urinary stoma such as an ileal conduit, or a continent catheterizable pouch. In some patients, management of a stomal device may be preferable to UI. However, these are major surgical procedures, and care through careful preoperative assessment (see Chap. 3) must be taken to weigh the risks and benefits for a given patient before selecting this type of therapy [65, 66].

Urinary catheters are sometimes used in the management of urological and non-urological conditions. For example, patients with perineal skin breakdown or sacral pressure ulcers may require temporary indwelling catheter drainage to keep the affected area dry and allow for tissue healing. Temporary urinary catheter drainage is also used after reconstructive surgery with flap placement in order to keep the surgical site dry during healing.

However, in older adults, chronic indwelling catheters should be avoided if at all possible [67]. Indwelling catheters are associated with substantial complications including urinary tract infections, bacterial colonization, urosepsis, and stone formation [68]. Catheters should be removed when feasible, and patients should be monitored for signs or symptoms of infection. Tissue irritation from chronic catheterization can lead to squamous metaplasia of the bladder epithelium, and development of squamous cell carcinoma. If chronic catheter use is needed, suprapubic tube drainage is generally preferred over urethral catheterization. This reduces the risk for urethral and bladder neck erosion. In addition, it is often more comfortable for patients. It may be easier for caregivers to change compared to urethral catheterization, particularly in men, and also gets the catheter out of the genital tract which is beneficial for older adults who remain sexually active.

Persistent urinary leakage around an indwelling catheter is typically due to either bladder spasms or catheter blockage. Irrigation of the catheter with sterile saline can be helpful to relieve obstruction of the tube from urinary sediment. Clinicians should avoid placing larger caliber catheters, which will only serve to dilate the tract and will not solve the underlying problem of detrusor overactivity. If used in the urethra, larger catheters increase the risk of tissue erosion which can lead to severe urinary incontinence and can require advanced surgical reconstruction even bladder removal. Use of antimuscarinic medications to reduce bladder contractions can be very useful in patients who experience urinary incontinence associated with indwelling catheter drainage.

A variety of devices are available to manage urinary leakage including absorbent pads and condom catheters. These are useful for select patients. For example, they can be used when someone wants to participate in social activities that they might otherwise avoid due to UI. Numerous designs are available, and recent improvements have helped enhance odor control, fluid absorbency, and other associated factors [69–71]. Condom catheters are useful for men with UI. These disposable devices are designed to surround the penis and are connected to a urinary collection device. They can be particularly helpful for management of bothersome nocturia or if UI prevents men from participating in activities outside their home. Proper sizing and skin hygiene are important to prevent skin irritation or breakdown.

Urinary tract infection (UTI) is one of the most common urologic conditions that occur in older adults. Although both males and females experience UTIs, they tend to be more common in older women. It can sometimes be challenging to differentiate symptomatic UTIs, which need treatment and asymptomatic bacteriuria that does not require antibiotic therapy. Urine cultures are strongly recommended to confirm infection, help identify the associated bacterial organisms, and guide therapy. Antibiotic susceptibility patterns are in constant flux, and it is crucial to identify drug resistance and select appropriate treatment. Although empiric antibiotic therapy may be started based on clinical symptoms and dipstick urine results, antibiotics may need to be changed depending on results of antibiotic susceptibility testing. Catheterized urine samples may be needed if older adult patients have difficulty producing an adequate clean-catch specimen [72].

The most common symptoms of UTI include urinary urgency and frequency, dysuria, bladder pain, and fever. Cloudy and foul-smelling urine are common, but this can also be due to causes other than a UTI. Many older adults may not show these typical symptoms [73]. Instead, they may exhibit ‘atypical symptoms’ including confusion, lethargy, anorexia, agitation, UI, and behavioral changes [74]. Delirium may occur in some patients with UTIs [75]. Upper tract involvement with pyelonephritis or other complex forms of UTI are often associated with comorbidity such as stone disease, diabetes, or anemia [76]. Urosepsis in elderly patients may be serious, and is associated with increased risk of mortality due to decreased physiological reserve. Factors that increase the risk of mortality in older adults with urosepsis include advanced age (≥85 years), hypothermia, severe cognitive impairment, and chronic renal disease [77]. Hospital acquired UTIs are also associated with an increased risk of mortality compare to community acquired infections [78]. Management with fluid resuscitation and appropriate antibiotic therapy is crucial. Fungal UTIs are less common, and tend to occur with advanced age in patients with reduced immune status including those with a prior history of organ transplant on immunosuppressive therapy, those with HIV disease or AIDS, and in those with poorly controlled diabetes . Treatment may require antifungal agents such as fluconazole [79].

In contrast, asymptomatic bacteriuria with or without pyuria is a very common condition in older adults and should not be treated with antibiotics unless there are special considerations such as planned genitourinary surgery. In community dwelling older adults, asymptomatic bacteriuria occurs in about 10 % of men and 10–20 % of elderly women [80, 81]. Extensive data supports that asymptomatic bacteriuria does not require antibiotic therapy [82]. See also Chap. 24 Infection and Immunity in Older Adults for diagnosis and discussion of asymptomatic bacteriuria.

A number of clinical factors increase the risk of UTIs among older adults. Catheter associated UTIs are highly prevalent in acute care hospitals and other inpatient settings [68, 83]. Clean intermittent catheterization can reduce infection rates in patients with retention, and risk is lower compared to chronic indwelling catheter use. Obesity and significant underweight body mass index have both been linked to higher rates of UTI in older patients [84].

Several different therapies have been used to try to prevent UTIs in older adults. Administration of vaginal estrogens can reduce symptomatic UTI rates in elderly women by causing reacidification of the vaginal fluid milieu. This allows growth of Lactobacillus sp., the normal flora in the vagina. These bacteria act as an important host defense by killing bacteria associated with UTIs. Contraindication to vaginal estrogen use includes a personal history of breast or uterine cancer. Ingestion of cranberry juice or cranberry supplements is popular for UTI prevention. Proanthocyandidins in cranberry interact with fructose in bacterial cell walls and potentially prevent adherence of bacteria to the urothelium. However, data on clinical efficacy has been mixed. Recent evidence from a double-blind, randomized, placebo-controlled clinical trial in nursing home residents showed reductions in infection rates, but these statistically significant changes were limited to those with prior high rates of UTI [85]. In general, chronic antibiotic use for prophylaxis should be avoided unless no other options are available. Although it can be useful in select patients, it is also associated with an increased risk of drug resistant bacterial infection which makes treatment more challenging.

Evaluation and treatment of UTIs in nursing homes and other chronic care settings requires special consideration. Differentiation between symptomatic UTIs and asymptomatic bacteriuria can be particularly challenging in this setting, and overuse of antibiotic is common [86, 87]. Drug selection should be guided if possible by local antibiogram data based on local prevalence of specific organisms and resistance patterns [88]. Environmental contamination in nursing home and other chronic care settings may be associated with certain types of infection including methicillin-resistant Staphylococcus aureus (MRSA) [89]. Strict hand-washing and other infection prevention protocols can help to reduce this risk.

The overall costs associated with the evaluation and treatment of UTIs is staggering, and in the USA surpasses the cost of almost all other major genitourinary disorders [90, 91]. The high incidence of UTI certainly contributes, but overtreatment of asymptomatic bacteriuria and care provided in emergency rooms and urgent care centers are also important factors.

Hematuria is defined as the presence of blood in the urine. This is almost always abnormal, and clinical evaluation is generally indicated to identify potentially serious underlying causes [92]. Common etiologies for hematuria include urolithiasis, malignancies such as kidney cancer or urothelial tumors in the bladder, ureter or kidney, or trauma. Men with severe benign prostatic hyperplasia (BPH) may have bleeding from prostatic capillaries. The use of anticoagulation is common in geriatric patients for treatment of cardiac arrhythmias for stroke prevention. Both normal and supratherapeutic levels of anticoagulation can cause bleeding from a lesion in the urinary tract. All patients with hematuria, including those who develop hematuria after the initiation of anticoagulation, should undergo appropriate clinical evaluation [93]. This includes both cystoscopy and some type of contrast based imaging such as CT urogram or retrograde pyelography.

Sexuality and sexual health remain an important part of life for many older adults who wish to remain sexually active if possible [94]. Survey data demonstrates that up to 20–30 % of all older adult men and women remain sexually active well into their 80s [95]. Urologic care providers can help to evaluate and treat sexual health issues in this population. Many common comorbid conditions including diabetes, hypertension, peripheral vascular disease, and heart disease can negatively impact sexual health in geriatric patients. In addition urinary incontinence and treatments for prostate cancer or other malignancies can substantially reduce sexual health in this population [96, 97]. Those with better overall health and less comorbidity tend to remain more sexually active with advancing age [98, 99]. Sexual health changes may also be signs or symptoms of underlying comorbid disease. Frailty has been shown to negatively affect sexual health status, and is associated with multiple changes in both physical and psychosocial domains [100]. Other gynecological disorders such as pelvic organ prolapse or atrophic vaginitis can also impair sexual function in elderly women. Impaired sexual health in older adults is also associated with higher rates of depression and other forms of mental health issues [101, 102].

Partner availability may limit sexual activity, and masturbation may become a primary form of sexual expression for some older people. Other forms of sexual expression may change with aging including a reduction in the emphasis on penetrative sexual activity and increased attention to intimacy with close physical and emotional contact [103]. The living environment may also influence sexual expression, particularly for those living with extended family caregivers or in nursing homes. Increased awareness of sexual health needs has led many nursing homes to work to better accommodate these residents [104]. Inappropriate sexual behavior may be problematic for older adults with cognitive impairment or dementia, and may be particularly challenging for caregivers [105]. Screening and treatment for sexually transmitted diseases may be indicated in some patients depending on sexual activity , and if signs or symptoms of infection are present [106].

A wide variety of therapies are available for sexual health dysfunction in older adults ranging from sexual therapy and counseling, to medications and surgeries designed to improve erectile function in men and sexual response in women. Treatments should be targeted on the patient’s specific goals and outcomes, and should be selected within the scope of overall health and comorbidity. Chapter 22—Endocrinology provides a thorough discussion of the endocrine evaluation and treatment of hormonal deficiencies related to sexual dysfunction.

Stone disease affects about 20 % of all adults at some point in their lives. Rates of stone formation are similar among older and younger adults, and those with a prior history are at risk for recurrence. Poor hydration status is one of the strongest risk factors for stone formation, and older adults often have a reduced sensation of thirst, or may have difficulty swallowing which can lead to inadequate fluid intake. Recent Medicare data suggest that compared to younger adults, older patients have a 2.5 to 3-fold increased rate of inpatient hospitalization for stone disease [107].

Stone composition may change with age, and older adults more often have uric acid stones compared to younger people [108]. This may particularly affect older patients with diabetes who may have impairments in urinary ammoniagenesis and produce abnormally high levels of uric acid with a low urinary pH [109]. Age-related alterations in vitamin D and calcium metabolism may also affect urolithiasis risk in older adults. Hyperuricosuria and hypercalcuria appear to be common in older patients with recurrent stone disease [110].

Small stones (<5 mm) often pass spontaneously with hydration and oral analgesics. Oral selective alpha-blockers such as tamsulosin may be helpful to enhance ureteral relaxation. Cystoscopy with ureteral stent placement is indicated to bypass the obstruction in cases of larger stones, particularly if the patient experiences intractable nausea, vomiting, or pain. Other indications for ureteral stent insertion include baseline renal insufficiency, a solitary functioning kidney, or significant urinary infection or bacteriuria. Surgical therapy with ureteroscopic stone fragmentation and extraction, extracorporeal shock wave lithotripsy, or percutaneous nephrostolithotomy may be required. The overall success rates for these procedures are similar in geriatric and younger patients [111, 112].

Cancers of the genitourinary tract increase in incidence and prevalence with advancing age. Depending on the type of cancer and the grade and stage, treatment ranges from surgical excision to chemotherapy, radiation therapy, or immunotherapy. Consideration of overall health, quality of life, and goals of care are important, and treatment choices must be made in the context of associated comorbidities. For a discussion of the general approach to the older patient with cancer, please see Chap. 26 Oncology. This section will review selected relevant issues associated with cancer diagnosis and treatment in the older adult population.