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Urinary Incontinence-Women

Frequently seen in Primary Care. This chart on A4Medicine describes the types, causes, impact, and management of urinary incontinence in women. Bladder control is complex and is briefly mentioned – this helps to understand the pharmacological management of UI. On the first presentation, the reader is advised to complete the sections of history, examination ( if indicated ) to determine the type of UI.Pelvic floor muscle exercises are considered the first line in both type of UIs and pharmacological management is discussed. Use of individual anti-cholinergic is beyond the scope of this review and clinician should consider familiarising themselves with 2-3 preparations. Indications for referral are also discussed.

Involuntary passage of urine

Stress UI- Decreased outlet resistance
( eg pelvic floor muscle weakness , bladder outlet or urethral sphincter weakness )
 Damage to the urethral sphincter from childbirth , pelvic surgery  Involuntary leakage on effort or exertion eg when sneezing , coughing or laughing

Urgency UI-Involuntary increase in bladder pressure due to detrusor over-activity – caused by a range of factors as
outflow obstruction
CNS conditions
Local conditions as bladder stone , tumor Involuntary leakage accompanied , or immediately preceded by a strong urge to urinate

Mixed UI-Combination of urgency and stress – most common in older women and symptoms depend on which type predominates

Overactive Bladder Syndrome
( OAB ) Urinary urgency ( with or without urgency incontinence ) usually associated with increased frequency and nocturia

overflow incontinence- Complication of chronic urinary retention ( also known as Incontinence with high post-void residual )
Can lead to continuous or frequent loss of small quantities of urine

○ Outflow obstruction
○ Detrusor underactivity

Continous urinary incontinence-Constant leakage of urine- wet all the time- may be due to severity of the persons condition eg overflow incontinence or due to an underlying cause such as a fistula

Functional-Inability to reach the toilet in time – mobility , cognitive impairment , access

Disease burdrn-Under-diagnosed and underreported condition Extremely common in every part of world Older people more likely to delay seeking help Affects more than 5th of people aged 85 or over Causes significant distress and embarrassment
Physical social and emotional burden Estimates of prevalence vary widely- differing
○ study populations
○ definitions
○ methods of study Women suffer approximately twice more than men Significant costs to both individual and society–> Skin damage UTIs Increased risk falls Social isolation and alienation Increased risk of institutionalization Sexual problems Constipation 
( decreased fluid intake )Impaired quality of life

Causes of stress incontinence-Pregnancy ( ↑ intra-abdominal pressure ) Vaginal delivery ( pudendal N damage ) Obesity ( ↑ intra-abdominal pressure ) Constipation Deficiency of supporting tissues
○ prolapse
○ hysterectomy
○ collage disorders
○ oestrogen deficiency Family history Smoking Drugs

Urge incontinence causes- UTI Obstruction Impaired bladder contractility Bladder abnormalities- leading to inflammation Oestrogen deficiency Sphincter weakness Brain disorders
Multiple sclerosis Spinal cord
Canal stenosis 
( cervical or lumbar )
Disc herniation
Injury CCF Venous insufficiency with oedema Diabetes Hypercalcaemia Excess coffee , alcohol , fluids Constipation Impaired dexterity Psychological conditions

history-Urinary symptoms
○ frequency
○ urgency
○ haematuria
○ UTIs
○ nocturia Duration and if symptoms worsening Pad usage Fluid intake Pelvic organ prolapse Obstetric history – difficult deliveries , grand multiparity , forceps use , lacerations and large babies Pelvic surgery , hysterectomy Lifestyle- eg smoking , alcohol or excess caffeine Medications

Examination-Focused physical examination Examine abdomen Pelvic examination – look for
○ leakage on coughing ( full bladder )
○ pelvic floor musculature ( squeeze the finger )
○ pelvic organ prolapse
○ urethral diverticulum
○ pelvic mass
○ atrophic vaginitis Lower extremity oedema Cognitive status Neurological exam Urine analysis ( all patients )
○ microalbumin , glucose , protein , leucocytes , nitrites ( MSU if indicated ) Renal function if AKI , obstruction suspected and other bloods if systemic cause suspected BMI

management stress UI- Manage any reversible cause or contributing factor Lifestyle advice
○ caffeine ( may improve urgency , frequency but not incontinence )
○ fluid intake ( 6-8 glasses of water / day is N )
○ weight loss
○ smoking –> cough ↑↑ SUI Supervised Pelvic floor training ( PFMT ) Anti-incontinence devices Pessaries
 Duloxetine is the only licensed medication in UK for SUI
○ offer only if women prefers drug to surgical Rx
○ not suitable for surgical Rx
○ may increase urethral sphincter contraction and closure pressure via effects in the sacral spinal cord–> reducing UI
○ can effectively treat SUI
○ + 100 surgical procedures described – but common types are
♦ urethral bulking agents
♦ mid-urethral tape procedures
♦ colposuspension
♦ fascial slings

Urge UI-Address treatable cause if possible Fluid intake and lifestyle measures , self help Supervised bladder retraining AUA/SUFU guideline recommends pelvic floor muscle training as a 1st line Rx for overactive bladder syndrome Anticholinergics Beta3-Adrenoceptor Agonists- Mirabegron® Mirabegron works on beta3 adrenoceptors- decreased traditional adverse effects compared to anticholinergics Medications target the parasympathetic acetylcholine pathway to reduce intensity of detrusor contraction –> reduce feeling of urgency and improve bladder capacity Advice that it may take upto 4 weeks to work and can be continued long term if effective and advice about adverse effects + behavioral therapy Referral Alternative antimuscarinic for 4 weeks Mirabegron for 4 weeks Review at 12 weeks and annually after that

Pelvic floor muscle 
training -offer 1st line 
for Urinary Incontinence 
 with 8 contractions
 3 times
 a day for 3 months
(Cochrane database syst review 2010 )

Referral-Macroscopic ( visible ) haematuria without UTI Age 60 and over and have unexplained non-visible haematuria and either dysuria or a raised WCC count on a blood test-
( NICE 2015 ) A suspected malignant mass arising from the urinary tract or pelvis Visible haematuria that persists or recurs after successful treatment of UTI 
( NICE 2015 ) Symptomatic pelvic organ prolapse Persistent bladder or urethral pain ( USC if cancer suspected) Benign pelvic mass -eg uterine fibroids Associated faecal incontinence Suspected or known neurological disease Previous h/o
○ prolapse surgery
○ incontinence surgery
○ pelvic cancer surgery
○ previous radiation therapy Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent UTI ( NICE 2015 )


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