Urinary Incontinence

Related articles include lower urinary tract symptoms in women, lower urinary tract symptoms in men, urinary frequency and nocturnal enuresis in children. Faecal incontinence is not included here.

In October 2006, NICE released clinical guidance on the management of urinary incontinence in women. It did not address the problem in men but women represent by far the majority of sufferers, especially amongst younger adults and in middle age. This article will borrow heavily from the NICE recommendations. In December 2004, SIGN published guidance for the management in primary care of urinary incontinence in both men and women.

There are several different types of urinary incontinence:

• Functional incontinence is when the patient is unable to reach the toilet in time for such reasons as poor mobility or unfamiliar surroundings.
• Stress incontinence is involuntary leakage of urine on effort or exertion or on sneezing or coughing.
• Urge incontinence is involuntary urine leakage accompanied or immediately preceded by urgency. This means a sudden and compelling desire to urinate that cannot be deferred.
• Mixed incontinence is involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.
• Neuropathic incontinence may be due to detrusor instability, with or without incompetence of the sphincter. It may occur in multiple sclerosis, stroke, Parkinson's disease, dementia and diabetes.
• Overflow incontinence is due to chronic bladder outflow obstruction. It is often due to prostatic disease in men. It can rapidly lead to obstructive nephropathy due to back pressure and so early assessment and intervention is vital.

Of these types of incontinence, stress incontinence, detrusor instability and mixed type are the most important and will receive the most attention. NICE defines overactive bladder syndrome (OAB) as urgency that occurs with or without urge incontinence and usually with frequency and nocturia. It may be called OAB wet or OAB dry depending upon whether or not the urgency is associated with incontinence. The usual cause of these problems is detrusor overactivity, but it can result from other forms of urethrovesical dysfunction.

Surveys of prevalence have to be interpreted with care because of different criteria for what constitutes a diagnosis of urinary incontinence.

The prevalence of urinary incontinence increases with age. In men it tends to be confined to the later years when benign prostatic hyperplasia is common or almost invariable. In women, it is very much more common and occurs at a much earlier age. It is found in approximately half of those living in residential nursing homes and is reported by 15 to 30% of women over the age of 30 years.

A questionnaire was given to women attending primary care at a cross-section of sites across Britain and 3,273 responded, giving a rather low uptake of 54%.¹ Stress incontinence only had been experienced by 21% at some time in the past month. Urge incontinence only was reported by 3.5% and 21% reported mixed stress and urge incontinence in the past month. Symptoms were moderate or severe in 9%. There had been no consultation on the subject in 53% of those affected. This is equivalent to 1 in 20 of women in GP waiting rooms, most of whom have stress and urge incontinence (75%) or stress incontinence only (21%). Even amongst the nearly 1 in 10 women with moderate or severe incontinence, only about half had sought help. There is a vast, hidden problem in the community.

A similar figure of only half of women seeking help, even when they recognise the problem as significant, was reported a few years earlier.² Half of the women who did consult their GP did not find the treatment offered helpful. Perhaps a better understanding of the management of incontinence from within primary care would improve the uptake of the services and result in more successful outcomes.

A study from Sweden looked at the younger age group.³ They questioned just under 3,500 women aged 18 to 70. Overall they found a prevalence of urinary incontinence of 26% but the figure was 12% for those under 30 years of age.

A study of the elderly, but living independently, in Holland⁴ found that when patients perceive their incontinence as not very serious or distressing and have a lack of knowledge about cause and treatment options, they usually do not seek help. When they perceive an increase in severity or distress or require incontinence materials, they usually do seek help.

A study from Bristol⁵ of men and women over 65 years old found that 31% of women and 23% of men had been incontinent in the past month. Presentation with the problem was low.

• The most important risk factor is being female.
• In both males and females, prevalence increases with age.
• Neurological disease including stroke and dementia.
• Cognitive impairment increases the risk in both sexes.
• Obstruction including enlarged prostate and pelvic tumours in women.
• Vaginal delivery of a baby, especially if traumatic, almost certainly increases risk.⁶ A study from Scotland⁷ found that whilst caesarian section was protective, that forceps delivery and an infant of more than 4kg did not have an adverse influence. Prolonged labour and episiotomy were of doubtful signficance. There are also contradictory results in other papers. The implications for obstetric practice will not be discussed here.
• Prostate surgery is a risk factor for men.

The history is extremely important in deciding the aetiology, and hence the management of the condition.

• How long has the problem existed? Is it static or deteriorating?
• What leads to the loss of urine?
  • In the functional type described above it is simply being unable to get to the toilet on time.
  • Is there a cough or sneeze or sudden exertion that causes the problem?
  • Is it when walking or perhaps on getting out of bed, when the feet touch the floor?
  • Is there a sudden and irresistible urge to pass urine?
• Is only a small amount of urine lost or is it a large amount as if the whole bladder empties?
• Ask about obstetric history with particular regard to:
  • Number of vaginal deliveries
  • Any difficulties including instrumental delivery
  • Size of babies. As noted above, the importance of some of these factors is debated.
• When there is not a problem of incontinence, can she hold urine for several hours to pass a large volume or does she have to urinate every hour or two, managing to hold only a small volume?
• Is there nocturia? How many times a night?
• Ask about how the condition affects quality of life. Does she wear pads as a matter of routine? Does she restrict fluid intake? There are a number of validated quality of life scales that can be used⁸ but they are not available free of charge to be downloaded from the Internet as there are issues of copyright and intellectual property.

After taking a history, even without examination, NICE suggests that it should be possible to categorize the incontinence. This will usually be one of:

• Stress Incontinence
• Urge incontinence including OAB syndrome
• Mixed incontinence

When there is a mixed aetiology, management should be directed towards the dominant symptom.

Examination

The basics of abdominal examination are described in the article of that name. Attention is required to a possible large bladder arising from the pelvis and abdominal masses. Examining a woman for prolapse is described in postmenopausal cystourethritis. In a man, digital rectal examination to assess the prostate is required. In old people, beware of the problem of faecal impaction.

• In addition, NICE recommends that an attempt should be made to assess the pelvic floor musculature, at least before pelvic floor exercises are started.
• If there is demonstrable utero-vaginal prolapse, referral should be made.
• If the bladder is palpable, ask her to empty it. If it remains palpable, referral is required.

NICE suggest that a woman should be asked to keep a bladder diary. In view of day to day variation they suggest that 3 days should be the duration and it should include both working and rest days. The SIGN guidelines in the list at the end includes annex 1 on page 32 that is the international consultation on incontinence questionnaire to ask patients about symptoms and annex 2 that is sample of a urine diary. It is helpful, but not essential that the patient gives volumes of amount drunk and urine passed but estimates such as "mug of coffee", "large volume of urine" and "incontinence++" are still useful.

A midstream urine to check for infection should be routine. Also check for glucose, albumin and blood.

NICE advises that pad testing is not recommended and cystoscopy is not required unless there is a specific indication. If residual urine volume is to be measured, ultrasound is preferred.

Other investigations that are often undertaken include multi-channel cystometry, ambulatory urodynamics or videourodynamics. NICE says that they are unnecessary if there is a clear clinical diagnosis of stress incontinence or if there is urge or mixed incontinence but the initial management will be conservative. They do recommend it before surgery if there is:

• Clinical suspicion of detrusor overactivity
• There has been previous surgery for stress incontinence or anterior compartment prolapse
• There are symptoms suggestive of voiding dysfunction.

In short, they recommend such investigation where there is doubt about the diagnosis, previous surgery has failed or a surgical technique is proposed that aims at a specific problem and it is important to confirm that problem first.

There are a number of causes for concern when NICE recommends appropriate action:

• Microscopic haematuria if aged 50 years and older
• Visible haematuria
• Recurrent or persisting UTI associated with haematuria if aged 40 years and older
• Suspected malignant mass arising from the urinary tract

All the above are suggestive of malignancy and hence demand urgent referral.

The following suggest a complex situation that requires specialist help:

• Persisting bladder or urethral pain
• Clinically benign pelvic masses
• Associated faecal incontinence
• Suspected neurological disease
• Symptoms of voiding difficulty
• Suspected urogenital fistulae
• Previous continence surgery
• Previous pelvic cancer surgery
• Previous pelvic radiation therapy

Although this article concentrates on the problems of urinary incontinence in adult women and elderly men, detrusor instability can be a problem in children too. An article from Archives of Diseases of Childhood⁹ is recommended for the management of children.

NICE recommend the following:

Conservative Management

• In women with stress or mixed incontinence, the first line should be a trial of supervised pelvic floor muscle training of at least 3 months' duration.
• Women in their first pregnancy should be taught pelvic floor exercises as a prophylactic measure.
• Women with urge or mixed incontinence should be offered bladder training lasting for a minimum of 6 weeks.
• Pelvic floor exercises may also be of value in men who have radical prostatectomy.
• In OAB, reduction in caffeine consumption may be beneficial.
• If the woman has a BMI in excess of 30, weight loss should be advised. Explain it to the patient as taking some of the pressure off the bladder and pelvic floor.

Drug Treatment

This may well be used in addition to behavioural treatment such as pelvic floor exercises.

• If bladder training has failed in OAB or mixed incontinence, a trial of an anti-muscarinic drug should be offered. There are several available, but NICE says that the first line should be generic, immediate release oxybutynin. If this causes intolerable side-effects, then alternatives including darifenacin, solifenacin, tolterodine and trospium may be tried. There is said to be no significant clinical difference between these drugs.
• Propiverine can be used to treat frequency in OAB but it does not affect incontinence.
• Flavoxate, propantheline and imipramine are not recommended.
• NICE advises that desmopressin may be considered to reduce nocturia in women with incontinence or OAB who find it a troublesome symptom but they add that this is an unlicensed indication and so informed consent must be obtained and documented. Beware of fluid overload.
• NICE advises that HRT, whether systemic or local, is not recommended.

Surgery

• Where there has been demonstrable utero-vaginal prolapse, gynaecologists have used a number of operations over the years including, anterior repair, Manchester repair that includes amputation of the cervix and vaginal hysterectomy and repair. If there is laxity of the posterior wall or rectocoele, a posterior repair is added. Now NICE states that anterior colporrhaphy, needle suspensions, paravaginal defect repair and the Marshall-Marchetti-Krantz procedure are not recommended.
• NICE suggests that retropubic mid-urethral tape procedures using a "bottom-up" approach with macroporous polypropylene meshes should be used for stress incontinence where conservative management has failed. Open colposuspension and autologous rectus fascial sling are the recommended alternatives when clinically appropriate. Many procedures have been described for the treatment of stress incontinence but there is no strong evidence of superior effectiveness of any one. The best available data support the use of retropubic mid-urethral tape procedures, colposuspension and autologous rectus fascial sling. Retropubic mid-urethral tape procedures consume fewer hospital resources and are associated with faster recovery than the other two procedures.
• In women contemplating repair operations, discussion about intentions for further children may be included and at all ages discuss sexual activity. Generally, a tight repair will be more effective but it may make sexual activity difficult or impossible. Before operation, prolapse more than incontinence is likely to lead to sexual inactivity.¹⁰
• In women who have detrusor instability and who have not responded to conservative management, operative options are limited. NICE states that they are all costly and associated with significant morbidity. There is a stronger body of evidence for the effectiveness of sacral nerve stimulation than for other procedures. Up to two-thirds of patients achieve continence or substantial improvement in symptoms after this treatment.
• Other surgical interventions for this condition include augmentation cystoplasty and urinary diversion. They seem rather drastic. Injection of the bladder wall with botulinum toxin A is still experimental.

As is so often the case when NICE recommends surgery, they add that it should be performed in a unit that performs as significant number of such procedures each year as results are very much dependent upon the skill of the surgeon.

In the elderly and infirm and in palliative care, incontinence of urine may lead to breakdown of skin and associated complications. In these circumstances, where health is poor and life expectancy limited, catheters may well be justified. Catheterising bladders is described elsewhere. Silastic urethral catheters may be left in situ for 6 weeks. If long term drainage is required a suprapubic catheter may be preferable. This may be worth considering in a patient with a serious but chronic condition such as multiple sclerosis.

Incontinence of urine is an enormous problem that affects a significant number of adult women, the prevalence increasing with advancing age. Men are much less often affected until they become elderly. Only around half of those affected, even to a moderate or severe extent, have not consulted a healthcare professional about it.

Accurate diagnosis and effective treatment is essential. Many people who fail to present with the problem do so because they believe that there is no available treatment. Perhaps management too often leaves something to be desired.

This would seem to be a very suitable subject for the development of protocols for use by all clinicians in the primary healthcare team and integrated care pathways, agreed with secondary care providers, could be included in practice based commissioning.

No one dies of incontinence, although some may feel that they could "die of embarrassment". Nevertheless, it is an enormous medical problem with a profound adverse effect on quality of life.