> Table of Contents > Incontinence, Urinary Adult Female
Incontinence, Urinary Adult Female
Cara Marshall, MD
image BASICS
DESCRIPTION
  • Urinary incontinence: involuntary loss of urine that is objectively demonstrable and is of medical, financial, social, or hygienic concern
  • Stress incontinence: associated with increased intraabdominal pressure such as coughing, laughing, sneezing, or exertion
  • Urge incontinence: sudden uncontrollable loss of urine (also known as overactive bladder or detrusor overactivity)
  • Mixed incontinence: loss of urine from a combination of stress and urge incontinence
  • Overflow incontinence: high residual or chronic urinary retention leading to urinary spillage from an overdistended bladder
  • Functional incontinence: loss of urine due to deficits of cognition and/or mobility
  • Total incontinence: continuous leakage of urine; leakage without awareness
EPIDEMIOLOGY
  • Affects 25% of young women and up to 57% of women aged 40 to 60 years. Women 19 to 64 years of age have predominantly stress incontinence (12-28%), followed by mixed (7-12%), and urge (5-10%) incontinence.
  • Prevalence in women >75 years is 75%, and 6% of nursing home admissions are directly attributable to incontinence (1).
  • Severe or large-volume incontinence is primarily mixed (37%), followed by urge (27%) and stress (15%) (2).
ETIOLOGY AND PATHOPHYSIOLOGY
  • Stress incontinence: occurs with increased intraabdominal pressure. Two types:
    • Anatomic: due to urethral hypermobility from lack of pelvic support
    • Intrinsic sphincter deficiency (ISD): impaired closure of urethra. Urethral mucosal seal and inherent closure from collagen, fibroelastic tissue, smooth and striated muscles, and so forth, may be lost secondary to surgical scarring, radiation, or hormonal and senile changes.
  • Urge incontinence: may be due to detrusor overactivity or may be idiopathic
  • Overflow incontinence: urinary retention (usually from neurogenic bladder)
  • Total incontinence: constant loss of urine. Ectopic ureters in females usually open in the urethra distal to the sphincter or in the vagina, causing continuous leakage. May also occur with fistulous connections between bladder, ureters, or urethra, and vagina or uterus.
RISK FACTORS
Advanced age, impaired functional status, obesity (BMI >30), history of gestational diabetes, pregnancy, vaginal childbirth, pelvic surgery or radiation, urethral diverticula, genital prolapse, smoking, chronic obstructive pulmonary disease (COPD), cognitive impairment, constipation, caffeine, and pelvic floor dysfunction
GENERAL PREVENTION
Obesity avoidance, smoking cessation, high-fiber diet to reduce constipation
COMMONLY ASSOCIATED CONDITIONS
Pelvic organ prolapse, UTI, COPD, diabetes mellitus, neurologic disease, obesity, chronic constipation, depression, low libido, dyspareunia, and any disease that results in chronic cough
image DIAGNOSIS
PHYSICAL EXAM
  • General status
    • Obesity (BMI)
  • General neurologic examination
    • Mental status, speech, intellectual performance
    • Motor status: gait, generalized or focal weakness, rigidity, tremor
    • Sensory status: impairment of perineal-sacral area sensation
  • Urologic examination
    • Abdomen: masses, incisional scars of previous surgeries
    • Suprapubic tenderness: may indicate cystitis
    • Palpable, distended bladder: chronic urinary retention
  • Pelvic examination
    • Examination of the perineum and external genitalia, including tissue quality and sensation
    • Vaginal (half-speculum) examination for prolapse
    • Bimanual pelvic and anorectal examination for pelvic masses, fecal impaction, pelvic floor function, and so forth
      • Urethral hypermobility: gauged by palpation of the descent of the proximal urethra on straining
      • Assessment of pelvic floor resting tone and function (ability to isolate and contract pelvic floor musculature) (3)[C]
    • Stress test for urinary incontinence: Patient is asked to cough or strain to reproduce stress incontinence.
    • Cystocele: if evident, stage (grade 0 to 4)
    • Rectocele: if evident, stage (stage 0 to IV)
DIFFERENTIAL DIAGNOSIS
  • Nocturnal enuresis: idiopathic, detrusor overactivity, neurogenic, cardiogenic, or sleep apnea
  • Continuous leakage: ectopic ureter, urinary fistulas
  • Postvoid dribbling: urethral diverticulum, idiopathic, iatrogenic, surgical
  • Pelvic pain/dyspareunia: interstitial cystitis
  • Pelvic organ prolapse
  • Hematuria/recurrent UTI/pelvic mass: malignancy (4)
DIAGNOSTIC TESTS & INTERPRETATION
  • Urinalysis and urine culture
  • Renal function assessment: recommended if renal impairment is suspected
Initial Tests (lab, imaging)
  • Unnecessary in uncomplicated patients
  • Bladder scan to evaluate postvoid residual if overflow is suspected (<50 to 100 mL expected) (4)
  • Upper tract imaging if upper tract involvement is suspected: scan or renal ultrasound (US)
  • International Consultation of Incontinence Modulator Questionnaire (ICIQ) is highly recommended for assessment of patient's perspective of symptoms of incontinence and his or her impact on quality of life.
  • 3IQ questionnaire helps differentiate between stress and urge incontinence (http://www.overactivebladder.com/sites/g/files/g10016541/f/201502/3IQ_updated.pdf) (2).
  • 3-day voiding diary to evaluate fluid intake, caffeine intake, timing of leakage, and patient habits
Follow-Up Tests & Special Considerations
Asymptomatic bacteriuria is common. With a positive urine culture, initial treatment is indicated; however, if this is ineffective, repeat treatment is not indicated (3).
Diagnostic Procedures/Other
Urodynamic studies (not indicated in initial workup):
  • Cystometric study of detrusor function
  • Results on urodynamic testing are not predictive of treatment or surgery success (5)[A].
image TREATMENT
GENERAL MEASURES
  • Treat correctable causes (e.g., UTI).
  • Encourage weight loss in obese patients.
  • Aggressively correct constipation.
  • Treat mixed for primary symptom type (4)[C].
P.551

MEDICATION
First Line
  • Stress incontinence
    • Lifestyle changes
      • Reduce BMI to <25 (5)[A].
      • Reduce caffeine to <1 cup coffee/day (5)[B].
      • Aggressive treatment of constipation: Limit medications that may induce constipation, polyethylene glycol 3350 (PEG 3350), increased fluid intake, and so forth.
    • Kegel exercises
      • Pelvic floor muscle training, at least eight contractions TID (3)[A]
      • Proper technique should be confirmed on exam; training by physical therapists.
      • Maintain treatment for at least 3 months (2).
      • 5 times as effective as placebo (1)[A]
  • Urge incontinence
    • Supervised bladder training/scheduled voiding (1)[C]
Second Line
  • Stress incontinence
    • Surgical management for stress incontinence:
      • Midurethral sling (preferred surgical intervention) (4)[A]
        • Women with moderate to severe stress incontinence have better outcomes at 1 year with midurethral slings than pelvic floor muscle training (6)[A].
        • Retropubic (more perioperative complications)
        • Transobturator (more pain/dyspareunia)
        • Single-incision sling (MiniArc, SOLYX)
      • Abdominal approaches: Marshall-Marchetti-Krantz cystourethropexy, Burch colposuspension, laparoscopic colposuspension (4)[A]
      • Periurethral injection of bulking agents (may provide symptom relief but not permanent cure): silicone particles, carbon beads, calcium hydroxylapatite (5)[B]
  • Urge incontinence: anticholinergic agents (1)[A]
    • Tolterodine (Detrol LA): 2 to 4 mg/day PO
    • Oxybutynin (Ditropan XL): 5 to 30 mg/day PO
    • Solifenacin (VESIcare): 5 to 10 mg/day PO
    • Darifenacin (Enablex): 7.5 to 15 mg/day PO
    • Trospium chloride (Sanctura XR): 60 mg/day PO
    • Transdermal oxybutynin gel (Gelnique): 10% applied daily
    • Transdermal oxybutynin patch (Oxytrol): twice weekly—available over the counter (OTC)
    • Fesoterodine (Toviaz): 4 to 8 mg/day PO
    • Dry mouth, dry eyes, constipation, impaired cognitive function, and other anticholinergic side effects can limit use.
    • Avoid with narrow-angle glaucoma, urinary retention (postvoid residual [PVR] >250 mL), impaired gastric emptying, and frail elders (3)[A]. No single agent has been shown to be overall superior (1)[A].
    • Fesoterodine achieves incontinence > tolterodine, at the expense of greater adverse effects (1)[B].
    • Extended-release and transdermal medications cause fewer side effects (5)[B].
    • &bgr;-3 agonist: mirabegron (Myrbetriq ER): 25 to 50 mg/day PO (1)[B]; onset of action delayed ˜8 weeks; increases BP (avoid use in those with uncontrolled HTN)
Third Line
  • Stress incontinence
  • Duloxetine (Cymbalta) may have some limited efficacy (1)[C].
  • Estrogen may be beneficial in topical form, but transdermal estrogen may worsen symptoms (1)[B].
    • Biofeedback and electrostimulation of pelvic floor muscles
    • Occlusive and supportive devices (e.g., cones, pessaries, and super tampons)
    • Acupuncture (in selected cases)
  • Urge incontinence
    • Intradetrusor onabotulinumtoxinA 100 to 200 U (urinary retention common, temporary selfcatheterization may be needed) (4)[A]
    • Sacral nerve stimulation: 50% reduction in episodes in 2/3 of patients who have failed other treatments. Invasive with frequent complications (4)[B]
    • Percutaneous tibial nerve stimulation: office-based therapy, requires frequent visits (3)
    • Bladder augmentation (4)[C]
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Postoperative assessment: Rule out UTI, check postvoid residual, check suture lines.
  • Periodic long-term follow-up with outcome-based questionnaire surveys
PATIENT EDUCATION
Instructions on self-care and warning signs are available at PubMed Health: Urinary Incontinence: https://www.nlm.nih.gov/medlineplus/urinaryincontinence.html
PROGNOSIS
Significant improvements are usually obtained with most patients.
REFERENCES
1. Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
2. Myers DL. Female mixed urinary incontinence: a clinical review. JAMA. 2014;311(19):2007-2014.
3. Smith A, Bevan D, Douglas HR, et al. Management of urinary incontinence in women: summary of updated NICE guidance. BMJ. 2013;347:f5170.
4. Lucas M, Bedretdinova D, Bosch J, et al. Guidelines on urinary incontinence. European Association of Urology; 2014. http://uroweb.org/guideline/urinary-incontinence/?type=summary-of-changes
5. Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014;349:g4531.
6. Labrie J, Berghmans BL, Fischer K, et al. Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med. 2013;369(12):1124-1133.
Additional Reading
&NA;
  • 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(1):213-240.
  • Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (nonneurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188(6 Suppl):2455-2563.
  • Nygaard I. Clinical practice. Idiopathic urgency urinary incontinence. N Engl J Med. 2010;363(12):1156-1162.
  • Visco AG, Brubaker L, Richter HE, et al. Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. N Engl J Med. 2012;367(19):1803-1813.
Codes
&NA;
ICD10
  • R32 Unspecified urinary incontinence
  • N39.3 Stress incontinence (female) (male)
  • N39.41 Urge incontinence
Clinical Pearls
&NA;
  • Urinary incontinence is the involuntary loss of urine that is objectively demonstrable; markedly detrimental to quality of life; and is of medical, financial, social, or hygienic concern.
  • Stress incontinence: associated with increased intraabdominal pressure such as coughing, laughing, sneezing, or exertion
  • Urge incontinence: sudden uncontrollable urgency, leading to leakage of urine (also known as overactive bladder or detrusor overactivity)
  • Rule out UTI or STI by culture.
  • Aggressively treat constipation.
  • Assume that the majority of women can be significantly helped by treatment.
  • For stress incontinence, physical therapy/pelvic floor rehabilitation and midurethral sling surgeries are most commonly used.
  • For urge incontinence, if anticholinergic agents fail, intradetrusor onabotulinumtoxinA is often beneficial.