Management of Urinary Incontinence in Women ( GP GUIDE)

A. Definition and Epidemiology

          B. Classification of Urinary Incontinence

C. Making the diagnosis (History/ Physical & pelvic Assessment/Investigation)

D. Red flags and Referral

E. Treatment option for Primary Care Givers

A. Definition and Epidemiology

Urinary incontinence (UI) has been defined the by International Continence Society (ICS) as involuntary loss of urine which is objectively demonstrable and is a social and hygienic problem1. Urinary incontinence is the most common chronic medical disorder in women, accounting for about 35% of all chronic medical conditions, much more common than hypertension (25%), depression (20%) and diabetes (8%) (2). The most common causes for urinary incontinence in women are urinary stress incontinence, urge incontinence, mixed urinary incontinence & overflow incontinence. Urine loss through other than the urethra is extra-urethral incontinence, e.g. congenital, fistula (3).

Prevalence data varies considerably with the definition of urinary incontinence and population base or studies. European and American epidemiological studies reported the prevalence to be between 10-40%. An Australian based study showed that every 1 in 4 women suffers from urinary incontinence(4). In a study in Malaysia, among young nulliparous women, the prevalence of Lower Urinary Tract Symptoms (LUTS) was 52.7% (5). 

Urinary incontinence has a significant impact on the quality of life. A wide range of women (8-58%) who suffer urinary incontinence reported some degree of interference with their physical, psychological, and social lives. The impact of urinary incontinence on the quality of life includes social isolation, and depression. Many of them suffer in silence and do not seek help (6,7).

B. Classification of Urinary Incontinence 

For simplicity the UI in women are divided in four categories.

SUI: (25-45 %) of UI usually seen in younger women can be due to childbirth trauma (urethral hypermobility), congenital weakness, previous surgery, radiation (intrinsic sphincter deficiency, ISD). Usually it is easy to diagnose this condition; patients usually have urine leakage on valsalva/ exersion/ cough/sneezing /physical activity7. The urine leakage can be demonstrable on lying down, at the time of pelvic examination. We can also ask patients to stand on covered sheet and ask them to bend forward and do some valsalva/cough vigorously few times. Presence of urine leakage on the cover sheet indicates a positive stress test. Patients must not empty the bladder before this test (there must be at least 150mls in bladder before doing this test) (1,2,7).

Urge Incontinence: (9-31 %) Idiopathic in most cases, nervous system disorders like multiple sclerosis, diabetes, genital syndrome of menopause (GSM)/ atrophic vaginitis, constipation/ impaction stool, urinary stones, cancer or cystitis are some of the common causes for UI. In patients with Urge incontinence, most patients will have Frequency (F), Urgency (U) with or without incontinence and Nocturia (N):  “FUN” symptoms (1,2,7)

Mixed UI: (20-30%) In cases of mixed incontinence, the patients normally have mixed symptoms of stress incontinence and urge incontinence. In managing such patients the GP’s need to find out which is the predominant symptom and treat the most troubling symptom first (3,7). 

Overflow Incontinence: Occurs in 5-7% of cases. This is usually due to chronic retention which can be the result of local factors like urethral stricture/ stenosis, vaginal or peri-urethral mass or obstruction and in some case any pelvic organ prolapse may also cause obstruction or kinking effect on the urethra. The systemic factors are like brain (CNS) mass or lesions, cognitive disorders/impairments, spinal trauma, spinal disc problems, medications, CNS surgery and tumours (1,2,7).

C. Making the diagnosis (History/ Physical & pelvic Assessment/Investigation)

A thorough assessment is required to make an accurate diagnosis. This includes history-taking, physical examination and some relevant investigations. 

1. History taking 

The assessment of urinary incontinence (UI) involves taking a detailed history regarding the duration and nature of UI. Understanding the symptoms allows appropriate questions to be asked, and this is crucial to differentiate the types of urinary incontinence.

-  Stress urinary incontinence: Urine leak on exertion, like coughing, sneezing, laughing or doing certain physical activity that causes increase intra-abdominal pressure.

- Urge urinary incontinence: Urine leak associated with urgency (women may have urgency and wet themselves before reaching the toilet)

- Urgency: A strong desire to pass urine, in which the patient finds it hard to differ urination.

          - Frequency: Urinating more than 8 times /day during the day time.

- Nocturia: Urinating more than once after going to bed. 

- Overflow incontinence: Patient may present with difficulty to initiate micturition, some may need to strain to void, poor or disruptive flow of urine & incomplete voiding.

- Mixed urinary incontinence:  The presence of both  stress & Urge urinary incontinence.

In addition:

- Fluid intake history

- Symptoms suggestive of utero-vaginal prolapse, bowel symptoms & sexual history

- Past obstetric history including the number deliveries, the weight of the babies and       any episiotomy or instrumental vaginal deliveries. 

- Past surgical history, e.g. incontinence surgery, caesarean section, pelvic organ prolapse repair and hysterectomy

- Patient general health or medical problems like COAD, asthma, mental status/cognitive disorders and any neurological condition

- Drug history, as some medications may contribute to UI, such as diuretics, some anti-depression, anti-psychotic, alpha & beta-adrenergic blockers & agonist.

2. Physical examination: 

- In patients with UI, it’s essential to perform an abdominal and pelvic examination/assessment (7,8). Neurological assessment may need to be done in certain indicated cases.

- Abdominal examination: look for old surgical scars which may indicate prior hysterectomy or incontinence surgery; also feel for any pelvic masses or distended bladder

- Pelvic assessment: look at the external genitalia, any prolapse, vaginal discharge and signs of  atrophy of the vulvo-vaginal. Speculum and bimanual examination will provide some information on the stage of prolapse if any, the size of uterus and any pelvic masses.

- Cough/stress test: This simple test can be done on lying or standing. The patient must not pass urine before the test. Ask patients to cough or perform valsalva manoeuvre a few times. Any urine leakage may indicate the patient has stress urinary incontinence (SUI).

- In some cases, a gentle stroke on the urethral or bladder base may induce spontaneous urinary leakage. This may suggest overactive bladder/ urge incontinence.

- Neurological examination: Look for any upper motor or lower motor lesions or disorders. Pay more attention to the nerve distribution of S2-4. These nerves can be assessed by assessing the lower limb motor function & reflex responses, testing the perineal and perianal sensation/ tone.

3. Investigations

- Bladder diary: This basic investigation tool is also known as Frequency Volume Chart (F/Q Chart). It is simple and patients can easily complete it. Patients are required to list down all the type and volume of fluid intake and output. They also need to record any events like urgency, urinary leakage and condition associated with the urine leak. By looking at the pattern of fluid intake and urine output, the GP’s can assess if the patients are consuming too much or too little fluids. They can also detect the presence of urinary frequency and nocturia. The presence of urgency and urge incontinence may indicate urge incontinence.

- Urine analysis and culture: This may rule out any evidence of urinary tract infection (UTI) as the cause for the UI. If there is a presence of significant hematuria, the patient may require further evaluation.

- Pelvic/Bladder Ultrasound: A pelvic ultrasound can exclude any pelvic masses, can assess the bladder volume and post-void residual urine (PVR). Overflow urinary incontinence can easily be diagnosed if a woman has urinary incontinence and ultrasound showed a distended bladder high PVR, more than 100mls after micturition (7,8).

D. Assessment to rule out RED flag cases and referrals

- Presence of RED flag markers may indicate some serious pathology & these patients need further evaluation. The Red flag markers including recurrent UTI, painful bladder syndrome, distended bladder,  presence of hematuria, passing out urinary stones, presence of a visible vaginal prolapse, neurological deficits and etc. It is advisable to refer such patients to the respective specialty. 

- If no improvement in 6-8 weeks, a referral can be made to the community continence service/ urogynaecologist or urologist for further assessment, conservative or supportive treatment, and in some cases surgery may be indicated

E. Treatment option for Primary Care Givers

Management of urinary incontinence encompasses detail history taking, doing proper general & pelvic assessment and doing appropriate investigation. In most cases the diagnosis can be established if we follow the sequence of investigation as mention above. Once the diagnosis is establish than we can focus on managing them based on the diagnosis (7,8). 

1. The initial treatment in any of the urinary incontinence is behavioral modification or life style intervention. 

- Patient should be advised to consume about 2-litres (6-8 cups) a day. The change in fluid intake is adjusted based on the bladder dairy (9).

- In older/geriatric patients, there is a strong correlation between evening fluid intake and nocturia. In such cases, patients are advised to avoid any fluid intake 2 hours before going to bed. 

- Avoid ‘just in case’ voiding patterns or habits

- They should be taught on proper toiletry hygiene 

- Proper technique to pass urine (lean forward technique), passing urine with feet flat on the floor and elbows resting on knees (10,11). 

- Patients are also advice to avoid bladder irritants like caffeinated drinks & alcohol. Patients are encouraged to consume cranberry/ spirulina juice or tablets as some studies consider them as bladder friendly.(12)

- Other interventions include reducing weight, reduction in excessive physical activity, avoidance of constipation/straining and cessation of smoking (13). 

- Patients who are post-menopausal and have symptoms of GSM are advised to apply topical estrogen.  

2.  Pelvic floor exercise (PFE): The pelvic floor exercises are aimed at strengthening the pelvic floor muscles. The PFE can be taught to patients at the time of pelvic assessment or referred to the physiotherapist to help with the exercises. The exercises should be done with three to four sets of about 8-10 slow pelvic contractions, sustained for 8-10 seconds and repeated 3-4 times per week. The PFE is performed for 6 weeks to 3 months. The short term improvement & cure rate are quoted from 65-75%. PFE is effective for stress as well as mixed urinary incontinence (14). 

3. Bladder Retraining: Is a behavioral modification technique which can be taught to patients at GP setting. The aim of bladder retraining is to increase the capacity of the bladder until it can hold the normal amount of urine (300 – 500 mls). By stretching the bladder, patients can reduce visits to the toilet to 5-7 times during the day and 0-1 time at night. Patients can be taught about proper bladder care, technique to increase the void internal in cases of urgency, urge incontinence and overactive bladder. Patients are advised to delay the void interval from 15-30min initially and gradually  increase the intervals to 3-4 hours. They are also taught how to defer the void sensation with various distractive techniques. The distractive techniques include in-curving of the 1st toes, squeezing the pelvic muscle, mental distraction at the time of urge and others (15).

4. Estrogen Therapy: Application of topical estrogen has been shown be effective in reducing vaginal & bladder irrigative symptoms. Meta-analysis by Fantl & Sultana in 1994 has shown that it is more effective for urge incontinence, recurrent urinary tract infection than stress incontinence (16,17). 

5. Pharmacological therapy: 

- There is no effective medical treatment for stress incontinence.  Alpha- adrenergic agonists & duloxetine are some of the drugs used for SUI. These drugs did not get US FDA approval for usage in SUI.

- For urge incontinence/ overactive bladder symptoms: 

The commonly used drugs are anticholinergic or antimuscarinic drugs. These drugs are contraindicated in patients with narrow-angle glaucoma and cardiac arrhythmia. Patients also need to be counseled about the common side effects which include dry mouth, constipation, tachycardia and transient blurring of vision. Antimuscarinic drugs that are commonly used are oxybutynin, tolterodine, solifenacin, derifenacin and others. Mirabegron is a beta –adrenergic agonist that acts on beta-3 receptors in the detrusor muscles and increase the bladder capacity (18,19,20). Use of medical therapy is ONLY recommended after the first line / initial treatment fails.

- When using medical therapy, there must be a clear indication. Patient must be adequately counselled with regards to the indication, side effects, contraindications, duration of treatment and the benefits of this treatment

- Initial medical treatment is started with low dose & long acting drugs, patient must be review 6-8 weeks to assess the side effects & effectiveness of this treatment. Doses can be adjusted depending on patients’ response. Bladder dairy can be of use to assess the symptoms & effectiveness of the treatment  (20).

F. Devices & other no pharmacological therapy

- In patient with genuine stress incontinence (SUI), one can try incontinence pessaries/occlusive devices. Some form of training is required before GP’s can try these pessaries or occlusive devices.( 21)

- Electrical stimulation (percutaneous tibial nerve stimulation) can be tried for urge UI. A weekly stimulation for 3 months followed by monthly stimulation has shown similar effect as antimuscarinics medication (21).

- For patients with obstructive bladder symptoms secondary to prolapse, one can insert a vaginal pessary to release the pressure / kinking effect. Application of pessary or devices needs practice & some training.

-  If there is an over-distended bladder without any obstructive pathology, one can insert an indwelling catheter to empty the bladder before sending to specialist hospitals.

References

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