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Urinary Incontinence

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Overview

Urinary incontinence describes the involuntary passage of urine and is relatively common, especially in older women. It can be the result of functional abnormalities in the lower urinary tract or disorders that tend to cause urinary leakage such as infection or neurologic pathology.

Epidemiology

  • The prevalence of urinary incontinence increases until 50-70 years of age and levels out before rising again after 70 years
  • Urinary incontinence is more common in women than men

Types and Features

Urge incontinence

Urge incontinence describes a sudden sense of urgency (the patient suddenly feels an intense need to pass urine that cannot be delayed) followed by involuntary urination.

It is part of a larger symptom complex known as overactive bladder syndrome (OAB), which is urinary urgency associated with increased frequency and nocturia in the absence of a urinary tract infection (UTI) or other obvious pathology. OAB with incontinence is known as ‘OAB wet’ and if incontinence is not present, this is known as ‘OAB dry’.

The cause of urge incontinence is bladder detrusor muscle instability or hyperreflexia leading to involuntary detrusor contraction. This is idiopathic in most cases, but can be secondary to a neurological disorder such as stroke, multiple sclerosis, spinal cord injury, dementia, or Parkinson’s disease.

Stress incontinence

Stress incontinence describes the loss of urine during activities that increase intra-abdominal pressure (such as laughing, coughing, or sneezing. This occurs due to weak pelvic floor muscles being unable to support and keep the urinary sphincter closed.

Risk factors include increasing age, pregnancy and vaginal delivery, obesity, pelvic organ prolapse, family history, smoking, and drugs that can cause coughing (e.g. angiotensin-converting enzyme inhibitors).

Mixed incontinence

Mixed incontinence has features of both urge and stress incontinence.

Overflow incontinence

Overflow incontinence describes the involuntary leakage of urine in people with chronic bladder outlet obstruction without the urge to pass urine. Urine accumulates in the bladder slowly and eventually overwhelms the urethral sphincter and leaks out.

This can cause obstructive uropathy and hydronephrosis and should be managed accordingly. Its causes can include causes of urinary retention, such as neurologic damage and anticholinergic drugs.

Continuous (true) urinary incontinence

Continuous (or true) urinary incontinence describes a constant loss of urine. This may be present in severe overflow incontinence or due to underlying structural abnormalities such as fistulae.

Functional incontinence

Functional urinary incontinence describes the involuntary passage of urine when a person recognises the need to pass urine, but cannot reach the toilet in time. Its causes can include confusion, dementia, reduced mobility, using sedative drugs, or unfamiliar surroundings.

Situational incontinence

Situational incontinence describes the involuntary passage of urine during specific activities that cannot be classed into another type. This can include sexual activity, changing body position, or giggling/laughter. 

History Taking

Overview

  • Identify the type of urinary incontinence:
    • Stress incontinence:
      • Does incontinence occur when coughing, sneezing, straining, or laughing?
    • Urge incontinence:
      • Do they feel a sudden and intense need to pass urine?
      • Do they make it to the toilet in time?
    • Overflow incontinence:
      • Do they have difficulties passing urine (such as straining, feeling of incomplete emptying)?
    • Continuous (true) incontinence:
      • Does urine leak continuously or intermittently depending on position? (may suggest a fistula, such as a vesicovaginal fistula)
    • Functional incontinence:
      • Are they able to get to the toilet in time?
      • Is there anything that they feel stops them from being able to get to the toilet? 
  • Ask about the severity of incontinence:
    • How often are they incontinent?
    • Do they use pads or change clothing?
    • Are they avoiding usual activities due to incontinence?
    • How has this affected their life?
  • Screen for other features of urological disorders:

Assessment and Investigations

Physical examination

Examinations to consider include:

  • General examination:
    • To screen for features of neurologic disease (e.g. gait problems)
  • Abdominal examination:
    • To screen for a palpable bladder or mass
  • Pelvic examination
    • To screen for involuntary leakage when asking the person to cough and to assess pelvic muscle tone and contraction by asking the patient to squeeze the examining finger

Investigations

Initial tests include:

  • Bladder diary for 3 days:
    • May help with identifying the type of incontinence present
  • Urine dipstick and culture:
    • May identify blood, protein, leukocytes, and nitrites
    • To screen for infection
  • Urea and electrolytes:

Other tests may involve:

  • Residual urine assessment:
    • For people who have features suggesting problems with passing urine or recurrent UTI
    • Measures how much urine remains in the bladder after micturition
    • This may be done via ultrasound or may require catheterisation
  • Urodynamic testing:
    • If other initial tests are inconclusive
    • Generally performed before surgery for urinary incontinence and not routinely performed for people who are treated conservatively 

Management

Referral

If features of renal cell cancer or bladder cancer are present, urgently refer to secondary care in line with the NICE guidelines.

A referral may be considered in some people, such as if any of the following apply:

  • Associated faecal incontinence
  • Neurologic disease
  • Voiding difficulty
  • Fistulae are suspected
  • Previous surgery for urinary incontinence
  • Previous pelvic cancer surgery or radiotherapy
  • Persistent bladder/urethral pain
  • Pelvic masses that do not warrant an urgent referral to secondary care
  • A history of chronic urinary retention and overflow incontinence

Treatment

For those that do not require a referral, management in primary care depends on the predominant type of urinary incontinence:

  • Predominantly urge incontinence:
    • 1st-line: offer bladder training for at least 6 weeks – this involves training to increase the time periods between passing urine
    • If unsuccessful, continue bladder retraining and consider drug treatment:
      • 1st-line: antimuscarinics (e.g. oxybutynin, tolterodine, or darifenacin)
      • If an antimuscarinic is not appropriate, mirabegron (beta-3 agonist) may be considered.
  • Predominantly stress incontinence:
    • 1st-line: offer pelvic floor muscle training for at least 3 months
      • At least 8 pelvic floor muscle contractions 3 times a day should be done
    • If the above fails or the person wants further management consider:
      • Refer to secondary care for surgery
      • If the person does not want surgery: offer duloxetine

Complications

  • Reduced quality of life
  • Psychological problems (e.g. anxiety, depression, embarrassment)
  • Social isolation (e.g. if people avoid going to places where finding a bathroom is difficult)
  • Sexual problems
  • Reduced sleep – particularly in people with nocturia
  • Falls and fractures
  • Long-term anticholinergic therapy is associated with increased dementia and cognitive decline

Prognosis

  • Depends on the type of urinary incontinence, its severity, and its underlying cause
  • Combinations of different treatment options may be beneficial

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