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Urinary Incontinence

Basics

Description

- Urge incontinence: - Episodes of large volume loss secondary to uninhibited detrusor contractions - Disruption of coordinated components of bladder filling and emptying

- Functional incontinence: - Patients with intact lower urinary tract unable/unwilling to reach toilet to void - Visual impairment, limited manual dexterity, and limited mobility

- Intrinsic sphincter deficiency - Intrinsic muscular tone is weakened. - Reduces resting urethral tone and resistance to increases in intra-abdominal pressure

- Urinary retention - Outflow obstruction (uncommon in women) - Failure of urethra or pelvic floor to relax during voiding - Pelvic organ prolapse - Neoplasm - Prior anti-incontinence procedures

- Hypotonic bladder - Detrusor unable to generate enough pressure to overcome urethral resistance - Autonomic, peripheral neuropathy - Pharmacologic (anticholinergics, calcium channel blockers, adrenergic agonists, narcotic analgesics) - Spinal disorders (disc herniation, spinal stenosis, tumor, congenital abnormalities) - Radiation fibrosis

- Obtain a complete history to differentiate type of incontinence (1,2)[C] - Stress incontinence: Urine leakage with cough, sneeze, laugh, exercise, or exertion - Urge incontinence: Uncontrollable urinary urge, large volume accidents, urinary frequency, nocturia - Severe urge with incontinence when hearing running water or placing "key in door "

- Pelvic examination (1 " 4)[C] - Assess pelvic organ support - Assess neurologic function - Assess pelvic muscle strength

- A complete listing of all medication therapies is beyond the scope of this text; please see article by Vij et al. under "Additional Reading. " - Stress incontinence: Pharmacotherapy limited - Duloxetine (1)[B] - Not FDA approved in the US - Starting dose: 20 mg b.i.d. for 2 weeks - Maintenance dose: 40 mg b.i.d.

- Urge incontinence - Antimuscarinics (1)[A]: Efficacy around 60% - Do not use in women with narrow angle glaucoma - Start at lower dose and titrate based on response after 3 " 4 weeks of therapy - Start at the lowest possible dose then increase based on response (2)[C] - Similar efficacy among different medications (3)[A] - Typical side effects: Dry mouth, constipation, headache, dyspepsia, and dizziness

- Oxybutynin (Ditropan): - IR 2.5 " 5 mg b.i.d. or ER 5 " 30 mg - Transdermal patch: 1 patch changed twice weekly (delivers 3.89 mg/24 hours) - Topical gel (sachets): 1 g/day

- Solifenacin (Vesicare): 5 " 10 mg/day - Darifenacin (Enablex): 7.5 " 15 mg/day - Fesoterodine (Toviaz): 4 " 8 mg/day

- Urge incontinence - Pelvic floor rehabilitation and physical therapy as described above (2 " 4)[A] - Bladder retraining (14)[A] - Patient records all voids for 6 " 8 weeks - Patient voids on frequent schedule whether or not experiences urge to void - Teach patients not to rush to toilet - Provide relaxation techniques to suppress urgency to prolong interval between voids - Slowly increase duration between voids to goal interval of 2 " 3 hours

- For collagen, prior skin testing required - Midurethral slings (1 " 2)[A]: - Permanent, synthetic sling - Outpatient procedure or overnight stay - Minimally invasive - Local or minimal regional anesthesia - Low complication rates (urinary retention 2%; sling erosion <1%; de novo urinary urgency 5%) - Success rates: 77 " 96%

- Retropubic colposuspension (1)[A]: - Equal efficacy with midurethral slings but with higher postoperative complications - Sutures placed to stabilize bladder neck - Success rate: 84% at 2 years

  • Urinary incontinence is defined as unacceptable involuntary leakage of urine.
  • Urinary incontinence is rarely life-threatening.Often causes insecurity, embarrassment, depression, social disengagement, sexual dysfunction, and/or psychological and functional decline
  • In 2001, annual direct cost in the US was $12.43 billion.
  • Most common types of urinary incontinence:Stress incontinence:Urethra fails to maintain watertight sealResults in leakage with increases in intra-abdominal pressureUrge incontinence:Episodes of large volume loss secondary to uninhibited detrusor contractionsDisruption of coordinated components of bladder filling and emptyingMixed incontinence:Combination of stress and urge incontinenceApproximately 30% of women presenting with incontinence will have mixed components.Urinary retention:Inability to empty bladder completely with voiding resulting in "overflow " incontinenceFunctional incontinence:Patients with intact lower urinary tract unable/unwilling to reach toilet to voidVisual impairment, limited manual dexterity, and limited mobility

Epidemiology

Incidence

  • Limited information given long latency period
  • Estimate: 7 " 11% in women age <55
  • Estimate: 13 " 34% in women age >50

Prevalence

  • Rates vary based on definition and survey.
  • Only 30 " 45% of women will seek care.
  • Among adult women in the community, prevalence ranges from 9% to 75%.
  • In nursing homes, prevalence at least 50%

Risk Factors

  • Female sex
  • Pregnancy/childbirth
  • Age: Prevalence increases with agePeak prevalence from age 50 to 54
  • Menopause
  • Obesity
  • Smoking
  • Diabetes
  • Chronic increase in intra-abdominal pressure
  • Prior pelvic surgery
  • Cognitive, mobility impairment

50% of pregnant women report incontinence; usually spontaneous resolution after delivery

Pathophysiology

Weakening or injury of pelvic supportive structures (connective tissue, pelvic floor muscles, and nerves)

Etiology

  • Stress incontinenceUrethral hypermobilityLoss of muscular and/or fascial supports compromises ability of urethra to maintain watertight seal with increases in intra-abdominal pressureIntrinsic sphincter deficiencyIntrinsic muscular tone is weakened.Reduces resting urethral tone and resistance to increases in intra-abdominal pressurePharmacologic (alpha-adrenergic blockers)
  • Urge incontinenceMuscularMyogenic changes in detrusor muscle may lead to overactivity/underactivity of bladder.NeurologicPostoperative effectsAgingSpinal cord diseaseMultiple sclerosisDiabetesParkinsonismCerebrovascular accident
  • Urinary retentionOutflow obstruction (uncommon in women)Failure of urethra or pelvic floor to relax during voidingPelvic organ prolapseNeoplasmPrior anti-incontinence proceduresHypotonic bladderDetrusor unable to generate enough pressure to overcome urethral resistanceAutonomic, peripheral neuropathyPharmacologic (anticholinergics, calcium channel blockers, adrenergic agonists, narcotic analgesics)Spinal disorders (disc herniation, spinal stenosis, tumor, congenital abnormalities)Radiation fibrosis
  • Transient causes: Deliriuminfectionpharmacologic (antihypertensives, antidepressants, hypnotics), endocrine (diabetes, hypercalcemia), stool impaction, pregnancy

Associated Conditions

  • Pelvic organ prolapse (29%)
  • Fecal incontinence (~57%)
  • Depression

Diagnosis

History

  • Obtain a complete history to differentiate type of incontinence (1,2)[C]Stress incontinence: Urine leakage with cough, sneeze, laugh, exercise, or exertionUrge incontinence: Uncontrollable urinary urge, large volume accidents, urinary frequency, nocturiaSevere urge with incontinence when hearing running water or placing "key in door "Mixed incontinence: Components of both stress and urge incontinenceUrinary retention: Incomplete emptying, double voiding, voiding difficulty
  • Document severity of symptoms/quantify amount of leakage (1,3,4)[C]Duration of symptomsFrequency and amount of leakagePad use
  • Exacerbating factors (1)[C]
  • Coexisting pelvic floor disorders (1,4)[C]Sensation of bulge or pressure in vagina (pelvic organ prolapse)Urinary tract infections (UTIs)Defecatory dysfunction, fecal incontinence
  • Impact on quality of life (1,3)[C]Actual vs. desired activity levelPsychosocial impact
  • Fluid and caffeine intake (3,4)[C]
  • Prior therapies and effectiveness (physical therapy, Kegel exercises, medications, surgery) (1,4)[C]

Physical Exam

  • Pelvic examination (1 " 4)[C]Assess pelvic organ supportAssess neurologic functionAssess pelvic muscle strength
  • Cough stress test: Objective demonstration of stress incontinence (1,2,4)[C]

Tests

Lab

Urinalysis to rule out infection or diabetes (2)[C], (4)[C]

Surgery

  • Postvoid residual to rule out retention (1,4)[C]
  • Voiding diary (2 " 4)[C]Record number of voids, incontinence episodes with inciting/precipitating factors, and quantified fluid type (e.g., water, coffee)Pad testing for 24 hours (1)[C]
  • Urodynamic testing is not needed for basic or routine evaluation of incontinence (4)[B].Urodynamic evaluation indicated (1,4)[C]:Diagnosis unclear based on history and physical and results may change managementSymptoms not consistent with exam findingsPatient not improved with initial treatmentPrior anti-incontinence surgeryNeurologic disorders (e.g., multiple sclerosis)
  • Cystoscopy and renal ultrasound or CT scan in patients with recurrent UTIs

Differential Diagnosis

See "Etiology "

Treatment

Medication

  • A complete listing of all medication therapies is beyond the scope of this text; please see article by Vij et al. under "Additional Reading. "
  • Stress incontinence: Pharmacotherapy limitedDuloxetine (1)[B]Not FDA approved in the USStarting dose: 20 mg b.i.d. for 2 weeksMaintenance dose: 40 mg b.i.d.
  • Urge incontinenceAntimuscarinics (1)[A]: Efficacy around 60%Do not use in women with narrow angle glaucomaStart at lower dose and titrate based on response after 3 " 4 weeks of therapyStart at the lowest possible dose then increase based on response (2)[C]Similar efficacy among different medications (3)[A]Typical side effects: Dry mouth, constipation, headache, dyspepsia, and dizzinessTolterodine (Detrol):Immediate release (IR) 1 " 2 mg b.i.d. or extended release (ER) 2 " 4 mg/dayOxybutynin (Ditropan):IR 2.5 " 5 mg b.i.d. or ER 5 " 30 mgTransdermal patch: 1 patch changed twice weekly (delivers 3.89 mg/24 hours)Topical gel (sachets): 1 g/dayTrospium (Sanctura):IR 20 mg b.i.d.ER 60 mg/daySolifenacin (Vesicare): 5 " 10 mg/dayDarifenacin (Enablex): 7.5 " 15 mg/dayFesoterodine (Toviaz): 4 " 8 mg/day

Additional Treatment

General Measures

  • Treatment strategy should be based on the severity of symptoms, degree of bother, associated pelvic floor conditions, prior surgery, and patient 's willingness to accept risks and success rates of different interventions (1)[C].
  • For patients with mixed incontinence treat the most bothersome symptom first (1)[C].
  • Observation is appropriate in patients with symptoms not severe enough to start intervention. Treat UTI if found, then reassess symptoms (1)[B].

Issues for Referral

  • Failed conservative or medical management (1 " 2)[C]
  • Prior gynecologic/urologic surgery (2)[C]
  • Recurrent UTIs (2)[C]
  • Associated severe pelvic organ prolapse (2)[C]
  • Postvoid residual >200 mL (2)[C]

Additional Therapies

  • Weight loss (1, 3)[A]
  • Decrease caffeine (1)[A]
  • Decrease fluid intake (2, 3)[C]
  • Smoking cessation (3)[C]
  • Barrier pads (4)[C]Women with mild or refractory symptoms benefit from absorbent pads.Disposable inserts more effective than menstrual pads for small volume incontinence (2)[B]
  • Stress incontinencePelvic floor rehabilitation, Kegel exercises, and physical therapy (14)[A]Regimen: 3 daily sets of 15 squeezes held for 10 secondsNo serious side effectsLong-term success unclearContinence pessary (4)[C]
  • Urge incontinencePelvic floor rehabilitation and physical therapy as described above (2 " 4)[A]Bladder retraining (14)[A]Patient records all voids for 6 " 8 weeksPatient voids on frequent schedule whether or not experiences urge to voidTeach patients not to rush to toiletProvide relaxation techniques to suppress urgency to prolong interval between voidsSlowly increase duration between voids to goal interval of 2 " 3 hours

Surgery

  • Stress incontinenceUrethral bulking agents (collagen, carbon-coated zirconium oxide beads, calcium hydroxyapatite, and ethylene vinyl alcohol) improve urethral coaptation (4)[B]:Outpatient/office cystoscopic procedureSuccess rates: 7 " 83%Results limited to ~12 monthsLow-risk option when surgery contraindicated
  • For collagen, prior skin testing requiredMidurethral slings (1 " 2)[A]:Permanent, synthetic slingOutpatient procedure or overnight stayMinimally invasiveLocal or minimal regional anesthesiaLow complication rates (urinary retention 2%; sling erosion <1%; de novo urinary urgency 5%)Success rates: 77 " 96%Retropubic colposuspension (1)[A]:Equal efficacy with midurethral slings but with higher postoperative complicationsSutures placed to stabilize bladder neckSuccess rate: 84% at 2 yearsArtificial urinary sphincter (1)[B]
  • Urge incontinenceSacral neuromodulation (1)[A]50% improvement 12 months after procedure (2)[A]Cystoscopic Botox detrusor muscle injection (2)[A]

References

1Abrams P, Andersson KE, Birder L. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn. 2010;29(1):213 " 240. (Level III)2Goode PS, Burgio KL, Richter HE. Incontinence in older women. JAMA. 2010;303(21):2172 " 2181. (Level III)3Nygaard I. Clinical practice: Idiopathic urgency urinary incontinence. N Engl J Med. 2010;363(12):1156 " 1162. (Level III)4 ACOG Practice Bulletin No. 63: Urinary incontinence in women. Obstet Gynecol. 2005;105(6):1533 " 1545. (Level III)

Additional Reading

1Rogers RG. Clinical practice: Urinary stress incontinence in women. N Engl J Med. 2008;358(10):1029 " 1036. (Level III)2Sung VW, Hampton BS. Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin North Am. 2009;36(3):421 " 443. (Level III)3Vij M, Robinson D, Cardozo L. Emerging drugs for treatment of urinary incontinence. Expert Opin Emerg Drugs. 2010;15(2):299 " 308. (Level III)

Codes

ICD9

  • 625.6 Stress incontinence, female
  • 788.30 Urinary incontinence, unspecified
  • 788.31 Urge incontinence
  • 788.33 Mixed incontinence (male) (female)
  • 788.34 Incontinence without sensory awareness
  • 788.20 Retention of urine, unspecified
  • 788.38 Overflow incontinence
  • 788.91 Functional urinary incontinence

ICD10

  • N39.3 Stress incontinence (female) (male)
  • N39.41 Urge incontinence
  • R32 Unspecified urinary incontinence
  • N39.46 Mixed incontinence
  • R33.9 Retention of urine, unspecified
  • N39.490 Overflow incontinence
  • R39.81 Functional urinary incontinence

SNOMED

  • 165232002 urinary incontinence (finding)
  • 60241006 female urinary stress incontinence (finding)
  • 87557004 urge incontinence of urine (finding)
  • 413343005 mixed incontinence (finding)
  • 267064002 retention of urine (disorder)
  • 397878005 overflow incontinence of urine (finding)
  • 129847007 functional urinary incontinence (finding)

Clinical Pearls

  • Urinary incontinence is a common, treatable disorder.
  • Few women with incontinence will spontaneously seek help.
  • There are many minimally invasive options for treating urinary incontinence.
  • Incontinence is often associated with pelvic organ prolapse and fecal incontinence.