Urinary incontinence

Last updated: August 10, 2022

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Urinary incontinence (UI) is a common condition characterized by involuntary leakage of urine. Causes and presentations are variable. Stress incontinence, urge incontinence, and mixed incontinence are the most common types. UI is more common in older individuals, and approximately twice as common in women than in men. The diagnosis can often be made based on a detailed medical history, a voiding diary, physical examination, and basic testing including urinalysis and measurement of postvoid residual volume (PVR). Advanced diagnostic studies may be required for patients with red flags in urinary incontinence or incontinence refractory to treatment. Initial management involves conservative measures (e.g., management of comorbidities, pelvic floor exercises, bladder training) and provision of continence products; further treatment is based on the underlying mechanism and may involve pharmacotherapy or surgery. If left untreated, UI can have a severely detrimental effect on patients' psychosocial well-being, mobility, and independence, and can increase the risk of infection.

For the management of stress incontinence and urge incontinence, see also the respective articles.

Epidemiological data refers to the US, unless otherwise specified.

DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.

Types of urinary incontinence

Overview of urinary incontinence [3][4][5]
Underlying mechanism Clinical features Treatment
Stress incontinence
Urge incontinence [6]
  • Strong, sudden sense of urgency, followed by involuntary leakage
Mixed incontinence
  • May have any of the clinical features above
Total incontinence
  • Urinary leakage occurs at all times, with no associated preceding symptoms or specific trigger activity.
  • Short-term management: pads and external catheters [9]
  • Long-term management: usually surgical (e.g., fistula repair), in consultation with urology and/or urogynecology [3]
Overflow incontinence (overflow bladder) [10]
  • Frequent, involuntary intermittent/continuous dribbling of urine in the absence of an urge to urinate
  • Occurs only when the bladder is full
  • Often occurs with changes in position
  • Postvoid residual urine volume (seen on ultrasound or with catherization)
Neurogenic bladder dysfunction [3][13]
  • Voiding and/or storage dysfunction, intermittent voiding, urinary retention
  • Irregular, small volume incontinence without an associated urge to void (sometimes referred to as reflex incontinence)
Enuresis risoria [16]
  • Unknown; not related to stress or detrusor weakness
  • Affects children
  • Involuntary complete voiding triggered by laughing
  • Voiding behavior is otherwise normal (not a feature of enuresis).

Neural control of micturition: parasympathetic nervous systemS2S4 ventral root → inferior hypogastric plexus → contraction of the detrusor muscle → voluntary relaxation of the external urethral sphincter muscle via the pudendal nerve micturition

Stress incontinence is caused by urethral dysfunction, while urge incontinence is caused by bladder dysfunction. Mixed incontinence is a combination of both. [17]

Overview of pharmacotherapy

Autonomic drugs used to treat bladder incontinence [3][4][5]
Drug group Indications Mechanism of action

Muscarinic antagonists

e.g., oxybutynin

Sympathomimetics

e.g., mirabegron

Muscarinic agonists

e.g., bethanechol [10][12]

Alpha-1 antagonists

e.g., tamsulosin

The use of muscarinic agonists may lead to urinary urgency, while the use of sympathomimetics or muscarinic antagonists may lead to urinary retention, especially if there is an untreated outlet obstruction. [3]

No pharmacological therapies are FDA-approved for stress incontinence; treatment is primarily conservative with surgery. [4]

The following outlines a general approach for the workup of incontinence of unknown mechanism; if the mechanism is known, see “Diagnostics” in “Stress incontinence” and “Urge incontinence.”

Approach

Red flags in urinary incontinence [3][5][17]

Refer to urology or urogynecology for specialist workup if any of the following features are present:

Initial evaluation for urinary incontinence [3][4][18]

Focused history

  • Chronicity: Determine whether the incontinence is acute or chronic.
  • General history
  • Focused history of incontinence
    • If possible, use a validated incontinence questionnaire. [3][5]
    • Inquire about symptoms that occur with voiding.
    • Assess for barriers to voiding (e.g., limited mobility, which may delay patients reaching the bathroom).
    • Ask patients to record fluid intake and micturition for 3–5 days using a voiding diary.

Physical examination [3][17]

Perform a urinary stress test in all patients to distinguish between stress and urge incontinence.

Initial diagnostics

Differentiation between types of incontinence

Diagnostic overview of types of incontinence [17]
Clinical history Urinary stress test Postvoid residual volume
Stress incontinence
  • Leakage with coughing, sneezing, and/or exercising
  • < 50 mL
Urge incontinence
  • May have delayed leakage [17]
Overflow incontinence
  • No leakage
  • > 200 mL
Functional urinary incontinence
  • Variable

Patients with features of both stress and urge incontinence have mixed incontinence.

Upper urinary tract studies [3][21]

Only perform upper urinary tract studies if the initial assessment indicates a possible renal pathology and/or renal impairment due to urinary retention and vesicoureteral reflux. [5][21]

Advanced studies [3][4][22]

Advanced studies are performed under specialist guidance for patients with red flags in urinary incontinence or incontinence refractory to initial management.

Approach [3]

Assess the impact of incontinence symptoms on the patient's daily activities and discuss their treatment goals; use shared decision-making to individualize treatment plans.

Conservative management of urinary incontinence [6][8]

Management of comorbidities

Lifestyle recommendations

Pelvic floor physical therapy [24]

  • Exercises that target the pelvic floor to strengthen the muscles that control urinary flow and bowel movements
  • To increase efficacy, exercises may be supplemented with:

Bladder training

  • Scheduled voiding regimens and patient education are used to increase leak-free intervals. [4]
    • Timed voiding: Intervals between voiding are sequentially increased until the goal of at least 3–4 hours is met.
    • Relaxation and distraction techniques: used to suppress the urge to urinate.
  • Indications: urge incontinence, but also effective for stress and mixed incontinence

Type-specific management

Urinary incontinence in older adults [3]

Overview

  • Management of older patients is similar to that of other populations, but with some modifications.
  • Functional incontinence due to cognitive or mobility impairment is more common than in younger patients.
  • Comorbid conditions and polypharmacy can make pharmacological management challenging.

Modification to urinary incontinence diagnostics

Modifications to the management of urinary incontinence

  • Consider life expectancy, goals of care, and the patient's and/or caregiver's ability to manage therapy when planning treatment.
  • Prompted voiding may be helpful for older patients with cognitive impairment. [3]
  • Start any medications at the lowest dose possible and follow-up frequently to assess for adverse effects.
  • Consider specialist referral if conservative therapies fail or other chronic conditions need to be addressed (e.g., dementia, functional impairment).

Urinary incontinence in pregnancy [10]

We list the most important complications. The selection is not exhaustive.

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