Urinary incontinence

By Dr Caroline Taylor-Walker on the 6 October 2011

It is vital to identify the type of incontinence, says Dr Caroline Taylor-Walker.

Treatment for stress incontinence may include an artificial sphincter (Photograph: SPL)

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Urinary incontinence is the involuntary leakage of urine, usually caused by an underlying condition. More than 50% of people who experience incontinence are too embarrassed to seek help. An estimated 46% of women and 34% of men over 80 years of age are affected. It is important to identify this condition in order to minimise the physical, psychological and social impact.¹

1. Risk factors
All patients at risk should be asked about incontinence problems. Risk factors include increasing age, female, enlarged prostate or prostate surgery, neurological disease, cognitive impairment, high BMI, childbirth, constipation and hysterectomy or menopause.²

2. Types of incontinence
Types of incontinence include functional, stress, urge or mixed incontinence. Functional incontinence is when the patient is unable to reach the toilet due to poor mobility or unfamiliar surroundings.

Stress incontinence is where sphincter incompetence causes urine leakage on effort such as exertion, coughing or sneezing.

Urge incontinence is where urine leakage is accompanied or preceded by urge of micturition that cannot be deferred.

This is idiopathic or secondary to detrusor instability, neurological problems, such as stroke and spinal cord injury, or local irritation, such as infection or bladder stones. Patients may also have mixed incontinence where both urge and stress symptoms are present and treatment is guided by the predominant symptom.

Detruser instability can also cause overactive bladder syndrome (OAB) where patients get frequency, nocturia and urgency with or without incontinence. Overflow incontinence is important to recognise. It occurs due to chronic bladder outflow obstruction such as prostatic disease and if unidentified can result in nephropathy due to back pressure.

Lastly, true incontinence causes a continuous leakage of urine from a fistula between urethra, ureter or bladder and vagina.³

3. History
It is important to identify the type of incontinence and a bladder diary for a minimum of three days is recommended to aid diagnosis. GPs should remember to identify secondary causes, such as infections, constipation or obstruction, that need to be treated first.

Obtain a full obstetric history and ask about medication. The patient's social and functional status, including toilet access, should be understood.

Consider using a quality of life and incontinence severity questionnaire to evaluate impact of symptoms, for example, the International consultation of incontinence questionnaire.¹

4. Examination and investigations
An abdominal, pelvic and neurological examination is required. Perform a digital and internal examination for evidence of atrophy or prolapse and to assess contraction of the pelvic floor muscles in women.

In men perform a digital rectal examination to assess the prostate or any rectal pathology.

A urine dipstick should be carried out in all patients to identify infection. Measure post-void residual volume and flow rates in all men but only in women if there are symptoms of voiding dysfunction or recurrent UTIs. Further investigations, such as urodynamics or cystoscopy, are not recommended before starting conservative treatment.³

Key points
Urinary incontinence is more common in women than in men. It is vital to identify the type of incontinence in order to guide management. First-line therapy is a trial of pelvic floor exercises. Consider referral if the diagnosis is uncertain.

5. Management
Urge and mixed incontinence and OAB

Lifestyle changes are important in managing symptoms. Reduction of caffeine and alcohol plus maintaining fluid intake of between one to two litres a day can help. If the patient has a BMI of 30kg/m² or above, weight loss must be encouraged.

First-line therapy is a minimum of six weeks' bladder training. This involves pelvic floor muscle training of at least eight contractions three times per day, scheduled voiding intervals and suppression of urge with distraction or relaxation techniques.³

If the above is ineffective, first-line medication is the antimuscarinic oxybutynin.

Alternatives are darifenacin, solifenacin, tolterodine or trospium. Patients should be aware of the potential side-effects, such as dry mouth, and should be reviewed regularly.

If vaginal atrophy is present, vaginal estrogens can be considered. Desmopressin is available for nocturia and propiverine for urinary frequency.^1,3

If conservative measures fail, consider surgical options. These include sacral nerve stimulation, augmentation cystoplasty, urinary diversion or botulinum toxin injection.^1,3

Stress incontinence
The first-line therapy for men and women is a three-month trial of pelvic floor exercises. Electrical stimulation and/or biofeedback is not routine but can be considered in women who cannot actively contract pelvic floor muscles. If this proves to be ineffective, duloxetine can be prescribed.

Surgical options include retropubic mid-urethral tape procedures in women and suburethral synthetic sling insertion or bulking agents and artificial urinary sphincter in men.^1,3

6. Catheterisation
The use of catheters may be indicated in patients with problems such as persistent urinary retention leading to incontinence, recurrent infections or renal impairment.

Intermittent catheterisation may be performed in some, otherwise indwelling catheters are necessary. Pads and toileting aids should only be used as an adjunct to treatment.

7. Referral
Women should be referred under the two-week wait rule if there is any suspicion of malignancy, for example, microscopic haematuria in the over 50s.

Referral should also be made if there is a palpable bladder after voiding or a prolapse at or below the introitus

Consider referral if the diagnosis is uncertain or there are complex issues, such as persistent bladder or urethral pain, benign pelvic masses, faecal incontinence, suspected neurological disease, voiding difficulty, urogenital fistulae, previous pelvic cancer or continence surgery or previous pelvic radiation therapy.^1,3

SIGN guidelines recommend that men should be referred if they have reduced urinary flow rates (<15ml/second) or elevated post-void residual volumes (>100mls) or any symptoms that meet the two-week wait criteria.^1,3

8. Prevention
All women in their first pregnancy should be offered pelvic floor muscle training. Weight should be controlled in both sexes in order to reduce the risk of developing incontinence.³