Ten Key Points
1. Obtain a sexual history. One in 4 older adults in their 80s are sexually active.1 A broad question such as “Are you currently satisfied with your sexual activity?” may be followed by questions regarding gender identity, sexual orientation, number of partners, etc.
2. Clarify the acuity of urinary incontinence to determine the appropriate workup. Twenty percent of community-dwelling older adults have an element of urinary incontinence at baseline.2
3. Obtain a thorough medication history, as polypharmacy may contribute to acute urologic complaints. This includes prescribed, over the counter, and recreational medications (especially with peripheral alpha-1 blockers and anticholinergic properties).
4. Fully undress the patient for a physical exam, even if their clinical presentation is not specifically GU-related. Fournier’s gangrene, cellulitis, decubitus ulcers, and signs of obvious trauma are diagnoses which can be easily missed in the fully dressed adult.
5. Have a high index of suspicion for elder mistreatment in the form of neglect, or physical or sexual abuse, particularly for older adults with cognitive or physical impairment. Improper toileting, poor hygiene, and delay in seeking care should be red flags for further inquiry. Consider consulting www.elderabuseemergency.org.
6. Rapidly reduce paraphimosis. Applying ice and/or a mixture of 50% dextrose solution with 2% lidocaine gel may increase the success.
7. Treat the cause of acute urinary retention, if identified (e.g., infection, constipation, medication). It is reasonable to discharge the patient with an indwelling catheter if a spontaneous voiding trial is unsuccessful in the ED with follow up in 72 hours.3
8. Do not treat patients with asymptomatic bacteriuria. The presence of bacteria in the urine in the absence of GU complaints is common in older adults and should not be treated.4
9. Expedite follow up for postmenopausal women with vaginal bleeding and ensure the patient/caregiver are aware of its importance. Ten percent of cases are caused by endometrial cancer.
Arrange follow up for older adults with microscopic hematuria, as it can be an indicator of malignancy. This is especially important in current or former smokers.5 Clear communication with the patient/caregiver is important.
Urinary retention, neglect, polypharmacy, urinary incontinence, asymptomatic bacteriuria.
Nicole Soria, MD
Division of Geriatrics, University of Cincinnati Family Medicine, Cincinnati, OH, USA
Assistant Medical Director, Department of Emergency Medicine, Mercy Health – West Hospital, Cincinnati, OH, USA
Danya Khoujah MBBS, MEHP, FACEP, FAAEM
Attending Physician, MedStar Franklin Square Hospital
Adjunct Volunteer Assistant Professor, University of Maryland School of Medicine
Department of Emergency Medicine
Conflicts of Interest
The authors have no conflicts of interest to report.
Author Contributions: Both authors contributed to the conceptualization, writing, and revision of this article.
Funding: No funding was provided for this work.
- Wilson MMG. Sexually transmitted diseases. Clin Geriatr Med 2003;19(3):637-55
- Adelmann PK. Prevalence and detection of urinary incontinence among older Medicaid recipients. J Health Care Poor Underserved 2004;15(1):99–112.
- Marshall JR, Haber J, Josephson EB. An evidence-based approach to emergency department management of acute urinary retention. Emerg Med Pract 2014;16(1):1-20.
- Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis 2019;68(10):e83–110.
- Gonzalez AN, Lipsky MJ, Li G, et al. The prevalence of bladder cancer during cystoscopy for asymptomatic microscopic hematuria. Urology 2019;126:34-8.