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

Urinary incontinence is common and it can have an impact on the physical, psychological and social wellbeing of sufferers, as well as their families and carers.¹

Definitions

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

• Functional incontinence, which is when the patient is unable to reach the toilet in time for such reasons as poor mobility or unfamiliar surroundings.
• Stress incontinence, which is involuntary leakage of urine on effort or exertion, or on sneezing or coughing.¹ This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.
• Urge incontinence, which is 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.¹ 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. It can sometimes be caused by local irritation due to infection or bladder stones.
• Mixed incontinence, which is involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.¹
• Overactive bladder syndrome (OAB), which is 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.¹ See also the separate article Detrusor Instability and Irritable Bladder.
• Overflow incontinence, which is 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 also the separate articles Acute Urinary Retention and Chronic Urinary Retention. Overflow incontinence may also be due to a neurogenic bladder.
• True incontinence, which may be due to a fistulous track between the vagina and the ureter, or bladder, or urethra. There is continuous leakage of urine.

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.²
• Urinary incontinence, or urine loss occurring at least once during the previous 12 months, has been estimated as occurring in 5-69% of women and 1-39% of men. In general, urinary incontinence is twice as common in women as in men.³
• The prevalence increases with age. It is estimated that 46% of women and 34% of men aged over 80 years have urinary incontinence.^4,5 In a recent cohort study of individuals aged over 85 years, severe or profound urinary incontinence was reported by 21%.⁶
• It is estimated that fewer than half of adults with moderate or severe urinary incontinence seek help from healthcare providers.²
• The prevalence of urinary incontinence for adults living in institutions is as high as 50%.⁷

Risk factors

• Women:
  • 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. Menopause does not appear to be a risk factor and the evidence for hysterectomy is conflicting.^3,8,9,10
  • Childbirth can cause anatomical or neuromuscular injury and can damage the pelvic floor muscles.⁷ A vaginal delivery, parity, the use of forceps, and babies of a heavier birthweight are all risk factors.^11,12,13 Caesarean section may be partly protective.^14,15
• Risk factors in men include lower urinary tract symptoms (LUTS), infections, functional and cognitive impairment, neurological disorders and prostatectomy.^2,3
• Neurological disease/organic brain damage can be a risk factor for incontinence in men and women, e.g. stroke, dementia and Parkinson's disease.
• 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.³
• Obstruction, including enlarged prostate in men and pelvic tumours in women, can lead to incontinence.
• Stool impaction may be implicated in elderly patients.⁷

Assessment¹

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

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:²
  • 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.
• A full obstetric history should be taken in women.
• The patient should be asked during their initial assessment to complete a bladder diary for a minimum of three days. These should include both working days and days off. An example of a bladder diary can be found in Annex 2 of the Scottish Intercollegiate Guidelines Network (SIGN) guidelines.²
• Enquire about sexual dysfunction and quality of life.²
• Assess functional status and access to toilet.²
• Does any medication contribute to symptoms?
• Enquire about bowel habit.
• Enquire about desire for treatment.³

Examination

• Women:
  • Perform digital assessment of pelvic floor muscle contraction.
  • Perform a bimanual/vaginal examination to assess for the presence of prolapse. Please refer to the separate Genitourinary Prolapse article for more details about this examination.
  • Look for signs of vaginal atrophy.³
  • Abdominal, pelvic and neurological examination should also be performed.³
• Men:
  • Perform digital rectal examination to assess prostate shape, size and consistency and to check for other rectal pathology.²
  • Digital anal assessment can be used to give an indication of pelvic floor muscle strength in men.²
  • Abdominal, pelvic and neurological examination should also be performed.³

Investigations in primary care

The National Institute for Health and Clinical Excellence (NICE) suggests the following for women.¹ 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 urinary tract infection (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 women 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.¹
  • Post-void residual volume should also be measured in men.²
• Urinary flow rates:
  • Assessment of urinary flow rates is disputed. They may be measured in men.²
• Other investigations:
  • Urodynamic studies: urodynamic testing including 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.¹
  • Cystoscopy is not recommended in the initial assessment of women with urinary incontinence alone.¹
  • No imaging techniques are recommended in the initial assessment in women, except for ultrasound assessment of residual volume.¹

When to refer directly to secondary care

Women¹

Men²

• SIGN guidelines state that men with reduced urinary flow rates (<15 ml/second) or elevated post-void residual volumes (>100 mls) should be referred to secondary care. Local protocols may be in use.
• If there are any criteria present that meet the 2-week 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.¹⁶

Management

Temporary containment products (e.g. 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.^1,16

Urge incontinence and overactive bladder syndrome

See separate Detrusor Instability and Irritable Bladder article.

Stress incontinence

NICE suggests the following management in women:

• Pelvic floor muscle exercises:
  • A 3-month trial of pelvic floor muscle exercises is the first-line treatment.
  • 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.
• 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.
• Surgical treatment:
  • Retropubic mid-urethral tape procedures using a 'bottom-up' approach with macroporous (type 1) polypropylene meshes are recommended if conservative treatment has failed.
  • Alternative procedures are open colposuspension and autologous rectal fascial sling. Biological slings are recommended by NICE as a treatment option for stress urinary incontinence in women.¹⁷
  • If synthetic slings using a retropubic 'top-down' or a transobturator foramen approach are used, women should be informed of the lack of long-term outcome data.
  • Intramural bulking agents (e.g. glutaraldehyde cross-linked collagen, silicone) may be considered if conservative management has failed.¹⁸ However, their efficacy reduces with time, repeat injections may be needed and they are not as effective as retropubic suspension/sling procedures.
  • An artificial sphincter should only be considered if previous surgery has failed.
  • If laparoscopic colposuspension is used, the surgeon must be experienced and working in an experienced urogynaecology multidisciplinary team.
  • Anterior colporrhaphy, needle suspensions, paravaginal defect repair and the Marshall-Marchetti-Krantz procedure are not recommended for the treatment of stress incontinence by NICE.

Pelvic floor muscle exercises may also be used in men with stress incontinence and in men who have undergone radical prostate surgery.² NICE supports the use of suburethral synthetic sling insertion for stress urinary incontinence in men.¹⁹ The European Association of Urology Guidelines also suggest the use of bulking agents and artificial urinary sphincter for the specialised management of stress incontinence in men.³

Mixed incontinence

In mixed urinary incontinence, treatment should be directed towards the predominant symptom but may involve a combination of approaches.⁶

• Pelvic floor exercises and bladder training, as above, are first-line treatment in both men and women.²
• Oxybutynin can be started if these are not effective.
• Darifenacin, solifenacin, tolterodine, trospium, or extended-release or transdermal oxybutynin are alternatives if oxybutynin is not well tolerated.
• Regular review should be undertaken.

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. Please refer to the separate articles Benign Prostatic Hyperplasia and Prostatic Carcinoma for more details.

Catheterisation^1,16

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

• Intermittent catheterisation or indwelling urethral or suprapubic catheterisation may be needed for some patients, e.g. 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 points

• If someone has cognitive impairment, they should follow a prompted and timed toileting programme.
• Desmopressin may be prescribed in women with troublesome nocturia.¹ However, its use in idiopathic urinary incontinence is outside its UK license and women should be informed of this.
• Hormone replacement therapy or complementary therapies are not recommended for the treatment of urinary incontinence.¹
• NICE does NOT recommend the following for the treatment of urinary incontinence:¹
  • Propiverine, flavoxate, imipramine or propantheline.
  • Systemic hormone replacement therapy.
  • Complementary therapies.

Prevention

• Offer all women pelvic floor muscle training in their first pregnancy.¹
• Weight control may reduce the risk of developing incontinence.

Document references

1. Urinary incontinence: the management of urinary incontinence in women, NICE (2006)
2. Management of urinary incontinence in primary care, Scottish Intercollegiate Guidelines Network (SIGN), 2005
3. Guidelines on urinary incontinence, European Association of Urology (2009)
4. MacLennan AH, Taylor AW, Wilson DH, et al; The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000 Dec;107(12):1460-70. [abstract]
5. Stoddart H, Donovan J, Whitley E, et al; Urinary incontinence in older people in the community: a neglected problem? Br J Gen Pract. 2001 Jul;51(468):548-52. [abstract]
6. Thirugnanasothy S; Managing urinary incontinence in older people. BMJ. 2010 Aug 9;341:c3835. doi: 10.1136/bmj.c3835.
7. Norton P, Brubaker L; Urinary incontinence in women. Lancet. 2006 Jan 7;367(9504):57-67. [abstract]
8. Sampselle CM, Harlow SD, Skurnick J, et al; Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstet Gynecol. 2002 Dec;100(6):1230-8. [abstract]
9. Holtedahl K, Hunskaar S; Prevalence, 1-year incidence and factors associated with urinary incontinence: a population based study of women 50-74 years of age in primary care. Maturitas. 1998 Jan 12;28(3):205-11. [abstract]
10. Townsend MK, Danforth KN, Rosner B, et al; Body mass index, weight gain, and incident urinary incontinence in middle-aged women. Obstet Gynecol. 2007 Aug;110(2 Pt 1):346-53. [abstract]
11. Van Kessel K, Reed S, Newton K, et al; The second stage of labor and stress urinary incontinence. Am J Obstet Gynecol. 2001 Jun;184(7):1571-5. [abstract]
12. Mason L, Glenn S, Walton I, et al; The prevalence of stress incontinence during pregnancy and following delivery. Midwifery. 1999 Jun;15(2):120-8. [abstract]
13. Rortveit G, Hannestad YS, Daltveit AK, et al; Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol. 2001 Dec;98(6):1004-10. [abstract]
14. Rortveit G, Daltveit AK, Hannestad YS, et al; Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med. 2003 Mar 6;348(10):900-7. [abstract]
15. Wilson PD, Herbison RM, Herbison GP; Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol. 1996 Feb;103(2):154-61. [abstract]
16. Lower urinary tract symptoms, NICE Clinical Guideline (May 2010); The management of lower urinary tract symptoms in men
17. Insertion of biological slings for stress urinary incontinence, NICE (2006)
18. Intramural urethral bulking procedures for stress urinary incontinence, NICE (2005)
19. Suburethral synthetic sling insertion for stress urinary incontinence in men, NICE Interventional Procedure Guideline (March 2008)

Internet and further reading

• Surgical treatment of urodynamic stress incontinence, Royal College of Obstetricians and Gynaecologists (2004)

Acknowledgements