Urinary Incontinence

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

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 do represent the majority of sufferers. This article reflects the NICE recommendations for women.¹ Where appropriate, additional information about assessment and management of urinary incontinence in men is added using other sources. SIGN have also published guidance for the management of urinary incontinence in primary care in both men and women.² Guidelines on urinary incontinence have also been developed by the European Association of Urology.³

Urinary incontinence is the involuntary leakage of urine. There are several different types:

• 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.¹ This is due to an incompetent sphincter.
• Urge incontinence 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 is involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.¹
• Overactive bladder syndrome (OAB) 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
• Overflow incontinence 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 is required.
• True incontinence may be due to a fistulous track between the vagina and either the ureter, bladder, or urethra. There is continuous leakage of urine.

• 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
• It is estimated that less than half of adults with moderate or severe urinary incontinence seek help from healthcare providers.²
• Prevalence increases with age.
• Prevalence of urinary incontinence in women who are not living in institutions is 10-40%. For adults living in institutions, prevalence is as high as 50%.⁴
• It is estimated that 46% of women and 34% of men over 80 years have urinary incontinence.^5,6

• The most important risk factor is being female.
• In men, urinary incontinence can follow prostate surgery.²
• Neurological disease/organic brain damage can be a risk factor for urge incontinence including stroke, dementia and Parkinson's disease.
• Cognitive impairment increases the risk in both sexes.
• Obstruction, including enlarged prostate in men and pelvic tumours in women, can lead to incontinence.
• Women with a higher body mass index seem to be at increased risk.^7,8,9
• Childbirth can cause anatomical or neuromuscular injury and can damage the pelvic floor muscles.⁴ A vaginal delivery, parity, the use of forceps, and babies of a heavier birth weight are all risk factors.^10,11,12 Caesarean section may be partly protective.^13,14
• Stool impaction may be implicated in elderly patients.⁴
• Previous hysterectomy may increase the risk of developing stress incontinence.¹⁵

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
  • Do you leak urine on sneezing, coughing, exercise, rising from sitting or lifting?
  • Do you always reach the toilet in time?
  • Do you have frequency of urine during the day/at night?
  • Do you dribble urine after leaving the toilet?
  • Do you have loss of bladder control?
  • Do you have a feeling of incomplete bladder emptying?
  • Do you have pain on passing urine?
  • Do you have a burning sensation on passing urine?
  • Do you experience bladder spasms?
• A full obstetric history should be taken in women.
• The patient should be asked to complete a bladder diary for a minimum of 3 days during their initial assessment. These should include both working days and days off. An example of a bladder diary can be found in annex 2 in the SIGN guidelines below.
• 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 dedicated article Genitourinary prolapse 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

• Urinary dipstick testing: NICE suggests the following for women.¹ It would be reasonable to follow the same guidelines in men.
  • Perform a urinary dipstick test to look for blood, glucose, protein, leucocytes and nitrites.
  • If a woman has symptoms of a UTI and dipstick testing shows leucocytes 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 leucocytes 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 leucocytes, no MSU is needed.
• 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 testing including cystometry, ambulatory urodynamics or videourodynamics 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

Urge incontinence and overactive bladder syndrome

NICE suggests the following management for women.

• Lifestyle changes:
  • Trial of reduction in caffeine intake.
  • Modification of high or low fluid intake. (Some patients may cut back on the amount that they drink so that the bladder does not fill so quickly. However, this can make symptoms worse as the urine becomes more concentrated which may irritate the bladder muscle. Patients should aim to drink normal quantities of fluid per day: around 2 litres.)
  • If body mass index >30, advise to lose weight.
• Bladder training:
  • This is first line treatment and should be for a minimum of 6 weeks.
  • It typically involves pelvic muscle training, scheduled voiding intervals with stepped increases, and suppression of urge with distraction or relaxation techniques.¹⁶
• Drug treatment:
  • Immediate release oxybutynin may be started if bladder training is not effective. It may also be used in conjunction with bladder training.
  • Darifenacin, solifenacin, tolterodine, trospium, or extended release or transdermal oxybutynin are alternatives if oxybutynin is not well tolerated.
  • Regular review should be undertaken.
  • Propiverine may be used in overactive bladder syndrome but not if there is any urinary incontinence.
  • Intravaginal oestrogens can be used to treat overactive bladder syndrome in postmenopausal women who have vaginal atrophy.
• Surgical treatment:
  • Sacral nerve stimulation may be considered in women with detrusor overactivity if conservative treatment does not relieve symptoms.
  • Augmentation cystoplasty may also be considered. Women need to be able to self-catheterise after the procedure. There is a small risk of malignancy in the augmented bladder.
  • Urinary diversion should only be considered if the above two measures are not appropriate or unacceptable to the woman.
  • Injection of the bladder wall with botulinum toxin A may be used if there is idiopathic detrusor overactivity that has not responded to conservative treatment. However, this is outside UK marketing authorisation. Women need to be able to self-catheterise after the procedure.

Men with urge incontinence and overactive bladder syndrome should also be managed with similar lifestyle changes, bladder retraining and antimuscarinics in primary care. If this fails, consider secondary care referral.² The European Association of Urology Guidelines suggest neurostimulation, sacral blockade, botulinum toxin detrusor injections and bladder augmentation/substitution for detrusor overactivity in men.³

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 8 contractions, 3 times a day.
  • Continue if successful.
  • Consider electrical stimulation and/or biofeedback in women who cannot actively contract pelvic floor muscles.
  • (Please refer to the link below for 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.
  • 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. 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.¹⁷ 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

• 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 dedicated articles Benign prostatic hyperplasia and Prostatic Carcinoma for more details.

Catheterisation¹

NICE suggests the following in women:

• 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 women cannot perform self-catheterisation.
  • Skin wounds, pressure sores or ski 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.
• Pads and toileting aids should only be used as an adjunct to treatment and all treatment options should be explored as well as suggesting these aids for patients.¹
• 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

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