- Urinary incontinence is very common, occurring in one of every two women depending upon their age.
- The majority of urinary incontinence is classified as urge, stress, or a combination of both symptoms– “mixed.”
- The mainstay of treatment for urge incontinence is lifestyle modification, behavioral therapy and anticholinergic medication. Side effects and limited efficacy compromise symptom management in at least a third of women.
- Pelvic floor strengthening with Kegel exercises improves the symptoms of urge and stress incontinence.
- Moderate to severe stress urinary incontinence is most effectively treated with mid-urethral slings.
Table 1. Types of Urinary Incontinence in Women
|Type||Etiology||Clinical Presentation||Risk Factors|
|Mixed Incontinence||Combination of urge and stress incontinence|
Table 2. History and General Assessment
- Nature/duration of genitourinary and lower GI tract symptoms (eg, frequency, volume, precipitants to/timing of incontinence)
- Problem with urine storage (eg, urgency, frequency, urge incontinence)
- Problem with emptying urine (eg, hesitancy, dribbling, weak stream, sense of post-void fullness)
- Previous pelvic procedures affecting genitourinary tract
- Comorbidities (eg, congestive heart failure, pulmonary disease, nephrolithiasis)
- Pregnancy history and mode of delivery
- Bowel dysfunction (eg, constipation, difficult defecation, fecal incontinence)
- Medications (eg, affecting urinary retention/frequency) (Table 6)
- Impact of incontinence on quality of life, including sexual function
- Sociocultural and environmental issues
- Patient mobility and access to bathroom
- Patient goals/expectations of treatment
- Mental status affecting ability to understand management plans/treatment options
- Patient fitness for possible surgical treatment
For frail/elderly patient, emphasis on DIAPPERS:
- Atrophic vaginitis
- Excess urine output
- Reduced mobility
- Stool impaction and other factors
Table 3. Physical Examination
- General assessment of cognitive function, flexibility, ambulation
- Back: assess for costovertebral angle tenderness, surgical scars
- Abdominal: assess for surgical scars, muscle strength, hernia, mass, post-void palpable bladder
- Pelvic and speculum: assess for skin breakdown; sensation; pelvic support defects (with Valsalva maneuver); atrophy; levator muscle tone, symmetry and strength; evidence of fistula
- Rectovaginal: fecal staining, sphincter integrity and tone, consistency of stool, disruption of perineal body and rectovaginal septum
- Neurological: sensory and reflexes of sacral segments 2-4 (bladder and urethra, rectum, and anal canal), lower limbs, gait, cognitive function
- Stress test for urinary incontinence
- Tests: urinalysis, urine culture (if indicated), post-void residual urine volume
Table 4. Agents That Can Affect Bladder Function
Decrease bladder contractility
- ACE inhibitors (also may cause chronic cough)
Calcium channel blockers
Increase detrusor irritability/creatinine clearance
Increase urethral sphincter tone
- α-Adrenergic agonists (cold medications, decongestants)
Decrease urethral sphincter tone
- α-Adrenergic blockers
Table 5. Screening Questions
- Do you leak urine when coughing, sneezing, laughing, lifting, exercise? How often?
- Is the leakage a small spurt (stress incontinence) or all the urine in your bladder (urge incontinence)?
- Do you leak urine with a strong urge on way to bathroom? How often?
- How frequently do you urinate during the day? Do you think that is too often?
- How often do you awaken to urinate after going to sleep?
- Do you ever leak urine during sex? If yes, with penetration (stress incontinence) or at orgasm (overactive bladder)?
- Do you wear pads to protect your clothes from urine leaking? What kinds of pads do you wear? How often do you change wet pads?
(severity of urine loss)
- Do you ever find urine on pads or clothes and were unaware of leakage?
(severity of urine loss)
- Does your bladder hurt when it is full or while you are urinating?
(urinary tract infection, outlet obstruction, foreign body)
- Do you feel that you empty your bladder completely?
(urinary tract infection, outlet obstruction, overactive bladder)