With advanced age, older nervous systems sometimes develop problems that can result in overflow incontinence. Sensation of the bladder filling up may begin to diminish so that a woman doesn’t feel the desire to urinate until the bladder reaches its full capacity. At that point, if the urethra is very weak, she may already experience leaking. In some cases, she may feel urine escaping from the bladder or running down her leg. It might be assumed that she has an overactive bladder and is experiencing urge incontinence, but the leaking may actually be occurring before she feels any urgency at all.

Even if a woman has a normal amount of urgency, if she moves slowly with her advanced age, it may take her a long time to get to a toilet. More commonly, the urgency comes late in the filling cycle of the bladder, which means even less time to reach a toilet.

In advanced aging situations, in which a woman is affected by Alzheimer’s or another form of cognitive loss, the bladder may appear to the patient to empty completely on its own. Patients with neurological conditions can have varying degrees of awareness of their own problems. Sometimes it is the family or the caregiver that will bring the patient to a doctor, because the laundry or diaper bill has become too much, or because the patient has developed severe diaper rash.

It can be difficult to distinguish one cause of incontinence from another. Sometimes there are co-existing or overlapping causes. An experienced and sympathetic practitioner can sort out the various problems and help the patient and her family find the best treatment that is appropriate for her particular stage of life.

To help today’s caregiver, we have written A Woman’s Guide to Urinary Incontinence (Johns Hopkins Press, December 2007) – the first book about incontinence in 20 years. In it, we combine our urological and gynecological expertise into a practical and readable guide for patients and their families and caregivers. We explain the nature and causes of incontinence in reader-friendly terms. We also share our patients’ experiences, to help readers get their problems into perspective. Our hope is to prepare patients to become partners in their own health care decisions by becoming informed about their conditions and the available options. In the treatment of incontinence, one size does not fit all. It is tempting for physicians to group patients together into categories because “after all, leakage is leakage.” But this is not the best approach to use, especially if the patient is faced with choosing an invasive or irreversible treatment.

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