Urinary Incontinence in Women

Essentials

• It is important to differentiate stress incontinence from other types of incontinence which may also be caused by different treatable gynaecological, urological or neurological illnesses.
• Weight control, maintenance of pelvic floor muscle strength, abstaining from smoking, treatment of constipation as well as physical activity all prevent urinary incontinence.
• Guided pelvic floor muscle training is used in the treament of mild and moderate urge incontinence.
• For severe stress incontinence, mini-invasive suburethral sling procedures are applicable.
• Urge incontinence may be treated with pharmacotherapy.
• Topical oestrogen therapy, administered vaginally, alleviates the symptoms of urge incontinence in postmenopausal women.

Types of incontinence

• In stress incontinence, involuntary loss of urine occurs during physical exertion or strain (e.g. coughing or sneezing), and it affects up to three quarters of adult patients who present with incontinence.
• Urge incontinence is characterised by a sudden urge to urinate followed by involuntary loss of urine, either during the urge or immediately afterwards. It is typically seen in elderly post-menopausal women and also in young women. The detrusor muscle is hyperactive and hypersensitive.
  • Overactive bladder (OAB) is a contentious syndrome that is considered to consist of various combinations of urge to urinate and pollakiuria (> 8 voids per 24 hours) or nocturia (> 2 voids per night).
• Mixed incontinence is a combination of the two above types. It is most common in women aged over 70 years.
• Incomplete voiding and urinary retention, whether acute or chronic, may lead to overflow incontinence.

Epidemiology

• See Gynaecological Prolapses.
• In epidemiological studies, the prevalence of female urinary incontinence in the adult population has ranged between 5% and 58% (median 28%). More than 50% of patients conceal the problem.
• Approximately 6-7% of the population suffers from urinary incontinence of sufficient severity to interfere with their quality of life.
• Urinary incontinence increases in frequency with age. Around 60% of women over 70 years of age suffer from it.

Aetiology

• Stress incontinence is caused by weakness of the structures supporting the urethra or by sphincter insufficiency. The risk factors for stress incontinence include obesity (BMI > 25), pregnancy and giving birth as well as heavy smoking. Congenital connective tissue weakness may also be a risk factor for stress incontinence.
• In urge incontinence bladder muscles contract inappropriately, the cause of which may be
  • neurogenic (MS, memory disorders, disturbances in cerebral circulation, Parkinson's disease, diabetes)
  • non-neurogenic (acute or recurrent urinary tract infection, history of complicated urinary tract infections, tumour, disease affecting the bladder wall, bladder calculus, local oestrogen deficiency in postmenopausal women, fast bladder filling, diuretics, hysterectomy)
  • idiopathic; in approximately 80% of cases the cause remains unknown.
• Overflow incontinence is caused either by impaired micturition reflex (e.g. a neurogenic aetiology, post surgery, a drug adverse effect) or by a mechanical obstruction (tumour, prolapse).

Investigations

Indications for a referral to specialist care

• Haematuria or a suspicion of a bladder disease (difficulty urinating, pain associated with incontinence)
• Residual urine volume more than 300 ml
• Symptomatic prolapse
• Pelvic tumour
• Neurological problems
• Troublesome incontinence that has already been treated with surgery
• Suspicion of a fistula
• Treatment-resistant urge incontinence
• Severe stress incontinence, or if physiotherapy fails to provide adequate relief
• Problems in differential diagnosis

Conservative treatment Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women, Pelvic Floor Muscle Training for Urinary Incontinence in Women, Pelvic Floor Muscle Training Added to Another Active Treatment Versus the Same Active Treatment Alone for Urinary Incontinence in Women, Pelvic Floor Muscle Training for Urinary and Faecal Incontinence in Antenatal and Postnatal Women, Biofeedback to Augment Pelvic Floor Muscle Training for Urinary Incontinence in Women, Bladder Training for Urinary Incontinence

• Lifestyle changes may alleviate both urge and stress incontinence.
  • Weight loss (5-10%) alleviates incontinence symptoms and improves the quality of life Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women.
  • Fluid restriction for those who consume excessive amounts of fluids (usually 1.5-2 l/day is a sufficient fluid amount).
  • Avoid drinks that may possibly cause irritation (coffee, tea, caffeine, alcohol and beverages containing carbonic acid).
  • Treatment of constipation.
  • Not smoking.
• Pelvic floor muscle training Pelvic Floor Muscle Training Added to Another Active Treatment Versus the Same Active Treatment Alone for Urinary Incontinence in Women
  • Supervised regular pelvic floor muscle training of 2-6 months' duration is an effective form of therapy for stress incontinence, possibly also for other types of urinary incontinence Pelvic Floor Muscle Training for Urinary Incontinence in Women. Later, maintenance training should take place twice or thrice weekly.
  • Pelvic floor muscle training is also beneficial in postpartum incontinence Pelvic Floor Muscle Training for Urinary and Faecal Incontinence in Antenatal and Postnatal Women.
  • If the outcome of supervised training is not satisfactory after 2 months, the patient should be referred to an appropriately trained physiotherapist for biofeedback-assisted training Biofeedback to Augment Pelvic Floor Muscle Training for Urinary Incontinence in Women.
• Electrical stimulation of the tibial or pudendal nerve in order to reduce the overactivity of the bladder muscle as well as bladder training (deliberate increase of the time between emptying the bladder) may also be employed in urge incontinence Bladder Training for Urinary Incontinence.

Surgical treatment Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women, Periurethral Injection Therapy for Urinary Incontinence in Women, Botulinum Toxin Injections for Adults with Urgency Urinary Incontinence or Overactive Bladder Syndrome, Surgery for Pelvic Organ Prolapse with Stress Urinary Incontinence

• Stress incontinence may be treated surgically, if considered appropriate by a urogynaecologist.
  • Mini-invasive suburethral sling procedures are effective Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women and can be carried out under local anaesthesia.
    • Tension-free vaginal tape (TVT) made of polypropylene mesh may be inserted retropubically underneath the midurethral region Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women.
    • In transobturator tape procedures (TOT, TVT-O) the mesh is tunnelled from the vaginal side to the top of the thigh or vice versa Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women.
    • Postoperative check-up only as necessary.
    • In pure stress incontinence the long-term outcome is good.
      • In a follow-up study, 17 years after a TVT operation, 84% of the women were objectively and 79% subjectively cured of stress incontinence.
    • In mixed incontinence the results are poorer.
  • Injection therapies
    • Water-based polyacrylamide hydrogel (Bulkamid^® ) is injected around the urethra under local anaesthesia; it can be done as outpatient surgery.
    • Injection therapy is particularly applicable in high-risk patients and for recurring, but also for primary, stress incontinence.
    • Injection therapy is safer but less effective than a sling procedure Periurethral Injection Therapy for Urinary Incontinence in Women.
• Urge incontinence
  • Surgery is of no help in pure urge incontinence. In severe cases refractory to other treatments, injections of botulinum toxin A into the bladder wall have provided promising results.
    • Treatment can be performed in an outpatient setting by first applying local anaesthesia inside the bladder using lidocaine solution and then injecting the drug with an endoscopic needle inserted through a cystoscope.
    • Injection of botulinum toxin A restores continence in about 50% of patients and the effect remains for about 6 months Botulinum Toxin Injections for Adults with Urgency Urinary Incontinence or Overactive Bladder Syndrome.
  • Sacral nerve root neuromodulation
  • Augmentation cystoplasty or a urinary stoma may be considered in extreme cases.
• The treatment for mixed incontinence is chosen according to the dominant type of incontinence.

Incontinence protection

• Vaginal cones and tampons prevent incontinence during short-lasting physical exercise.
• Absorbent pads, pants and protective bedding will provide protection. In a persistent and severe incontinence the patient may be entitled to obtaining assistive devices and/or care supplies, such as pads or diapers, from public services. A trained incontinence nurse will be in charge of patient education and supplying incontinence products.