Urinary incontinence (UI) is defined as 'the complaint of any involuntary leakage of urine'.
UI is very common; it is still both under-reported and undertreated. The prevalence has been estimated as affecting as many as one in two adult women. Many women do not report their symptoms, mainly owing to embarrassment.
NICE has produced guidelines that offer best-practice advice on the care of women with UI.1
There are two main types of UI in women.
Stress UI is involuntary urine leakage on effort or exertion or on sneezing or coughing. This is due to an incompetent sphincter.
Urge UI is involuntary urine leakage accompanied or immediately preceded by urgency. There is detrusor overactivity leading to an involuntary detrusor contraction. This may be idiopathic or secondary to neurological problems such as stroke, Parkinson's disease, multiple sclerosis or spinal cord injury.
Approximately half of women with UI have stress urinary incontinence. Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing. This occurs in about 5 per cent of women with UI.
The most important risk factor for UI is being female. Other risk factors include:
- Neurological disease/organic brain damage.
- Cognitive impairment.
- Obstruction, including pelvic tumours.
- Stool impaction.
- Previous hysterectomy.2
In addition, poor mobility and visual impairment in the elderly compound the problem of incontinence.
Inspection of the pelvic floor may show visible stress incontinence on straining or coughing. Other signs of weakness of the pelvic floor (e.g. cystocoele, rectocoele, enterocoele) may be apparent on examination.
A urine dipstick test should be performed. A post-void residual volume should be measured by ultrasound in women who have symptoms suggesting voiding dysfunction or recurrent UTI.
NICE states that the use of multi-channel cystometry, ambulatory urodynamics or videourodynamics is not recommended before starting non-surgical treatment.1
Most forms of UI are amenable to treatment by conservative, medical, minimally invasive or surgical interventions.
It is very important that the cause of the UI is diagnosed promptly and accurately so that patients can be managed appropriately and the impact of the condition on quality of life and productivity minimised.
The treatment depends on the type of UI the patient has. In mixed UI, treatment should be directed towards the predominant symptom.
In urge incontinence caffeine intake should be reduced and there should be a modification of fluid intake.
Although many women reduce their fluid intake thinking that this will help, too little fluid actually leads to concentrated urine, which can irritate the bladder. Patients should aim to drink around two litres of fluid a day.
NICE recommends that patients with a BMI >30 should be advised to lose weight.1
Bladder training is first-line treatment and should be for a minimum of six weeks.
This typically involves pelvic muscle training, scheduled voiding intervals with stepped increases and suppression of urge with distraction or relaxation techniques. Fluid-volume charts might also be useful.
Drug treatment should be considered if bladder training is not effective. NICE recommends that immediate-release oxybutynin should be given as first line.1
Alternative anti-muscarinic medications or extended-release (or transdermal) oxybutynin can be considered if immediate-release oxybutynin is not tolerated.
Sacral nerve stimulation may be considered in women with detrusor overactivity if conservative treatment does not relieve symptoms. Augmentation cystoplasty may also be considered.
Urinary diversion should only be considered if these operations are not appropriate or unacceptable.
In stress UI, a trial of supervised pelvic floor muscle training (PFMT) of at least three months' duration should be offered as first-line treatment. This should include eight contractions, three times a day.
There is some evidence that PFMT in women having their first baby can prevent UI in late pregnancy and postpartum. There is also good evidence for the recommendation that PFMT is an appropriate treatment for women with persistent postpartum UI.3
Although HRT improves tissue tone in women with atrophic vaginitis, there is no evidence that estrogens by themselves are useful for the management of incontinence.4
There are various surgical procedures for stress UI available. Transvaginal mid-urethral tape procedures are recommended as treatment options for stress UI where conservative management has failed.1
Open colposuspension and fascial slings are the alternatives recommended by NICE.
- Dr Newson is a GP in the West Midlands.
1. NICE Clinical Guideline 40. Urinary incontinence: the management of urinary incontinence in women. London: NICE, 2006.
2. Altman D, Granath F, Cnattingius S et al. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370(9597): 1,494-9.
3. Hay-Smith J, Morkved S, Fairbrother K A, Herbison G P. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2008; 4: CD007471.
4. Shamliyan T A, Kane R L, Wyman J et al. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008; 148(6): 459-73.