Urinary incontinence is common and it can have an impact on the physical, psychological and social well-being of those affected, as well as on their families and carers.
Urinary incontinence is the involuntary leakage of urine. The different types of urinary incontinence include:
- Functional incontinence: the patient is unable to reach the toilet in time, for such reasons as poor mobility or unfamiliar surroundings.
- Stress incontinence: involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.
- Urge incontinence: involuntary urine leakage accompanied by, or immediately preceded by, urgency of micturition. This means a sudden and compelling desire to urinate that cannot be deferred. In urge incontinence there is detrusor instability or hyperreflexia leading to involuntary detrusor contraction. This may be idiopathic or secondary to neurological problems such as stroke, Parkinson's disease, multiple sclerosis, dementia or spinal cord injury. It can sometimes be caused by local irritation due to infection or bladder stones.
- Mixed incontinence: involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.
- Overactive bladder syndrome: urgency that occurs with or without urge incontinence and usually with frequency and nocturia. It may be called 'OAB wet' or 'OAB dry', depending on whether or not the urgency is associated with incontinence. The usual cause of this problem is detrusor overactivity. See separate Overactive Bladder article.
- Overflow incontinence: usually due to chronic bladder outflow obstruction. It is often due to prostatic disease in men. It can lead to obstructive nephropathy due to back pressure; therefore, early assessment and intervention are required. See separate Acute Urinary Retention and Chronic Urinary Retention articles. Overflow incontinence may also be due to a neurogenic bladder.
- True incontinence: may be due to a fistulous track between the vagina and the ureter, or bladder, or urethra. There is continuous leakage of urine.
- It is difficult to estimate the prevalence of urinary incontinence, due to differences in its definition and also the fact that it is thought that many people won't admit to having continence problems. A population-based cross-sectional postal evaluation of all female patients over 21 years registered at a single medical practice in the UK reported that 40% of respondents experienced urinary incontinence, which caused significant problems in 8.5%. Stress urinary incontinence was the most common problem, whilst 10% had voiding dysfunction. Only 17% had sought professional help, the perception being that incontinence was a natural part of the ageing process.
- Estimates suggest that approximately 3.5 million women have urinary incontinence in the UK. In general, urinary incontinence is two to three times as common in women as in men.
- The prevalence increases with age. In a cohort study of individuals aged over 85 years, severe or profound urinary incontinence was reported by 21%.
- The prevalence of urinary incontinence for adults living in institutions is as high as 25%.
- Risk factors in women include pregnancy and vaginal delivery (but become less important with age), diabetes mellitus, oral oestrogen therapy and high body mass index .
- One study found that the perimenopause was associated with stress but not urge incontinence. Postmenopausal women had no higher prevalence of urinary incontinence (any type) than those who were pre-menopausal.
- Hysterectomy is related to stress urinary incontinence, particularly vaginal hysterectomy.
- Childbirth can cause anatomical or neuromuscular injury and can damage the pelvic floor muscles. A vaginal delivery, forceps use and babies of a heavier birth weight are all risk factors[9, 10, 11]. Caesarean section does not necessarily confer protection against urinary incontinence. One study reported a 40% incidence of this complication, even in patients who had exclusively caesarean deliveries.
- Parity is associated with stress but not urge incontinence.
- Urinary incontinence occurs more frequently in women with urinary tract infections (UTIs).
- Risk factors in men include lower urinary tract symptoms (LUTS), infections, functional and cognitive impairment, neurological disorders and prostatectomy.
- Neurological disease/organic brain damage can be a risk factor for incontinence in men and women - eg, stroke, dementia and Parkinson's disease.
- Cognitive impairment increases the risk in both sexes. However, mild loss of cognitive function is not a risk factor for urinary incontinence but does increase the impact of urinary incontinence.
- Obstruction, including an enlarged prostate gland in men and pelvic tumours in women, can lead to incontinence.
- Stool impaction may be implicated in elderly patients.
- From the history, determine what type of urinary incontinence the patient has: stress, urge or mixed. If mixed, treatment should be directed towards the most prominent symptoms. Questions in the history can include:
- Stress incontinence: leakage of urine on sneezing, coughing, exercise, rising from sitting, or lifting.
- Urge incontinence: urgency and failure to reach a toilet in time.
- Frequency of urine during the day/at night.
- Dribbling of urine after leaving the toilet.
- Loss of bladder control.
- Feeling of incomplete bladder emptying.
- Dysuria: pain or burning sensation on passing urine.
- Bladder spasms.
- When assessing urinary incontinence in neurological disease, consider factors likely to affect management, such as mobility, hand co-ordination, cognitive function, social support and lifestyle.
- A full obstetric history should be taken in women.
- The patient should be asked, during their initial assessment, to complete a bladder chart for a minimum of three days. These should include both working days and days off. An example of a bladder chart can be found here.
- Enquire about sexual dysfunction and quality of life.
- Assess functional status and access to toilet.
- Establish whether any medication contributes to symptoms.
- Enquire about bowel habit.
- Enquire about desire for treatment.
- Perform digital assessment of pelvic floor muscle contraction.
- Perform a bimanual/vaginal examination to assess for the presence of prolapse. See separate Genitourinary Prolapse article.
- Look for signs of vaginal atrophy.
- Abdominal, pelvic and neurological examination should also be performed.
- Perform digital rectal examination to assess prostate shape, size and consistency and to check for other rectal pathology.
- Digital anal assessment can be used to give an indication of pelvic floor muscle strength in men.
- Abdominal, pelvic and neurological examination should also be performed[2, 14].
Investigations in primary care
The National Institute for Health and Care Excellence (NICE) suggests the following for women. It would be reasonable to follow the same guidelines in men.
- Urinary dipstick testing:
- Perform a urinary dipstick test to look for blood, glucose, protein, leukocytes and nitrites.
- If a woman has symptoms of a UTI and dipstick testing shows leukocytes and nitrites, send an MSU for culture and sensitivities. Prescribe antibiotics whilst waiting for results.
- Also send an MSU in other women with symptoms of UTI but negative urine dipstick testing. Consider antibiotics whilst waiting for results.
- If a woman has no symptoms of UTI but positive dipstick testing for leukocytes and nitrites, send an MSU but don't start antibiotics until results are available.
- If a woman has no symptoms and negative dipstick testing for nitrites and leukocytes, no MSU is needed.
- Renal function tests may be indicated.
- Assessment of residual urine:
- Post-void residual volume should be measured in women who have symptoms suggesting voiding dysfunction or recurrent UTI. This is best performed using a bladder scan. Catheterisation may also be used.
- Post-void residual volume should also be measured in men.
- Urinary flow rates:
- Assessment of urinary flow rates is disputed for most cases. They may be measured in men and in patients of either sex with neurological disease.
- Other investigations:
- Urodynamic studies: urodynamic testing including multi-channel cystometry, ambulatory urodynamics or video urodynamics is not recommended before starting conservative treatment in women. However, these investigations may be carried out before surgery for urinary incontinence.
- Multi-channel filling and voiding cystometry should not be performed in women in whom pure stress urinary incontinence is identified by history and examination.
- Ambulatory urodynamics or videourodynamics should be considered if the diagnosis remains unclear after conventional urodynamics.
- Cystoscopy is not recommended in the initial assessment of women with urinary incontinence alone.
- No imaging techniques are recommended in the initial assessment in women, except for ultrasound assessment of residual volume. However, ultrasound of the kidneys is indicated in men and women with neurological disease where renal complications could occur (eg, spina bifida, spinal cord injury).
When to refer directly to secondary care
An urgent two-week suspected cancer referral should be made for women who have any of the following:
- Microscopic haematuria if aged ≥50 years.
- Visible haematuria.
- Recurrent or persisting UTI associated with haematuria if ≥40 years.
- Suspected malignant mass arising from the urinary tract.
Refer women with:
- A palpable bladder on bimanual/abdominal examination after voiding.
- A prolapse visible at/below the introitus, with the patient symptomatic.
Consider referral to secondary care if:
- There is persisting bladder or urethral pain.
- There are clinically benign pelvic masses.
- There is associated faecal incontinence.
- There is suspected neurological disease.
- There are symptoms of voiding difficulty.
- Urogenital fistulae are suspected.
- Previous continence surgery has taken place.
- Previous pelvic cancer surgery has taken place.
- Previous pelvic radiation therapy has taken place.
- If there are any criteria present that meet the two-week suspected cancer referral in men, appropriate referral should be made.
- NICE recommends referral for men with LUTS complicated by recurrent or persistent UTI, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer.
Temporary containment products (eg, pads or collecting devices) to achieve social continence should be offered until there is a specific diagnosis and management plan. The permanent use of containment products should only be considered after assessment and exclusion of other methods of management.
Urge incontinence and overactive bladder syndrome
See separate Overactive Bladder article.
NICE suggests the following management in women:
- Pelvic floor muscle exercises:
- A three-month trial of pelvic floor muscle exercises is the first-line treatment (subsequent to digital assessment of pelvic muscle contraction).
- This should include eight contractions, three times a day.
- Continue if successful.
- Consider electrical stimulation and/or biofeedback in women who cannot actively contract pelvic floor muscles.
- Provide the patient with a patient information leaflet about pelvic floor exercises.
- Drug treatment:
- Duloxetine should not be used as first-line treatment. It may be considered as second-line treatment in women who do not want surgery or who are unsuitable for surgery.
- Surgical treatment:
- If conservative measures fail, consider:
- Retropubic mid-urethral tape procedures using a 'bottom-up' approach with synthetic tape.
- Open colposuspension
- Autologous rectal fascial sling.
- Procedures and devices should be used which have a robust evidence base for effectiveness and safety and for which the surgeon is trained.
- Synthetic tapes should be selected which are made from type 1 macroporous polypropylene material and are coloured for high-visibility colour.
- Autologous slings should be used in preference to synthetic tape in patients with neurological disease, due to the risk of urethral erosion.
- If a transobturator foramen approach is used, women should be informed of the lack of long-term outcome data.
- Synthetic slings using a retropubic 'top-down' should only be used as part of a clinical trial.
- Patients should be offered a six-month follow-up appointment (including vaginal examination to exclude cervical erosion).
- Intramural bulking agents (eg, glutaraldehyde cross-linked collagen, silicone) may be considered if conservative management has failed. However, their efficacy reduces with time, repeat injections may be needed and they are not as effective as retropubic suspension/sling procedures.
- An artificial sphincter should generally only be considered if previous surgery has failed. However, it may be considered first-line in neurological disease if another procedure such as a sling is considered less likely to promote continence.
- If laparoscopic colposuspension is used, the surgeon must be experienced and working in an experienced urogynaecological multidisciplinary team.
- Anterior colporrhaphy, needle suspensions, paravaginal defect repair and the Marshall-Marchetti-Krantz procedure are not recommended by NICE for the treatment of stress incontinence.
- If conservative measures fail, consider:
Pelvic floor muscle exercises may be used in men with stress incontinence and in men who have undergone radical prostate surgery. They are also useful for patients of both sexes with stress incontinence due to multiple sclerosis or stroke. NICE supports the use of intramural injectables, implanted adjustable compression devices and male slings to manage stress urinary incontinence in men but only as part of randomised controlled trials. The European Association of Urology guidelines also suggest the use of bulking agents and artificial urinary sphincter for the specialised management of stress incontinence in men.
In mixed urinary incontinence, treatment should be directed towards the predominant symptom but may involve a combination of approaches.
- Pelvic floor exercises and bladder training, as above, are first-line treatment, both in men and in women.
- The antimuscarinic drug oxybutynin can be started if these are not effective (not recommended in frail, elderly women).
- Newer antimuscarinic drugs such as darifenacin, solifenacin, tolterodine and trospium are alternatives if oxybutynin is not well tolerated. Extended-release or transdermal oxybutynin are other possibilities.
- Fesoterodine and propiverine are more recent antimuscarinics also licensed for this use.
- Antimuscarinics are useful in the management of patients with neurological disease affecting the brain (eg, cerebral palsy) and overactive bladder syndrome and in those with bladder storage disorders. They should, however, be used with caution, as they can cause constipation, urinary retention and confusion.
- Annual review should be undertaken of patients on long-term medication (six-monthly for women aged over 75 years).
- In women with predominantly stress incontinence, NICE recommends discussing conservative options including drugs, before considering surgery.
Dr Hayley Willacy draws your attention to the latest update of the European Association of Urology guidelines on urinary incontinence. The major changes deal with the prescription of antimuscarinics and key points are:
- All antimuscarinics are equally effective.
- Once daily or transdermal delivery minimises side-effects.
- Avoid oxybutynin in the elderly as it may adversely affect cognitive performance.
- Overflow incontinence due to bladder outlet obstruction should be managed by relieving/treating the obstruction.
- Intermittent self-catheterisation may be carried out.
- If there is obstruction due to prostatic hypertrophy (benign or malignant), this should be managed appropriately. See separate Benign Prostatic Hyperplasia and Prostate Cancer articles.
See also separate Catheterising Bladders article. NICE suggests the following:
- Intermittent catheterisation or indwelling urethral or suprapubic catheterisation may be needed for some patients - eg, if there is persistent urinary retention leading to incontinence, if there is renal impairment or if there are symptomatic infections.
- Women with urinary retention may be taught to perform intermittent urethral self-catheterisation.
- Indwelling catheters (either urethral or suprapubic) may be indicated if:
- There is chronic urinary retention and the person cannot perform self-catheterisation.
- Skin wounds, pressure sores or skin irritations are being contaminated by urine.
- There is distress or disruption caused by changing clothes and the bed.
- A woman would like this form of management.
- Suprapubic catheters may have lower complication rates, including lower rates of symptomatic UTI and by-passing.
- If someone has cognitive impairment, they should follow a prompted and timed toileting programme.
- Patients with neurological disease may also benefit from bladder retraining or habit retraining after assessment by a healthcare professional trained in such techniques. Carers/families should - with the patient's consent - be involved.
- Botulinum toxin type A is sometimes used in some patients with neurological disease - eg, those with spinal cord disease and overactive bladder or impaired bladder storage.
- Augmentation cystoplasty using an intestinal segment may be offered to patients with non-progressive neurological disease and impaired bladder storage.
- Ileal conduit diversion (urostomy) with or without cystectomy may be considered for patients whose neurological disease causes intractable problems.
- Desmopressin may be prescribed in women with troublesome nocturia. It should be used with caution in women with cystic fibrosis and is contra-indicated in those aged over 65 years with cardiovascular disease or hypertension. Its use in idiopathic urinary incontinence is outside its UK licence and women should be informed of this.
- NICE does not recommend the following for the treatment of urinary incontinence:
- Propiverine, flavoxate, imipramine or propantheline.
- Systemic hormone replacement therapy.
- Complementary therapies.
- Give patients the opportunity to return for review in the future to discuss investigations and management options, even if no treatment is wanted currently.
- Offer all women pelvic floor muscle training in their first pregnancy.
- Weight control may reduce the risk of developing incontinence.
Did you find this information useful?
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