Urinary Incontinence

Background/Classifications

Involuntary leakage of urine

• Functional incontinence: e.g. due to poor mobility (unable to reach the toilet)
• Stress incontinence: involuntary leakage on effort/exertion e.g. sneezing/coughing.  Most commonly in women due to weakness of the pelvic floor muscles
• Urge incontinence: involuntary leakage immediately preceded by urgency, usually due to bladder dysfunction
• Overflow incontinence: usually due to chronic bladder outflow obstruction (e.g. prostatic disease in men) and can be accompanied by urinary retention
• Much more common in women than in men and the elderly (46% of women >80 and 34% of men >80)

Risk factors

• Women
  • Parity (more pregnancies and vaginal deliveries- more risk) – particularly of stress incontinence
  • BMI
  • Menopause

History

• Determine type of incontinence (stress, urge, mixed)
  • NB if mixed focus mainly on the predominant symptoms
• Ask about other urinary symptoms
  • Frequency, nocturia, dribbling/incomplete emptying, dysuria
  • Also ask about any sexual dysfunction, bowel habit
• Ask about previous medical history and current/past medications
  • In women, this should a full PMHx for Obs/Gynae (particularly parity, deliveries, surgery etc)
  • Ask about any neurological conditions (personal or family history)
• Ask about social circumstances, including functionality/mobility
  • e.g. access to the bathroom, family support
  • Also ask about caffeine, alcohol and diet/fluids
• Patients may also be asked to fill out a symptom scoring checklist to estimate the severity/impact of symptoms

Examination

• Women
  • Perform a full gynaecological examination including testing the tone of the pelvic floor
    • Assess also any prolapse
• Men
  • DRE: prostate examination
• Also examine the abdomen, pelvis and nervous system

Investigations

• Urinalysis/MSSU
  • Important to exclude treatable cause like UTI
• Residual volume scan (USS) or catheterisation
• Urinary (voiding) diaries
• NB Urodynamic testing is not often used first line but can be used in
  • patients with symptoms of over-active bladder/detrusor overactivity
  • symptoms suggestive of voiding dysfunction e.g. poor flow
  • patients who have had previous surgery for stress incontinence

Management

• 1st line
  • Lifestyle
    • Reduce caffeine intake
    • Consider altering fluid intake
    • Weight loss
  • Physiotherapy
    • pelvic floor muscle training for stress incontinence
    • bladder re-training for urge incontinence
• 2nd line
  • Drug treatment
    • Oxybutynin or tolterodine can be offered for urge incontinence
      • Review in 4 weeks (benefit) and 6 months (review)
    • The use of drugs in treating stress incontinence is limited although duloxetine may be used in conjunction with pelvic floor exercises (SIGN not NICE)
• 3rd line
  • Surgery/Invasive
    • Consider retropubic mid-urethral tape procedure with synthetic tape
    • Other procedures include open colposuspension and autologous rectus fascial sling procedures
  • Intramural bulking agents (rare)
• Others
  • Catheterisation can be considered (first line for relief in obstructive incontinence)