Debra L. Fromer, MD
Drew A. Freilich, MD
BASICS
DESCRIPTION
• Incontinence is broadly defined as the loss of urine that is objectively demonstrable and is of social and hygienic concern
• Stress urinary incontinence (SUI): Involuntary loss of urine on effort of physical exertion
• Urgency incontinence (UI): Involuntary loss of urine associated with urgency
• Mixed incontinence (MI): Lost of urine associated with urgency and also with effort
• Overflow incontinence (OI): High residual or chronic urinary retention leads to urinary spillage from bladder overdistention
• Functional incontinence: Loss of urine due to deficits of cognition and mobility
• Coital incontinence: leakage urine during intercourse
• Continuous incontinence: Continuous involuntary loss of urine
EPIDEMIOLOGY
Incidence
N/A
Prevalence
• Affects 30–50% of adult women
• Stress urinary incontinence is the most common (49%), followed by mixed (29%) and urge (21%) incontinence
RISK FACTORS
• Advanced age
• Cognitive impairment
• COPD
• Menopause
• Obesity
• Pelvic organ prolapse
• Pelvic surgery or radiation
• Pregnancy
• Smoking
• Vaginal childbirth
Genetics
Evolving data to support genetic predisposition
PATHOPHYSIOLOGY
• Stress incontinence: Occurs with increased intra-abdominal pressure without detrusor contraction. 2 types:
– Anatomic: Due to urethral hypermobility from lack of pelvic support
Hammock theory: Normally, the suburethral support contributed by the endopelvic fascia and anterior vaginal wall provides a stable backboard against which the urethra is compressed while intra-abdominal pressure rises. When this suburethral support layer is lax and mobile, any effective compression is not achieved, causing leakage
– Intrinsic sphincter deficiency (ISD): Impairment of urethral mucosal seal and inherent closure from collagen, fibroelastic tissue, smooth and striated muscles. May be lost secondary to surgical scarring, radiation, or hormonal and senile changes
• Urge incontinence: Detrusor overactivity (may be secondary to detrusor myopathy or neuropathy)
• OI: Urinary retention (usually from lower motor paralytic neurogenic bladder in women)
• Total incontinence: Constant loss of urine. Ectopic ureters in females usually open in the urethra distal to the sphincter or in the vagina, causing continuous leakage
– Suspect fistula if pneumaturia or fecaluria in history of radiation
• Coital incontinence: Up to 60% of women who report incontinence appear to leak urine during intercourse
ASSOCIATED CONDITIONS
• Pelvic organ prolapse
• Diabetes
• Neurologic disease (ie, multiple sclerosis, Parkinson)
GENERAL PREVENTION
• Weight loss
• Optimization of medical health (ie, diabetes)
• Smoking cessation
DIAGNOSIS
HISTORY
• Parity: Weakness of the pelvic floor is more likely in multiparous women leading to SUI
• Amount and frequency of leakage
• Continuous slow leakage in between regular voiding indicates ectopic ureter, urinary fistula, etc.
• Pain: Suprapubic pain with dysuria implies urinary infection, interstitial cystitis, etc.
• Medical history:
– Cerebrovascular accidents, Parkinsons disease, multiple sclerosis, myelodysplasia, diabetes, spinal cord injury
– Radiation to pelvic and vaginal areas: Causes ISD, urgency, and low bladder compliance
• Medications
• Surgical history: Pelvic and vaginal surgeries can weaken the pelvic floor support
PHYSICAL EXAM
• General neurologic exam:
– Mental status, speech, intellectual performance
– Motor status: Gait, generalized or focal weakness, rigidity, tremor
– Sensory status: Impairment of perineal-sacral area sensation helps localize the level of neurologic deficit
– Reflex: A bulbocavernous reflex implies contraction of the anal sphincter in response to squeezing the clitoris. This reflex tests the integrity of S2–S4 spinal cord segments
• Urologic exam:
– Abdomen: Scars of previous surgeries
– Suprapubic tenderness: May indicate cystitis
– Palpable bladder: Chronic urinary retention
• Pelvic exam:
– The patient is asked to cough or strain to reproduce incontinence or demonstrate urethral hypermobility (Q-tip test positive if >30 degrees)
– Assess for atrophic vaginitis
– Examine vaginal for cystocele, enterocele, rectocele, or uterine descensus
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis
• Urine culture: Assess for infection
Imaging
• CT urogram: Determines status of upper urinary tract, duplicated systems for ectopic ureters, and associated pathologies (indicated only when upper tract issues are suspected)
• Voiding cystourethrogram: Preferably done in combination with videourodynamic studies
Diagnostic Procedures/Surgery
• 24-hr voiding diary to assess frequency, timing, volume of symptoms
• Cystoscopy: If concern for fistula or malignancy
• Urine cytology: If hematuria and urgency (concern for carcinoma in situ)
• Urodynamic studies:
– Filling cystometry: Pressure/volume relationship during bladder filling
Assess 1st sensation, desire to void, strong desire to void, capacity, detrusor overactivity
Assess Valsalva leak point pressure: Determines the intra-abdominal pressure at which leakage is observed at the meatus or by fluoroscopy; low leak point pressure (<60 mm H2O) implies ISD
Assess detrusor leak point pressure: Lowest detrusor pressure at which leakage of urine occurs in absence of detrusor contraction and increase abdominal pressure (>40 cm H2O risk or renal deterioration)
– Voiding cystometry: Pressure/volume relationship during micturition
Assess urinary flow rate, postvoid residual, detrusor sphincter synergy
– Videourodynamic studies: Combination of fluorocystourethrography and urodynamic studies mentioned above
Most useful in patients at risk for neurogenic bladder to assess for detrusor sphincter dyssynergia which is risk for renal deterioration
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Stress incontinence: Due to urethral hypermobility or ISD, although in the majority it is mixed or due to both of the factors
• Urgency incontinence: Can be due to urinary infection, interstitial cystitis, carcinoma in situ, bladder calculi, detrusor overactivity, or neurogenic detrusor overactivity. Most often idiopathic
• Nocturnal enuresis: Idiopathic, neurogenic, cardiogenic, or obstructive causes
• Continuous leakage: Ectopic ureter, urinary fistulas, exstrophy–epispadias complex
• Postvoid dribbling: Urethral diverticulum, idiopathic or iatrogenic
• Mobility or cognitive impairment post stroke
• Coital or mixed incontinence
TREATMENT
GENERAL MEASURES (1)
• Nonsurgical management (helps ∼50–65% patients with milder symptoms)
• Treat correctable causes (Atrophic vaginitis, constipation, UTI, fistula, etc.)
• Encourage weight loss in obese patients
• Biofeedback and pelvic floor exercises (Kegel exercise) (3)
• Behavioral therapy: Voiding at progressively increasing predetermined intervals
MEDICATION
First Line (2)
• Stress incontinence: Activation of α-adrenergic receptors in the internal urethral sphincter increases the urethral resistance to urinary flow with sympathomimetic drugs, estrogen, and tricyclic agents (not used commonly due to side effects and interaction concerns and potential-limited efficacy)
• Urge incontinence: Anticholinergic, antispasmodic, and tricyclic antidepressant medications have been used to treat overactive bladder symptoms
– Mirabegron is a 1st in class β3-agonist for treatment of urge incontinence. When compared to anticholinergic medications much less dry mouth and constipation, but risk of hypertension
Mirabegron (25–50 mg/d)
Second Line
Other antichlonergic agents oxybutynin, ect.
SURGERY/OTHER PROCEDURES
• Stress urinary incontinence
– Vaginal pessary
– Surgical management: Provides more successful and sustained outcome (5)
Periurethral injection of bulking agents: Calcium hydroxylapatite/sodium carboxymethylcellulose and hyaluronic acid
Pubovaginal sling suspension: Used for coaptation and compression of the incontinent urethra, using autologous fascia or xenograft or allograft materials
Midurethral sling: Controversial as to if retropubic (TVT) or transobturator (TOT) better for urethral hypermobility and ISD patients
Postoperative de novo urgency, urge incontinence, voiding difficulty, and urinary retention, necessitating intermittent self-catheterization or take-down of the suspension, remain as concerns in up to ∼20% of patients
– Artificial urinary sphincter (not FDA approved for female incontinence)
• Refractory overactive bladder (failed 1st- and 2nd-line therapies including anticholinergics):
– Sacral neuromodulation: Efficacy ∼50% of patients who have failed other treatments
– Percutaneous tibial nerve stimulation
– Intravesical botulinum toxin for neurogenic detrusor overactivity or refractory UI
Efficacy: Up to ∼75% improved/cured in those refractory to other medical treatment
Side effects: UTI (∼25%), Urinary retention (∼10%) (patients must be counseled about possible need for postoperative intermittent catheterization)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Reduction or avoidance of spicy foods, citrus, or chocolate; limiting excessive fluid intake and caffeine can improve symptoms of urinary incontinence (especially if overactive bladder)
Complementary & Alternative Therapies
No high-level data to support
ONGOING CARE
PROGNOSIS
Excellent prognosis for many patients with awareness of this condition, combined with advances in diagnosis and management to minimize associated morbidity of this condition.
COMPLICATIONS
• Prolonged exposure to urine causes skin breakdown and dermatitis, which may lead to ulceration and secondary infection (4)
• Catheter-related complications can result from long-term indwelling catheters, such as recurrent UTIs, skin infections, and urethral erosion
FOLLOW-UP
Patient Monitoring
• Initial postoperative assessment after midurethral sling: Evaluate voiding function with estimation of postvoid residual and need for intermittent catheterization
• Periodic long-term follow-up with validated outcome-based questionnaire surveys
Patient Resources
National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) http://kidney.niddk.nih.gov/kudiseases/pubs/uiwomen/
REFERENCES
1. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188:2455–2463. [B]
2. Madhuvrata P, Cody JD, Ellis G, et al. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev. 2012;1:CD005429. [A]
3. Dumoulin C, Glazener C, Jenkinson D, et al. Determining the optimal pelvic floor muscle training regimen for women with stress urinary incontinence. Neurourol Urodyn. 2011;30(5):746–753. [B]
4. Shamliyan T, Wyman JF, Ramakrishnan R, et al. Benenefits and harms of pharmacologic treatment for urinary incontinence in women: A systematic review. Ann Intern Med. 2012;156(12):861–874. [A]
5. Schierlitz L, Dwyer PL, Rosamilia A, et al. Three-year follow-up of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency. Obstet Gynecol. 2012;119(2 Pt 1):321–327. [A]
ADDITIONAL READING
• Dmochowski RR, Blaivas JM, Gormley EA, et al. Update of AUA Guideline on the surgical management of female stress urinary incontinence. J Urol. 2010;183(5):1906–1914.
• Jha S, Strelley K, Radley S. Incontinence during intercourse: myths unravelled. Int Urogynecol J. 2012;23(5):633–637.
• Winters JC, Dmochowski RR, Goldman HB, et al. Urodynamic studies in adults: AUA/SUFU guideline.J Urol. 2012;188(Suppl6):2464–2472. https://www.auanet.org/common/pdf/education/clinical-guidance/Adult-Urodynamics.pdf (Accessed April 7, 2014)
See Also (Topic, Algorithm, Media)
• Coital Incontinence (Coital leakage/Intercourse Incontinence)
• Ejaculation, Female
• Incontinence, Urinary, Adult Female Image 
• Overactive Bladder
• Pelvic Organ Prolapse
• Urethral Sling, Indications and Anatomic Positions
• Urethral Sling, Materials
CODES
ICD9
• 625.6 Stress incontinence, female
• 788.30 Urinary incontinence, unspecified
• 788.31 Urge incontinence
ICD10
• N39.3 Stress incontinence (female) (male)
• N39.41 Urge incontinence
• R32 Unspecified urinary incontinence
CLINICAL/SURGICAL PEARLS
• Recent FDA Alerts regarding vaginal mesh applies to prolapse repair and not midurethral sling. Mesh for stress incontinence has been supported in multiple randomized controlled trials.
• Consider reduction of pelvic organ prolapse as part of evaluation for incontinence.
• Consider referral to neurologist in young patients with refractory idiopathic overactive bladder as 1st presenting symptom of multiple sclerosis is isolated urinary urgency in ∼15%.