Urinary Incontinence in Women

Background

• Urinary incontinence is the involuntary loss of urine and affects approximately 50% of women at some point in their lifetime with increasing incidence in older age.
  • Stress urinary incontinence occurs during physical exertion, effort, coughing, or sneezing.
  • Urge urinary incontinence (overactive bladder) is characterized by an associated sudden desire to urinate.
  • Mixed urinary incontinence is a combination of urge and stress urinary incontinence.
  • Overflow urinary incontinence is when urinary retention and bladder overdistention lead to dribbling.
  • Functional incontinence results from cognitive, functional, or mobility difficulties in a person with or without lower urinary tract deficits.
• In women < 65 years old, stress incontinence is slightly more common whereas women > 65 years old are more likely to have urge or mixed incontinence.
• Numerous types of medications are associated with urinary incontinence including diuretics, sedatives, hypnotics, antidepressants, and muscle relaxants.

Evaluation

• Clinical evaluation:
  • Ask about daytime frequency, nocturia, feeling of urgency, relationship of incontinence to effort or exertion, and the character of voiding (feeling of incomplete emptying, hesitancy, or strain during voiding).
  • If standard assessment is needed, use bladder diaries or validated questionnaires (Strong recommendation).
  • Not all women require comprehensive pelvic exam. Perform pelvic exam
    • when findings, such as detection of pelvic mass, would inform treatment selection or alter planned intervention
    • to detect other abnormalities such as severe pelvic organ prolapse in women with history of vaginal delivery and atrophic vaginitis in older women
  • Perform digital assessment of pelvic floor muscle contraction, functioning, strength, pressure, duration, and lift using 1 or 2 fingers in the distal one-third of vagina prior to considering supervised pelvic floor muscle training with a pelvic floor rehabilitation specialist for treatment of stress, urge, or mixed incontinence.
• The diagnosis of stress incontinence, urge incontinence, or mixed incontinence in women can usually be made when the typical findings are present on history and physical examination.
• Perform urine dipstick or urinalysis (Strong recommendation) with the addition of a urine culture if dipstick shows signs of infection.
• Use ultrasound (such as a bladder scan device) to measure postvoid residual volume in women with symptoms suggestive of voiding dysfunction, recurrent urinary tract infection (UTI), or complicated urinary incontinence.
• Urodynamic testing should not be routinely performed (Strong recommendation), but may be considered if:
  • initial conservative therapy fails
  • results may change choice of surgical management or other invasive treatment (Weak recommendation)

Management

• Referral (appointment within 2 weeks) to a specialist should be considered for women with urinary incontinence who have:
  • microscopic hematuria and are ≥ 50 years old
  • visible hematuria
  • recurrent or persistent urinary tract infection associated with hematuria and are ≥ 40 years old
  • suspected malignant mass arising from the urinary tract
• Lifestyle and behavior interventions for all types of urinary incontinence:
  • Consider advising patients to alter fluid intake if their intake is unusually high or low (Weak recommendation).
  • Encourage weight loss and maintenance of weight loss in women who are overweight or obese (Strong recommendation).
  • Offer incontinence pads and/or containment devices (Strong recommendation).
  • Offer prompted voiding for adults with cognitive impairment (Strong recommendation).
• Treatment for stress urinary incontinence:
  • Offer supervised intensive pelvic floor muscle training (PFMT) for ≥ 3 months as first-line treatment to women with stress urinary incontinence (Strong recommendation).
  • Offer the following surgical options for women with uncomplicated stress urinary incontinence (Strong recommendation):
    • midurethral sling (most frequently used surgical intervention for women with stress urinary incontinence)
    • pubovaginal sling
    • open or laparoscopic colposuspension (also known as retropubic bladder neck suspension)
    • urethral injection therapy (bulking agents)
• Treatment for urge urinary incontinence or overactive bladder:
  • Advise women that reducing caffeine intake may improve symptoms of urgency and frequency but not incontinence (Strong recommendation).
  • Offer bladder training as first-line treatment for urge incontinence in women (Strong recommendation).
  • Consider adding bladder relaxant medication if there is an inadequate response to bladder training.
    • Use of antimuscarinic (anticholinergic), for example oxybutynin or tolterodine, medication is associated with many adverse effects such as constipation, xerostomia, and headache, especially in the elderly. Extended release formulations are associated with lower adverse events rates and transdermal formulations are available for patients unable to tolerate oral formulations.
    • Exposure to bladder antimuscarinics may be associated with increased risk of dementia in middle-aged and older adults.
      • Avoid use of bladder antimuscarinics in older adults with or at risk of delirium due to potential of inducing or worsening delirium and in patients with dementia or cognitive decline due to adverse central nervous system effects.
      • Avoid simultaneous use of multiple drugs with strong anticholinergic activity, including bladder antimuscarinics, in older adults due to increased risk of cognitive decline.
      • Use caution when considering long-term use of antimuscarinics in the elderly especially those at risk of, or who have, cognitive dysfunction.
    • Offer beta-3-agonist (for example, mirabegron) drug therapy in persons where antimuscarinic drug therapy is ineffective, contraindicated, or who experience intolerable side effects (Strong recommendation).
  • Use intravaginal estrogen for the treatment of urinary incontinence and symptoms of vulvovaginal atrophy in postmenopausal women (Strong recommendation).
  • Second-line management for patients unresponsive to bladder relaxant medications therapy:
    • Offer percutaneous tibial nerve stimulation, sacral nerve neuromodulation or bladder wall injections of onabotulinum toxin A to patients with urge incontinence that is refractory to conservative therapies, including antimuscarinic therapy.
    • Consider augmentation cystoplasty only for patients with detrusor overactivity incontinence after failure of all other treatment options for patients who are willing and able to self-catheterize (Weak recommendation).
    • Consider urinary diversion only for patients who have failed less invasive therapies and who will accept a stoma (Weak recommendation).
• In patients with mixed urinary incontinence, treat the most bothersome symptom first (Weak recommendation).