Urinary incontinence

See also the separate Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women articles.

Urinary incontinence is common and it can have an impact on the physical, psychological and social well-being of those affected, as well as on their families and carers.

Definitions of urinary incontinence¹

Urinary incontinence is the involuntary leakage of urine. The different types of urinary incontinence include:

• Functional incontinence: the patient is unable to reach the toilet in time, for such reasons as poor mobility or unfamiliar surroundings.

• Stress incontinence: involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.

• Urge incontinence: involuntary urine leakage accompanied by, or immediately preceded by, urgency of micturition. This means a sudden and compelling desire to urinate that cannot be deferred. In urge incontinence there is detrusor instability or hyperreflexia leading to involuntary detrusor contraction. This may be idiopathic or secondary to neurological problems such as stroke, Parkinson's disease, multiple sclerosis, dementia or spinal cord injury.² It can sometimes be caused by local irritation due to infection or bladder stones.

• Mixed incontinence: involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.

• Overactive bladder syndrome: urgency that occurs with or without urge incontinence and usually with frequency and nocturia. It may be called 'OAB wet' or 'OAB dry', depending on whether or not the urgency is associated with incontinence. The usual cause of this problem is detrusor overactivity. See the separate Overactive Bladder article.

• Overflow incontinence: usually due to chronic bladder outflow obstruction. It is often due to prostatic disease in men. It can lead to obstructive nephropathy due to back pressure; therefore, early assessment and intervention are required. See the separate Acute Urinary Retention and Chronic Urinary Retention articles. Overflow incontinence may also be due to a neurogenic bladder.

• True incontinence: may be due to a fistulous track between the vagina and the ureter, or bladder, or urethra. There is continuous leakage of urine.

How common is urinary incontinence? (Epidemiology)

• It is difficult to estimate the prevalence of urinary incontinence, due to differences in its definition and also the fact that it is thought that many people won't admit to having continence problems. A population-based cross-sectional postal evaluation of all female patients over 21 years registered at a single medical practice in the UK reported that 40% of respondents experienced urinary incontinence, which caused significant problems in 8.5%. Stress urinary incontinence was the most common problem, whilst 10% had voiding dysfunction. Only 17% had sought professional help, the perception being that incontinence was a natural part of the ageing process.³

• The prevalence in men is largely unknown. Studies have produced figures ranging from 5.3%-45.8% of the population.⁴

• All types of urinary incontinence become more prevalent with age.

• Urinary incontinence is common in adults living in institutions.⁵

Risk factors

• Women:⁶
  

  • Risk factors in women include pregnancy and vaginal delivery (but become less important with age), diabetes mellitus, oral oestrogen therapy and high body mass index.

  • The association between the menopause and urinary incontinence is uncertain. Studies suggest that urinary incontinence sometimes starts at the time of the menopause.¹ Topical oestrogen has been shown to improve incontinence.⁷ However, the effects of oral hormone replacement have been disappointing.⁸

  • Hysterectomy is related to stress urinary incontinence, particularly vaginal hysterectomy.

  • Childbirth can cause anatomical or neuromuscular injury and can damage the pelvic floor muscles. A vaginal delivery, forceps use and babies of a heavier birth weight are all risk factors.⁹ Caesarean section does not necessarily confer protection against urinary incontinence but does reduce it.⁹

• Parity is a risk factor for urinary incontinence in young and middle-aged women.⁹

• Urinary incontinence occurs more frequently in women with urinary tract infections (UTIs).

• Risk factors in men include lower urinary tract symptoms (LUTS), infections, functional and cognitive impairment, neurological disorders and prostatectomy.

• Neurological disease/organic brain damage can be a risk factor for incontinence in men and women - eg, stroke, dementia and Parkinson's disease.²

• Cognitive impairment increases the risk in both sexes. However, mild loss of cognitive function is not a risk factor for urinary incontinence but does increase the impact of urinary incontinence.

• Obstruction, including an enlarged prostate gland in men and pelvic tumours in women, can lead to incontinence.

• Stool impaction may be implicated in elderly patients.¹⁰

Assessment¹¹

See also the separate Gynaecological History and Examination, Genitourinary History and Examination (Female) and Genitourinary History and Examination (Male) articles.

History

• From the history, determine what type of urinary incontinence the patient has: stress, urge or mixed. If mixed, treatment should be directed towards the most prominent symptoms. Questions in the history can include:
  

  • Stress incontinence: leakage of urine on sneezing, coughing, exercise, rising from sitting, or lifting.

  • Urge incontinence: urgency and failure to reach a toilet in time.

  • Frequency of urine during the day/at night.

  • Dribbling of urine after leaving the toilet.

  • Loss of bladder control.

  • Feeling of incomplete bladder emptying.

  • Dysuria: pain or burning sensation on passing urine.

  • Bladder spasms.

• When assessing urinary incontinence in neurological disease, consider factors likely to affect management, such as mobility, hand co-ordination, cognitive function, social support and lifestyle.²

• A full obstetric history should be taken in women.

• The patient should be asked, during their initial assessment, to complete a bladder chart for a minimum of three days. These should include both working days and days off.

• Enquire about sexual dysfunction and quality of life.

• Assess functional status and access to toilet.

• Establish whether any medication contributes to symptoms.

• Enquire about bowel habit.

• Enquire about desire for treatment.

Examination

Women

• Perform digital assessment of pelvic floor muscle contraction.

• Perform a bimanual/vaginal examination to assess for the presence of prolapse. See the separate Genitourinary Prolapse article.

• Look for signs of vaginal atrophy.

• Abdominal, pelvic and neurological examination should also be performed.²

Men

• Perform digital rectal examination to assess prostate shape, size and consistency and to check for other rectal pathology.

• Digital anal assessment can be used to give an indication of pelvic floor muscle strength in men.

• Abdominal, pelvic and neurological examination should also be performed.²

Investigations in primary care¹¹

The National Institute for Health and Care Excellence (NICE) suggests the following for women. It would be reasonable to follow the same guidelines in men.

• Urinary dipstick testing:
  

  • Perform a urinary dipstick test to look for blood, glucose, protein, leukocytes and nitrites.

  • If a woman has symptoms of a UTI and dipstick testing shows leukocytes and nitrites, send an MSU for culture and sensitivities. Prescribe antibiotics whilst waiting for results.

  • Also send an MSU in other women with symptoms of UTI but negative urine dipstick testing. Consider antibiotics whilst waiting for results.

  • If a woman has no symptoms of UTI but positive dipstick testing for leukocytes and nitrites, send an MSU but don't start antibiotics until results are available.

  • If a woman has no symptoms and negative dipstick testing for nitrites and leukocytes, no MSU is needed.

  • Renal function tests may be indicated.

• Assessment of residual urine:
  

  • Post-void residual volume should be measured in women who have symptoms suggesting voiding dysfunction or recurrent UTI. This is best performed using a bladder scan. Catheterisation may also be used.

  • Post-void residual volume should also be measured in men.²

• Urinary flow rates:
  

  • Assessment of urinary flow rates is disputed for most cases. They may be measured in men and in patients of either sex with neurological disease.²

• Other investigations:
  

  • Urodynamic studies: urodynamic testing including multi-channel cystometry, ambulatory urodynamics or video urodynamics is not recommended before starting conservative treatment in women. However, these investigations may be carried out before surgery for urinary incontinence.

  • Multi-channel filling and voiding cystometry should not be performed in women in whom pure stress or stress-predominant mixed urinary incontinence is identified by history and examination.

  • Perform multichannel filling and voiding cystometry before surgery for stress urinary incontinence in women who have any of the following:

    • Urge-predominant mixed urinary incontinence or urinary incontinence in which the type is unclear.

    • Symptoms suggestive of voiding dysfunction.

    • Anterior or apical prolapse.

    • A history of previous surgery for stress urinary incontinence.

  • Ambulatory urodynamics or videourodynamics should be considered if the diagnosis remains unclear after conventional urodynamics.

  • Cystoscopy is not recommended in the initial assessment of women with urinary incontinence alone.

  • No imaging techniques are recommended in the initial assessment in women, except for ultrasound assessment of residual volume. However, ultrasound of the kidneys is indicated in men and women with neurological disease where renal complications could occur (eg, spina bifida, spinal cord injury).²

When to refer directly to secondary care

Women¹¹

A suspected cancer referral should be made for women who have urinary incontinence in association with features suggestive of bladder or renal cancer.¹²

Consider referral to secondary care if:

• There is persisting bladder or urethral pain.

• There are clinically benign pelvic masses.

• There is associated faecal incontinence.

• There is suspected neurological disease.

• There are symptoms of voiding difficulty.

• Urogenital fistulae are suspected.

• Previous continence surgery has taken place.

• Previous pelvic cancer surgery has taken place.

• Previous pelvic radiation therapy has taken place.

Men¹³

• If there are any criteria present that meet the suspected cancer referral in men, appropriate referral should be made.

• NICE recommends referral for men with LUTS complicated by recurrent or persistent UTI, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer.

Treating urinary incontinence

Temporary containment products (eg, pads or collecting devices) to achieve social continence should be offered until there is a specific diagnosis and management plan.

The permanent use of containment products should only be considered after assessment and exclusion of other methods of management.

If such products are used, an annual review is advised which should include skin integrity, changes in the patient's life (eg, medication, lifestyle), other options for treatment and efficiency of absorbance.

Urge incontinence and overactive bladder syndrome

See the separate Overactive Bladder article.

Stress incontinence

NICE suggests the following management in women:¹¹

• Pelvic floor muscle exercises:

  • A three-month trial of pelvic floor muscle exercises is the first-line treatment (subsequent to digital assessment of pelvic muscle contraction).

  • This should include eight contractions, three times a day.

  • Continue if successful.

  • Consider electrical stimulation and/or biofeedback in women who cannot actively contract pelvic floor muscles.

  • Provide the patient with a patient information leaflet about pelvic floor exercises.

  • Pelvic floor muscle exercises may be used in men with stress incontinence and in men who have undergone radical prostate surgery. They are also useful for patients of both sexes with stress incontinence due to multiple sclerosis or stroke.²

• Drug treatment:
  

  • Duloxetine should not be used as first-line treatment. It may be considered as second-line treatment in women who do not want surgery or who are unsuitable for surgery. Counselling about adverse effects is important.

• Surgical treatment:

• If conservative measures fail, consider:

  • Open colposuspension.

  • Autologous rectus fascial sling.

• • With increasing use of the retropubic mesh sling procedure, various complications have come to light. These include pelvic/abdominal/perineal/leg/groin pain; dyspaerunia and penile trauma on intercourse; abnormal vaginal discharge and bleeding; urinary and faecal incontinence; and other bladder and bowel disturbance.

  • In the light of these, NICE has amended its guidance:

    • Only offer 'top-down' retropubic mid-urethral mesh sling or single-incision sub-urethral short mesh sling insertion as part of a clinical trial.

    • Women considering a retropubic mesh sling procedure should be advised that it is a permanent implant and complete removal may not be possible.

    • After mesh surgery, women should be given the name, manufacturer, date of insertion, and the implanting surgeon's name and contact detail.

    • Synthetic tapes should be selected which are made from type 1 macroporous polypropylene material and are coloured for high-visibility colour.

    • The transobturator foramen approach should not be used unless there are specific clinical indications (eg, previous surgery precluding a retropubic approach).

    • Postoperative follow-up is important and women should be advised of the other surgical and non-surgical options available, in the event of treatment failure.

  • Autologous slings should be used in preference to synthetic tape in patients with neurological disease, due to the risk of urethral erosion.²

  • Patients should be offered a six-month follow-up appointment (including vaginal examination to exclude cervical erosion).

  • Intramural bulking agents (eg, glutaraldehyde cross-linked collagen, silicone) may be considered if conservative management has failed. However, their efficacy reduces with time, repeat injections may be needed and they are not as effective as retropubic suspension/sling procedures.¹⁴

  • NICE supports the use of intramural injectables, implanted adjustable compression devices and male slings to manage stress urinary incontinence in men but only as part of randomised controlled trials.¹³ The European Association of Urology guidelines also suggest the use of bulking agents, although the evidence suggests only short-term benefit.¹⁴

  • An artificial sphincter should generally only be considered if previous surgery has failed. Post-procedure, offer a follow-up appointment and access to review. The procedure may be considered first-line in neurological disease if another procedure such as a sling is considered less likely to promote continence.²

  • There is limited evidence to support the use of artificial urinary sphincters or slings for the specialised management of stress incontinence in men.¹⁴

  • If laparoscopic colposuspension is used, the surgeon must be experienced and working in an experienced urogynaecological multidisciplinary team.

  • Anterior colporrhaphy, needle suspensions, paravaginal defect repair and the Marshall-Marchetti-Krantz procedure are not recommended by NICE for the treatment of stress incontinence.

Transvaginal laser therapy

NICE has assessed the use of transvaginal laser therapy for stress urinary incontinence.¹⁵ They conclude that while evidence does not show any short-term safety concerns, evidence on long-term safety and efficacy is inadequate in quality and quantity. As a result, they recommend that this procedure should only be used in the context of research.

Mixed incontinence¹⁶

In mixed urinary incontinence, treatment should be directed towards the predominant symptom but may involve a combination of approaches.

• Pelvic floor exercises and bladder training, as above, are first-line treatment, both in men and in women.¹⁷

• An antimuscarinic drug can be started if these are not effective. Oxybutynin has traditionally been used as first-line, but all antimuscarinics are equally effective. Oxybutynin should be avoided in the elderly as it may adversely affect cognitive performance.

• Newer antimuscarinic drugs such as darifenacin, solifenacin, tolterodine and trospium are alternatives. Extended-release or transdermal oxybutynin are other possibilities.

• Fesoterodine and propiverine are more recent antimuscarinics also licensed for this use.¹⁸

• Antimuscarinics are useful in the management of patients with neurological disease affecting the brain (eg, cerebral palsy) and overactive bladder syndrome and in those with bladder storage disorders. They should, however, be used with caution, as they can cause constipation, urinary retention and confusion.²

• Annual review should be undertaken of patients on long-term medication (six-monthly for women aged over 75 years).¹¹

• In women with predominantly stress incontinence, NICE recommends discussing conservative options including drugs, before considering surgery.¹¹

Overflow incontinence

• Overflow incontinence due to bladder outlet obstruction should be managed by relieving/treating the obstruction.

• Intermittent self-catheterisation may be carried out.

• If there is obstruction due to prostatic hypertrophy (benign or malignant), this should be managed appropriately. See the separate Benign Prostatic Hyperplasia and Prostate Cancer articles.

Catheterisation

See also the separate Catheterising Bladders article. NICE suggests the following:¹³

• Intermittent catheterisation or indwelling urethral or suprapubic catheterisation may be needed for some patients - eg, if there is persistent urinary retention leading to incontinence, if there is renal impairment or if there are symptomatic infections.

• Women with urinary retention may be taught to perform intermittent urethral self-catheterisation.

• Indwelling catheters (either urethral or suprapubic) may be indicated if:
  

  • There is chronic urinary retention and the person cannot perform self-catheterisation.

  • Skin wounds, pressure sores or skin irritations are being contaminated by urine.

  • There is distress or disruption caused by changing clothes and the bed.

  • A woman would like this form of management.

• Suprapubic catheters may have lower complication rates, including lower rates of symptomatic UTI and by-passing.

Other management points¹¹

• If someone has cognitive impairment, they should follow a prompted and timed toileting programme.

• Patients with neurological disease may also benefit from bladder retraining or habit retraining after assessment by a healthcare professional trained in such techniques. Carers/families should - with the patient's consent - be involved.²

• Botulinum toxin type A is sometimes used in some patients with neurological disease - eg, those with spinal cord disease and overactive bladder or impaired bladder storage. Recently, NICE has recommended a starting dose of 100 rather than 200 units in botulinum-naive women and early review (three months rather than six months after injection).

• Augmentation cystoplasty using an intestinal segment may be offered to patients with non-progressive neurological disease and impaired bladder storage.

• Ileal conduit diversion (urostomy) with or without cystectomy may be considered for patients whose neurological disease causes intractable problems.

• Desmopressin may be prescribed in women with troublesome nocturia. It should be used with caution in women with cystic fibrosis, reduced renal function and/or cardiovascular disease and is contra-indicated in cardiac insufficiency and other conditions requiring treatment with diuretic agents. Its use in idiopathic urinary incontinence is outside its UK licence and women should be informed of this.

• NICE does not recommend the following for the treatment of urinary incontinence:
  

  • Propiverine, flavoxate, imipramine or propantheline.

  • Systemic hormone replacement therapy.

  • Complementary therapies.

• Give patients the opportunity to return for review in the future to discuss investigations and management options, even if no treatment is wanted currently.

Preventing urinary incontinence

• Early versions of the NICE guidance on urinary incontinence recommended offering all women pelvic floor muscle training in their first pregnancy. This has disappeared from the latest version without comment.¹¹ This is possibly due to the latest Cochrane review which finds greater efficacy for a targeted approach (for example, in those with a higher BMI) rather than a population-based approach.¹⁹

• Weight control may reduce the risk of developing incontinence.