AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Urinary incontinence (UI) is the involuntary release of urine, which may be caused by physiologic, pharmacologic, pathologic, or psychological factors. According to the International Continence Society, urinary incontinence is defined as a condition of involuntary urine loss that is objectively demonstrable and is a social or hygienic problem.

Pathophysiology

Continence involves an interplay between micturition physiology and functional ability. The micturition physiology depends on the urinary tract, pelvic structure, and neurological components. In this system, the bladder neck and proximal urethra function as a sphincter. Sphincteric action results from the combined function of smooth and striated muscles, as well as other components, such as elastin, collagen, and a mucosal seal.

During voluntary micturition, the sphincter relaxes and the bladder empties. The micturition reflex is under the control of the parasympathetic and voluntary somatic nervous system. The components of the sacral spinal cord and sympathetic components of the thoracolumbar spinal cord all play a role in this process. A lesion in the pontine micturition center, the sacral spinal cord, or anywhere in between can lead to voiding dysfunction or neurologic incontinence.

The functional ability depends on factors such as sufficient mobility, manual dexterity, cognitive recognition of a full bladder, and appropriate reaction and access to a toilet facility.

Frequency

United States

Urinary incontinence affects 10 million Americans of which 85% are women. UI affects 15-30% of the general geriatric population and 50-84% of the elderly persons in long-term care facilities. UI affects up to 7% of children older than 5 years. Incidence is 1.4% of adults aged 15-24 years and 2.9% of those aged 55-64 years.

Mortality/Morbidity

Urinary incontinence is not associated with increased mortality. The medical morbidity includes perineal candidal infection, cellulitis, pressure sores, constant skin irritation and moisture, urosepsis from indwelling catheters, falls and fractures from slipping on urine, and sleep deprivation from nocturia. Psychological morbidity includes poor self-esteem, social withdrawal, depression, sexual dysfunction from embarrassment, and curtailed social and recreational activities.

Race

Stress incontinence is more prevalent in Caucasian women than in African American or Hispanic women (41% vs 31% vs 30%, respectively). The incidence of urge incontinence is similar in all 3 groups (19% vs 16% vs 16%, respectively). Mixed incontinence occurs more often in African American and Caucasian women compared with Hispanic women (14% vs 15% vs 0.9%, respectively).

Sex

Overall, rates in men are approximately one third of those in women until age 80 years when the rates converge.

Age

Age is a risk factor for UI. Older individuals may have medical conditions that impair continence. This may include diabetes, medications, mental status change, declining lower urinary tract function, alteration in volume status and urine excretion, and functional impairment of toileting ability.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

A thorough history is the most important step in the evaluation of UI. The clinical presentation of UI varies in many patients. These variations can be its severity, frequency, and amount of debilitation. It is always important to remember that many patients are reluctant to initiate a discussion about their continence; therefore, all patients (especially those >65 y) should be asked specific questions about voiding problems. Avoid using nonspecific terms such as urge or nocturia, as they may have different meanings to different patients.

• Onset (pregnancy, postpartum, surgery, trauma)
• Duration of complaint
• Patterns (nocturnal vs diurnal)
• Precipitants (cough, sneeze, position change, sound of running water)
• Frequency/severity/quantity
• • Number of pads
  • Voiding diary
  • Amount of urine can distinguish between overflow incontinence and detrusor overactivity.
• Concomitant symptoms
• • Fecal incontinence
  • Pelvic organ prolapse
  • Vaginal splinting for bowel movements
  • Urinary hesitancy, frequency, urgency, dysuria
  • Incomplete emptying, poor stream
  • Pelvic pressure/pain
  • Chronic constipation
  • Sacral backache
• Medical conditions
• • Cancer, radiation
  • Diabetes
  • Neurologic disease
  • Surgeries (pelvic, urologic, spinal, CNS)
  • Postmenopausal hypoestrogenism
  • Benign prostatic hyperplasia
  • Chronic UTI, stones
  • Prolonged labor, multiparity, obstetric lacerations, large babies
  • Connective tissue disease
  • COPD, obesity
  • Congestive heart failure (CHF), hypertension
  • Medications side effects (eg, anticholinergics, calcium channel blockers, diuretics, sedatives, alpha-agonists, alpha-antagonists, alcohol)
• Social history (living conditions, activities, history of smoking, alcohol and caffeine use)

Physical

A comprehensive examination is necessary to detect contributory factors and any underlying serious medical conditions. Evaluations should always consider neurologic conditions such as multiple sclerosis, cord lesions, and neoplasms (bladder and prostate), especially if risk factors exists.

• Neurologic
• • Check for perineal sensation, resting and volitional tone of anal sphincter, anal wink, and bulbocavernous reflex.
  • Assess cognitive status, motor strength and tone, vibration, and peripheral sensation.
• Abdomen
• • Examine for masses, distended bladder after voiding, hernia, and signs of fluid overload.
  • Examine flank for tenderness. Examine back for deformity, dimpling, or hair tuft.
• Pelvic
• • All women require a pelvic examination. Examine the vaginal mucosa for atrophy, narrowed introitus, vault stenosis, and inflammation.
  • Evaluate the anterior and posterior vaginal walls. Check for rectocele by pushing the speculum to support only the anterior vaginal wall while the patient coughs.
  • Bimanual examination to detect masses
  • Assess for adequate pelvic support by removing the top blade of the speculum and holding the bottom blade firmly against the posterior vaginal wall for support.
• Cotton swab test
• • This examination evaluates urethral mobility.
  • Place a sterile cotton swab through the urethra into the bladder. Pull the swab back until resistance is met, which indicates entry into the urethra. At this point, ask the patient to strain maximally.
  • A change of angle greater then 30 degrees indicates urethral hypermobility.
  • A positive finding does not confer a specific diagnosis, and older women have a high false-negative rate.
• Stress testing
• • This test evaluates stress-induced leakage when the bladder is full.
  • Ask the patient to cough forcefully or strain vigorously. Instantaneous urine leak is highly suggestive of stress incontinence, while delayed leakage is suggestive of stress-induced detrusor overactivity.
  • This test is very sensitive but can be misleading in inhibited patients and in those with low bladder volume.

Causes

Urinary incontinence can be caused by multiple factors and in most patients may not be accounted for by a single etiology. Physiologic etiology includes structural and functional abnormalities of the central nervous system, spinal cord, bladder, and urethra. Some cases of incontinence are pharmacologically induced; this is not limited to medications but may be caused by tobacco use, alcohol, and caffeine. Medical comorbidities and complications after surgeries, namely neurologic and abdominopelvic, also play an important role in development of urinary incontinence. While often overlooked, the functional status of the patient such as mobility also plays an important role in development of UI.

Four major clinical types of urinary incontinence are established. These 4 major types are stress incontinence, urge incontinence, mixed incontinence, and overflow incontinence.

• Stress incontinence
• • Two main causes of stress incontinence exist. The major cause is impaired urethral support from pelvic floor muscle weakness. The less common cause is an intrinsic sphincter deficiency usually from pelvic surgeries. In either case, diminished urethral sphincter function diminishes and its function is compromised with increased abdominal pressure.
  • Stress incontinence is characterized by urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical exertion.
• Urge incontinence
• • Urge incontinence is a result of uninhibited bladder contraction from detrusor hyperactivity. This hyperactivity can be caused by abnormalities of the CNS inhibitory pathway such as strokes and cervical stenosis. Other causes are bladder inflammation from infection, stones, or neoplasms.
  • Urge incontinence is characterized by involuntary urine loss accompanied by a sudden strong desire to pass urine that is difficult to suppress.
  • Urge incontinence usually entails urgency, frequency, or nocturia. These symptoms are often referred to as the overactive bladder syndrome (OAB).
  • Some individuals may have a pure sensory abnormality where they exhibit urinary frequency and urgency without urine loss. This is often referred to as overactive bladder dry.
  • Elderly persons frequently experience urinary loss without the sensation of urge, but the underlying mechanism of detrusor hyperactivity is still the same.
• Mixed incontinence
• • Mixed incontinence is the coexistence of stress and urge incontinence.
  • Although it is generally defined as detrusor overactivity and impaired urethral function, the actual pathophysiology of mixed urinary incontinence is still being studied.
  • Mixed urinary incontinence is characterized by involuntary loss of urine associated with urgency as well as exertion, cough, sneeze, or any effort that increase intra-abdominal pressure.
  • Mixed incontinence is the most common type of incontinence in women.
• Overflow incontinence
• • Overflow incontinence is incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction.
  • Factors involved in the development of overflow incontinence are physical obstruction, such as pelvic organ prolapse and enlarged prostate, and neurological abnormalities, such as spinal cord injuries. It is also commonly associated with bladder neuropathy as occurs in diabetes mellitus.
  • Patients often complain of continuous small-volume leakage associated with weak urinary stream, dribbling, hesitancy, frequency, and nocturia.
• Other less frequent causes of urinary incontinence include trauma from pelvic fracture, complications of urologic procedures, and fistulas. In the pediatric population, it includes enuresis and congenital abnormalities of the genitourinary system. Older adults can have transient incontinence from medication, decreased mobility, and fecal impaction.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Urinalysis and urine culture to look for infection
• Hematuria should be evaluated with urinary cytological studies, intravenous pyelogram (IVP), and cystourethroscopy.
• Check serum electrolytes, especially calcium level.
• Check BUN/CR. Decreased muscle mass in elderly patients may not reflect renal function.
• Check glucose level, especially in diabetic patients or patients with polyuria or polydipsia.

Imaging Studies

• Ultrasonography
• • Ultrasonography allows for evaluation of hydronephrosis, hydroureter, and urinary tract stones.
  • Ultrasonography is noninvasive, widely available, and cost-effective.
• Fluoroscopy and video urodynamics
• • This study determines bladder, intra-abdominal, and urethral pressures.
  • It is often a valuable tool in the evaluation of complex stress incontinence.
• Cystourethrography is a useful diagnostic adjunct in suspected cases of urinary tract fistulas.
• Intravenous pyelography (IVP) may differentiate between ureterovesical fistula and vesicovaginal fistula.
• Positive-pressure urethrogram is most useful for diagnosing urethral diverticulum.
• Chain bead cystography is historically used to define bladder neck anatomy and function; now, it is largely replaced by less invasive techniques such as the cotton swab test, videourodynamics, bladder neck ultrasonography, and MRI.
• Magnetic resonance imaging is the most accurate technique for visualizing pelvic floor defects.

Other Tests

• Urodynamic studies
• • Postvoid residual (PVR) urine volume is assessed by catheterizing and measuring residual urine within 5 minutes after voiding. It determines the functional status of the lower urinary tract by reproducing the patient's symptoms.
  • Synchronous multichannel urodynamics measures and gives urodynamic parameters with radiographic visualization simultaneously. It is the most precise diagnostic study to evaluate micturition abnormalities of the lower urinary tract.
  • Urodynamic studies are expensive and furthermore require specialized equipment and operator. They should be used in complex cases. Unfortunately, no universal evidence-based criteria exist for complex cases.
• Cystourethroscopy is indicated for visual evaluation in cases of hematuria; persistent postoperative incontinence; and suspected cases of malignancy, fistula, or diverticulum.
• Uroflowmetry is a method of measuring urine volume passed per unit time, which, in essence, evaluates detrusor contraction strength and urethral resistance.
• Cystometry is a technique for measuring bladder filling pressures. It is helpful in detecting detrusor hyperactivity.
• Valsalva leak point pressure is an objective evaluation of passive incontinence. It tests the urethral sphincter resistance against intra-abdominal pressure. It may be helpful in assessing the severity of stress incontinence; however, no consensus exists on how to perform this test.
• Urethral pressure profilometry (UPP) evaluates urethral pressure and external sphincter activity. It is usually performed after cystometry when the bladder is still full.
• Bladder leak point pressure is first described in patients with myelodysplasia. It is the pressure in which urine leak occurs with overwhelming bladder contraction. No consensus exists on its role in evaluation of patients without myelodysplasia.
• Pad testing is an objective method of quantifying incontinence, clinically useful in diagnosing stress incontinence. Patients are instructed to wear a preweighed sanitary napkin after which they drink a known volume of liquid. Patients are then asked to perform maneuvers that increase intra-abdominal pressure after which the pad is removed and weighed.
• Paper towel test is a recent, simpler test used to evaluate stress incontinence. The patient is asked to cough repetitively while the towel is held a short distance from the urethra. Area of visible staining on paper towel is used to estimate amount of urine loss.
• Bethanecol sensitivity test is used when cystometry does not diagnose detrusor instability in patients with high clinical suspicion. It usually involves administration of bethanecol subcutaneously with repetition of cystourethrogram 30 minutes after administration.
• Electromyography (EMG) is a neurophysiologic test used to determine the neuromuscular integrity of pelvic floor muscles. Most gynecologists and urologists have limited experience with this modality. It is mostly used in the research setting.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Emergency Department Care

The role of the emergency department is to identify and treat reversible causes of urinary incontinence and to identify causes that require further evaluation. These complex cases may require immediate care, admission for workup, or referral for further outpatient evaluation. These decisions should always be guided by the acuity of the situation and need to ensure comfort to the patient in a timely manner. Assessment of psychosocial impact can also be useful in properly evaluating and treating this multifactorial condition.

• Treatment of reversible causes
• • Discontinue medications causing detrusor hypoactivity (overflow incontinence) such as anticholinergic agents and calcium channel blockers.
  • On the other hand, if detrusor hyperactivity or stress incontinence is diagnosed, medications causing detrusor hypoactivity are very helpful.
  • Patients with bladder outlet obstruction resulting in urge incontinence benefit from alpha-adrenergic antagonists, which decrease sphincter tone. Antiandrogens and leuteinizing-releasing hormone are helpful in cases refractory to cholinergics.
  • Atrophic vaginitis can be easily identified on physical examination, and estrogen cream can be prescribed to increase tissue thickness. Alpha-agonists have been shown to be helpful in women on estrogen. They increase bladder outflow resistance and internal sphincter tone.
  • Treat the underlying cause of delirium from medical illness.
  • Identify and treat hyperglycemia which may cause excessive urination in diabetic patients
  • Disimpact patients with urinary incontinence presenting with fecal impaction.
  • Provide a commode or urinal to patients with limited mobility.
  • Treat coughs, which can aggravate stress incontinence.
  • Identify and treat all UTIs and stones.
  • A Foley catheter is helpful in cases of neurogenic bladder and overflow incontinence to prevent hydronephrosis but should be avoided in cases of urge incontinence because it usually exacerbates the patient's symptoms.
• Surgical/other treatment
• • Urge incontinence
    • Electrical stimulation reflex inhibition of detrusor
    • Cystoplasty augmentation
    • Urinary diversion
    • Artificial sphincter
    • Dorsal rhizotomy and sacral electrode implantation encourages bladder emptying and detrusor contraction
  • Stress incontinence
    • Periurethral bulking injections
    • Artificial sphincters
    • Pessaries for female
    • Penile clamps/sheaths for men
    • Bladder neck elevation surgery
    • Electric stimulation to encourage sphincter and pelvic floor muscle contractions
  • Urethral obstruction may require urethral stricture dilatation.

Consultations

• The following conditions should be evaluation by a urologist or a urogynecologist:
• • All suspected bladder neoplasm, unexplained hematuria, and recent voiding symptoms within 1-2 months require cystoscopic evaluation.
  • History of prior radical pelvic surgery or pelvic radiation
  • Prior pelvic incontinence surgery
  • Gross pelvic prolapse

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Goal of therapy is to improve the symptoms of frequency, nocturia, urgency, and urgency incontinence. Treatment options include anticholinergics, antispasmodic agents, and TCAs.

Drug Category: Anticholinergics

These agents inhibit the binding of acetylcholine to the cholinergic receptor, thereby suppressing involuntary bladder contraction of any etiology. In addition, they increase the volume of the first involuntary bladder contraction, decrease the amplitude of the involuntary bladder contraction, and may increase bladder capacity.

Drug Category: Tricyclic antidepressants

These agents have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. However, exact mechanisms by which these drugs act in the treatment of incontinence are not fully understood. The Agency for Health Care Policy and Research (AHCPR) guidelines caution that TCAs should be reserved for use in carefully evaluated patients.

Drug Category: Adrenergic agonists

These agents are beneficial in the treatment of mild to moderately severe stress incontinence in women.

Drug Category: Alpha-adrenergic blockers

These agents have been used to decrease bladder overactivity with some success in patients who have decentralized or autonomous bladders as the result of myelodysplasia, spinal cord injury, or radical pelvic surgery.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Outpatient Care

• Encourage maintenance of a voiding diary or incontinence charts where appropriate and encourage patients to take it to their follow-up appointment.
• Discharge patients with appropriate medications if indicated and scheduled follow-up care with a primary care physician. Complicated cases need referral to a urologist or urogynecologist.
• Timed voiding or bladder training regimens helpful for urge incontinence.
• Encourage weight loss in obese women with urethral hypermobility or stress incontinence. Motivated patients can benefit from Kegel exercise to strengthen the pelvic floor muscle important in urethral suspension.
• Evaluate and ensure adequate follow-up of patient's with functional incontinence; ie, arrangement of bedside commode if decreased mobility is an issue.
• Adequate follow-up of patients with impaired psychosocial function causing urinary incontinence or resulting from urinary incontinence.

Deterrence/Prevention

• Prevention includes effective voiding habits and limiting alcohol, caffeine, and carbonated beverages.
• Avoid indwelling urinary catheters to decrease the risk of infection.
• Women with pelvic floor laxity who avoid surgery may benefit from pessaries.

Complications

• Adverse effects from medication
• Development of skin break down and infection from continued exposure to urine
• Surgical complications such as bleeding and damage to surrounding nerves and blood vessels

Prognosis

• Stress incontinence: Medications do not play a major role in the management of stress incontinence. The most effective treatments of stress incontinence are muscle exercises and surgery. The improvement rate with alpha-agonists is 19-74%, while the rate with muscle exercise and surgery are 87% and 88%, respectively.
• Urge incontinence: Studies show that bladder training has a higher improvement rate (75%) compared with the use of anticholinergics (44%). Surgical options for urge incontinence are limited and have a high morbidity.
• Mixed incontinence: Bladder training and pelvic exercises result in higher improvement rate than the use of anticholinergic medications.
• Overflow incontinence: Medications and surgery are very effective in improving symptoms.

Patient Education

• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bladder Control Problems and Understanding Bladder Control Medications.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

• Barry WD. Selecting medications for treatment of urinary incontinence. Am Fam Physician. 2005;71(2):315-22,329.
• Chutka DS, Fleming KC, Evans MP. Urinary incontinence in the elderly population. Mayo Clin Proc. Jan 1996;71(1):93-101. [Medline].
• Dupont MC, Albo ME, Raz S. Diagnosis of stress urinary incontinence. An overview. Urol Clin North Am. Aug 1996;23(3):407-15. [Medline].
• Erdem N, Chu FM. Management of overactive bladder and urge urinary incontinence in the elderly patient. Am J Med. Mar 2006;119(3 Suppl 1):29-36. [Medline].
• Fultz NH, Herzog AR. Epidemiology of urinary symptoms in the geriatric population. Urol Clin North Am. Feb 1996;23(1):1-10. [Medline].
• Lemack G, Zimmern P. Treatment Options for Urinary Incontinence in Women. Resid Staff Physician. 2000;46(7):35-6, 43-6.
• Mills W, Grennland JE, McMurray G. Studies of the pathophysiology of idiopathic detrusor instability: the physiologic properties of detrusor smooth muscle and its pattern of instability. J Urol. Feb 2000;163(2):646-51.
• Nazir T, Khan Z, Barber HR. Urinary incontinence. Clin Obstet Gynecol. Dec 1996;39(4):906-11. [Medline].

Article Last Updated: Jul 13, 2006