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Evaluation and Management of Urinary Incontinence in Females

Female urinary incontinence is a common condition that affects women of all ages. Involuntary loss of urine can cause physical, psychological, and social consequences, and can lead to significant lifestyle restrictions. Its effects can range from bothersome to severely debilitating, but in many cases, simple measures such as lifestyle modification and medications are effective. It is therefore important to make a prompt diagnosis and early treatment to avoid its complications.

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Initial Assessment:

Initial evaluation of urinary incontinence should include a detailed history, physical examination, and request for urinalysis, post-void residual urinary volume and urine culture (as indicated). Treatment of ongoing urinary tract infection (UTI), if present, must be done.

A. History – Evaluate for:

1. Complicated Urinary Incontinence

  • Recurrent UTI
  • Neurologic disease/spinal cord injury
  • Previous pelvic procedures/irradiation

 

2. Drug intake:

  • ACE inhibitors
  • Alpha-blockers
  • Alpha-1-agonists
  • Antiarrhythmic Meds
  • Anticholinergics (anti-Parkinson meds)
  • Antidepressants
  • Antihistamines (H1 receptor antagonists)
  • Antimuscarinics for overactive bladder
  • Antipsychotics
  • Benzodiazepines
  • Beta -agonists
  • Caffeine
  • Decongestants
  • Diuretics
  • Opioids
  • Skeletal muscle relaxants
  • Spasmolytics

 

3. Sense of urgency

4. Association with physical activity

5. Symptoms of overflow incontinence

  • Urge incontinence with no triggers
  • Intermittent or continuous leakage
  • Incomplete bladder emptying

 

B. Physical Examination – Evaluate for:

         1. Abdominal/pelvic masses
         2. Palpable bladder
         3. Urogenital fistula
         4. Pelvic organ prolapse
         5. Neurogenic bladder

C. Laboratory Exams – Request for:

1. Urinalysis – to evaluate for infection, hematuria
2. Post-void residual urinary volume
3. Urine culture (as needed)

 

D. Diagnosis and Management

  1. Patients who have signs and symptoms of conditions causing complicated urinary incontinence (UI) should be referred to a specialist for further evaluation and treatment. These include:
  • Recurrent UTI
  • Neurologic disease/spinal cord injury
  • Urogenital fistula
  • Pelvic organ prolapse
  • Presence of benign or malignant masses in the pelvis
  • Complications from previous pelvic procedures or radiation

 

  1. Drugs that may cause or worsen UI should be titrated or eliminated if clinically feasible.

 

  1. Evaluate for stress and urge incontinence.

 

a. If UI is associated with physical activity, consider stress incontinence, where urine leakage occurs with effort or physical exertion in the absence of bladder. This is more common among parous women and may be due to loss of muscular strength caused by chronic pressure or trauma to the pelvic muscles.

  • Initial treatment involves lifestyle modifications: weight loss (if obese), dietary changes, modification of fluid intake, management of constipation, and smoking cessation.
  • Recommend pelvic floor muscle (Kegel) exercises, preferably under the guidance of a pelvic floor physical therapist.
  • Recommend vaginal estrogen therapy for perimenopausal and postmenopausal women.
  • If incontinence is refractory to initial treatment, consider other options including:
  • Use of continence pessaries.
  • Pharmacologic therapy such as duloxetine (for women who are also being treated for depression)
  • Surgery – placement of a retropubic or transobturator sling versus suture bladder suspension (Burch, MMK procedure)
  • Refer to a surgeon (gynecologists, urogynecologists, and some urologists.)

 

b. If UI is not related to activity, but a sense of urgency is present, consider urge incontinence. This is more common among older women and may be due to detrusor overactivity.

  • Initial treatment involves lifestyle modifications: weight loss (if overweight), dietary changes, modification of fluid intake, management of constipation, and smoking cessation.
  • Recommend pelvic floor muscle training and bladder training.

 

Kegel exercise: Instruct patient to do three sets of 8-12 contractions, sustaining each contraction for 8 to 10 seconds. These should be performed 3x/day, every day for 15-20 weeks.

  • Bladder training: Patients should be asked to keep a voiding diary to identify their shortest voiding interval and to void regularly by the clock, using the shortest voiding interval. If urgency occurs between voiding schedules, voiding can be controlled by using relaxation techniques or other forms of distraction. After two days, voiding interval can be increased gradually and progressively until the patient can void every 3-4 hours without urgency or leakage. Bladder training can take up to 6 weeks, so patient reassurance is needed to proceed.
  • Recommend vaginal estrogen therapy for perimenopasal or postmenopausal women.
  • Oral anti-muscarinic agents (ie tolterodine, solifenacin, etc.) and beta-adrenergic agents (mirabegron) can be effective in reducing urge incontinence in many women. These agents have side effects such as constipation and dry mouth. They are contraindicated in women with acute angle glaucoma.
  • For patients with severe urge incontinence who fail antimuscarinics and conservative therapies, or cannot tolerate side effects, consider placement of sacral nerve neuromodulation implants (i.e., Interstim).
  • Other therapies include acupuncture, botox injections into detrusor muscle, and surgical augmentation of the bladder (in severe refractory cases)
  • Referral to a urogynecologist or urologist is recommended.

 

c. For patients who experience symptoms of both stress and urge incontinence, consider mixed (stress and urgency) incontinence should be considered

  • Initial treatment involves lifestyle modifications: weight loss (if overweight), dietary changes, modification of fluid intake, management of constipation, and smoking cessation.
  • Recommend supervised pelvic floor muscle (Kegel) exercises and bladder training. Pelvic floor physical therapy consultation is often helpful.
  • Recommend vaginal estrogen therapy for perimenopausal or postmenopausal women, if not contraindicated.

 

  1. Evaluate for overflow incontinence, which occurs with no triggers, intermittent or continuous leakage, incomplete bladder emptying.
  • Consider clean intermittent catheterization.
  • Other treatment options for overflow incontinence are limited. These may include treating constipation, increasing urethral tone or sacral nerve neuromodulation.
  • Refer to a urologist for further management.

 

It is best to individualize the diagnosis and management of female urinary incontinence, depending on the patient’s clinical presentation. Sign up for a free trial of our application Infera to run our algorithms interactively and get specific recommendations customized to the patient:

References:

Abrams P, Andersson KE, Birder L, et al. Fourth International consultation on incontinence recommendations of the international scientific committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn. 2010;29: 213-40.

Brown JS, Wing R, Barrett-Connor E, et al. Lifestyle intervention is associated with lower prevalence of urinary incontinence: the Diabetes Prevention Program. Diabetes Care. 2006 Feb;29(2):385-90.

Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005654.

Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012 Dec;188(6 Suppl):2455-63.

Huang AJ. Nonsurgical treatments for urinary incontinence in women: summary of primary findings and conclusions. JAMA Intern Med. 2013 Aug 12;173(15):1463-4.

Milleman M, Langenstroer P, Guralnick ML. Post-void residual urine volume in women with overactive bladder symptoms. J Urol. 2004 Nov;172(5 Pt 1):1911-4.

Myers DL. Female mixed urinary incontinence: a clinical review. JAMA. 2014 May 21;311(19):2007-14.

National Collaborating Centre for Women’s and Children’s Health (UK). Urinary Incontinence in Women: The Management of Urinary Incontinence in Women. London: Royal College of Obstetricians and Gynaecologists (UK); 2013 Sep. National Institute for Health and Clinical Excellence: Guidance.

Nygaard I. Clinical practice. Idiopathic urgency urinary incontinence. N Engl J Med. 2010 Sep 16;363(12):1156-62.

Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med. 2008 Mar 6;358(10):1029-36.

Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008 Mar 18;148(6):459-73.

Smith PP. Aging and the underactive detrusor: a failure of activity or activation? Neurourol Urodyn. 2010 Mar;29(3):408-12.

Staskin D, Hilton P, Emmanuel A, et al. Initial assessment of incontinence. In: Incontinence, 3rd ed., Abrams P, Cardozo L, Khoury S, Wein A. (Eds), Health Publications, Plymouth, UK 2005. p.485

Verhamme KM, Sturkenboom MC, Stricker BH, Bosch R. Drug-induced urinary retention: incidence, management and prevention. Drug Saf. 2008;31(5):373-88.

Winters JC, Dmochowski RR, Goldman HB, et al. Urodynamic studies in adults: AUA/SUFU guideline. J Urol. 2012 Dec;188(6 Suppl):2464-72.