Urinary Incontinence

Urinary incontinence is an underdiagnosed and underreported problem that increases with age—affecting 50-84% of the elderly in long-term care facilities —and at any age is more than twice as common in females than in males.

Signs and symptoms

Types of urinary incontinence

• Stress: Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder 
• Urge: Involuntary leakage accompanied by or immediately preceded by urgency
• Mixed: A combination of stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing
• Functional: The inability to hold urine due to reasons other than neuro-urologic and lower urinary tract dysfunction (eg, delirium, psychiatric disorders, urinary infection, impaired mobility)

Diagnosis

Patients with urinary incontinence should undergo a basic evaluation that includes a history, physical examination, and urinalysis. In selected patients, the following may also be needed:

• Voiding diary
• Cotton swab test
• Cough stress test
• Measurement of postvoid residual (PVR) urine volume
• Cystoscopy
• Urodynamic studies (see the image below)

  Urinary incontinence. Urodynamic study revealing detrusor instability in a 75-year-old man with urge incontinence. Note the presence of multiple uninhibited detrusor contractions (phasic contractions) that is generating 40- to 75-cm H2O pressure during the filling cystometrogram (CMG). He also has small bladder capacity (81 mL), which is indicative of poorly compliant bladder.

The following points regarding the clinical presentation should be sought when obtaining the history:

• Severity and quantity of urine lost and frequency of incontinence episodes
• Duration of the complaint and whether problems have been worsening
• Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm)
• Constant versus intermittent urine loss
• Associated frequency, urgency, dysuria, pain with a full bladder
• History of urinary tract infections (UTIs)
• Concomitant fecal incontinence or pelvic organ prolapse
• Coexistent complicating or exacerbating medical problems
• Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies
• History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures
• Other urologic procedures
• Spinal and central nervous system surgery
• Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure
• Medications

Relevant complicating or exacerbating medical problems may include the following:

• Chronic cough
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure
• Diabetes mellitus
• Obesity
• Connective tissue disorders
• Postmenopausal hypoestrogenism
• CNS or spinal cord disorders
• Chronic UTIs
• Urinary tract stones
• Benign prostatic hyperplasia
• Cancer of pelvic organs

Medications that may be associated with urinary incontinence include the following:

• Cholinergic or anticholinergic drugs
• Alpha-blockers
• Over-the-counter allergy medications
• Estrogen replacement
• Beta-mimetics
• Sedatives
• Muscle relaxants
• Diuretics
• Angiotensin-converting enzyme (ACE) inhibitors

Management

Successful treatment of urinary incontinence must be tailored to the specific type of incontinence and its cause. The usual approaches are as follows:

• Stress incontinence: Pelvic floor physiotherapy, anti-incontinence devices, and surgery
• Urge incontinence: Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention
• Mixed incontinence: Pelvic floor physical therapy, anticholinergic drugs, and surgery
• Overflow incontinence: Catheterization regimen or diversion
• Functional incontinence: Treatment of the underlying cause

Absorbent products may be used temporarily until a definitive treatment has a chance to work, in patients awaiting surgery, or long-term under the following circumstances:

• Persistent incontinence despite all appropriate treatments
• Inability to participate in behavioral programs, due to illness or disability
• Presence of an incontinence disorder that cannot be helped by medications
• Presence of an incontinence disorder that cannot be corrected by surgery

In stress and urge urinary incontinence, the following medications may provide some benefit:

• Alpha-adrenergic agonists
• Anticholinergic agents
• Antispasmodic drugs
• Tricyclic antidepressants
• Estrogen
• Alpha-adrenergic blockers
• Botulinum toxin

Surgical care for stress incontinence involves procedures that increase urethral outlet resistance, including the following:

• Bladder neck suspension
• Periurethral bulking therapy
• Midurethral slings
• Artificial urinary sphincter

The transobturator male sling may be of particular benefit to men who experience stress incontinence after prostatectomy.^[5] Transobturator vaginal tape (TVT-O) is widely used for stress incontinence in women^[6]

Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity, including the following:

• Sacral nerve modulation
• Injection of neurotoxins such as botulinum toxin
• Bladder augmentation