Dr Toni Hazell Shares 10 Top Tips on Diagnosing and Managing Urinary Incontinence in Women
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Urinary incontinence is defined as ‘any involuntary leakage of urine’ and it is more common in women than in men, often related to childbirth. In one UK study involving female patients over the age of 21 at a single medical practice, 40% of respondents reported experiencing urinary incontinence.1 Prevalence varies with age and older women are more likely to have severe symptoms than younger women.2
1. Identify the Cause of Incontinence
There are three main causes of female incontinence: stress, urgency, and overflow.2 Treatment varies based on the cause, so it is important to take a focused history to try and work out which type the patient has, or which type predominates. The most common single cause is stress incontinence, but many women will have a mixed picture.2,3
Stress incontinence is often related to pregnancy and vaginal delivery (with or without instrumental assistance), which causes weakening of muscles and connective tissue, and damage to the pelvic and pudendal nerves. Other risk factors include anything that puts pressure on the pelvic structures, including obesity or constipation. Hysterectomy may damage the pelvic floor muscles, and a lack of oestrogen after the menopause may also be a contributing factor. Prolapse is not in itself a cause of stress incontinence, but a finding of prolapse indicates that tissues are poorly supported, which also increases the risk of stress incontinence.2
Urgency incontinence is usually idiopathic, and can be associated with overactive bladder syndrome. It can be exacerbated by obesity, diabetes, and chronic urinary tract infections. It can also be associated with a chronic neurological problem, such as a spinal nerve injury or multiple sclerosis, and can be iatrogenic (for example due to antidepressants and diuretics).2
Overflow incontinence is usually due to obstruction at the bladder outlet or an underactive bladder due to chronic neurological disease. It can also be iatrogenic; some causative agents include angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, and beta agonists, among other drugs.2
2. Base the Diagnosis Primarily on History
It is often taught at medical school that the diagnosis should be based 80% on the history, with examination and investigations only contributing 10% each, and this is certainly true for incontinence (with the tests probably contributing even less). There are typical presentations and things to note from the history for each type of incontinence (see Table 1).2 It may be helpful to establish the severity of the incontinence by asking the person to fill in a bladder diary, and asking about things such as the number of pads used and whether clothing needs to be changed during the day.
Table 1: Typical Presentations for Urinary Incontinence2
|Incontinence Type||Typical Presentations|
3. Do Not Limit Examination to the Pelvic Area
Determine whether there is anything in the examination to suggest a secondary neurological cause, such as an abnormal gait, a history of previously undiagnosed odd neurological episodes, or other obvious current neurological deficiency. Check the patient’s body mass index (BMI), and palpate the abdomen for an obviously large bladder or other pelvic mass (such as large uterine fibroids).2
Offer a chaperone for the pelvic examination and start by looking for obvious atrophic vaginitis at the introitus. If the person is comfortable doing this, and has not just emptied their bladder, you can ask them to cough and observe any leakage.
From the vaginal examination, look for signs of prolapse and ask the person to squeeze your fingers to assess pelvic muscle tone; this is useful if stress incontinence is suspected.2 A speculum examination will give a better idea of the degree of any prolapse, and a noticeable mass protruding from the anterior vaginal wall should raise a suspicion of urethral diverticulum, though this is often not easy to see clinically.
4. Ask About the Consequences of the Incontinence
Incontinence may have significant physical and mental health sequelae. Ask about anxiety and depression, including isolation if a person is frightened to go too far from the toilet. Quality of life and mood may also be impacted by lack of sleep if there is nocturia, and there may be relationship issues if they are too embarrassed to have sex. Older people are at particular risk of falls if they have urgency and/or nocturia and anyone with a bladder outlet obstruction is at risk of renal impairment.
5. Test Only When Required
NICE recommends that every person with incontinence should have urinary dipstick analysis to test for infection.2 If there are symptoms suggestive of infection and the sample has white cells and nitrites, the patient should be treated; NICE guidance offers separate guidance on treatment of urinary tract infections.4 Other than that, investigations do not really add much to the assessment of incontinence. NICE does not mention renal scans as part of the investigation of female incontinence, but if there is suspicion of chronic retention a scan would be a logical investigation—be sure to ask for pre- and post-void bladder volumes.
6. Refer if there are Red Flags
The NICE suspected cancer pathway for bladder cancer states that a patient should be referred if they are aged 45 years or older and have unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after the successful treatment of a UTI.5 The referral threshold drops once the patient reaches 60 years of age, at which point anyone with unexplained non-visible haematuria who also has dysuria or a raised white cell count on a blood test should be referred.5 Referral outside of the 2-week wait pathway should be considered if any of the criteria for non-urgent referral are met (see Box 1).
|Box 1: Criteria for Non-urgent Referral of People with Urinary Symptoms2|
7. Tailor Management to the Cause
Treatment of urinary incontinence depends on the cause, and where the cause is mixed incontinence, treatment should reflect the predominant symptom. Lifestyle advice could include smoking cessation, weight loss (if indicated), reducing caffeine intake, and drinking a sensible amount of fluid each day (not too much or too little).2
Pelvic floor muscle training (PFMT) is first-line management for stress incontinence, and this should ideally be done under supervision, for at least 3 months,2 rather than just giving the person a leaflet and telling them to try PFMT at home. Depending on the local pathway, supervision might be provided by a continence advisor, nurse specialist, or physiotherapist. Home exercises could be used while the patient is waiting to start the supervised course.6
NICE recommends referral to a urogynaecologist, gynaecologist, or urologist (depending on local service provision) if PFMT fails, although duloxetine is an option for where surgical treatment is unsuitable or unwanted.2 Be aware that duloxetine has significant potential drug interactions, such as with antiplatelet drugs, anticoagulants, antidepressants, and ciprofloxacin.2
Urgency incontinence should be treated in the first instance with bladder training (also known as bladder drill);2 as with PFMT, this is better if supervised rather than done by the patient on their own at home. If there is no access to supervised bladder training, or the patient wants to start on their own while waiting to be seen, there are explanatory leaflets available online.7 Setting reasonable explanations and acknowledging small gains is important.
Second-line management involves adding in an antimuscarinic drug (while encouraging ongoing attempts at bladder training). NICE advises using oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once-daily preparation) on the grounds of cost,2 but many patients find these difficult to tolerate due to side-effects, in which case it may be worth changing to an extended release version of oxybutynin (oral or transdermal), or to solifenacin.2 A list of second-line options is provided in Box 2. It is worth noting that anticholinergics were in the news last year due to concerns about an associated increased risk of dementia,8,9 and that immediate release oxybutynin is now contraindicated in older women.2
Mirabegron, a beta-3-adrenoceptor agonist, is also a second-line option but restricted by NICE to ‘treating the symptoms of overactive bladder in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects’.10 It is contraindicated in severe hypertension (≥180/110 mmHg), and caution should be applied in those with any hypertension.11
|Box 2: Second-line Antimuscarinics for Urgency Incontinence2|
NICE recommends that if a first-line medicine for overactive bladder is not effective or well tolerated, an alternative medicine with a low acquisition cost may be considered (do not offer flavoxate, propantheline, or imipramine). Options include:
© NICE 2019 Incontinence—urinary, in women. Available from cks.nice.org.uk/topics/incontinence-urinary-in-women All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Patients with overflow incontinence should generally be referred to an appropriate specialist as there may be a cause which is amenable to surgical intervention, and primary care has little ability to offer more in terms of management.
8. Offer Topical Oestrogen Where Helpful
Have a low threshold to offer topical oestrogen to women who are peri- or post-menopausal.12 There are a lot of urban myths out there regarding hormone replacement therapy (HRT); ensure patients are directed to good quality information such as the ‘Rock My Menopause’ campaign,13 reputable patient information sources (for example, patient.info14 or nhs.uk15), or the menopause hub on the Royal College of Obstetricians and Gynaecologists website.16
Some women may need vaginal oestrogen in addition to a systemic preparation of HRT and you can reassure them that this does not constitute an overdose. A helpful analogy is that using vaginal oestrogen for 1 year is equal to approximately one single tablet of oral HRT.17 The summary of product characteristics will often say that vaginal oestrogen is contraindicated in women who have had previous breast cancer, but data does not show an increased risk of recurrence or first breast cancer.18 Vaginal oestrogen remains a reasonable choice for these women (but not for those taking aromatase inhibitors) although it is sensible to try non-hormonal options such as lubricants first.19 If you or the patient are concerned, talk to the patient’s oncologist. It is also important to follow relevant professional guidance, taking full responsibility for all clinical decisions—informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices for further information.20
9. Avoid Overusing Pads
For most patients, pads and other toileting aids should not be a significant part of the management of incontinence.2 The aim should be to find the cause and treat it, and the ongoing use of pads in the long term suggests that this is not happening. Pads may be useful for some in the short-term, and there will be some patients for whom pads are the only reasonable option (for example those who are terminally ill, or too frail for any other treatment) but in general think twice before referring for pads—is there more that could be done for this patient?
10. Be Vigilant for Complaints About Mesh
There are lawsuits currently underway concerning the use of surgical mesh for procedures to treat prolapse and incontinence,21 with some concerning allegations raised about links between clinicians, regulators, and industry.22 The use of mesh is a surgical decision and not one made in primary care, but we may still encounter patients who experience pain or other symptoms that relate to the previous use of mesh in surgery, and who want to seek an opinion on what they should do now. The British Association of Urological Surgeons has published an interactive map of specialist centres for dealing with these issues; patients should be referred to one of these hospitals.23
Dr Toni Hazell
Part-time GP, Greater London
Declaration of interest
Dr Hazell is a member of the executive committee of the Primary Care Women’s Health Forum, a role which involves both paid and unpaid work.
The author would like to thank Dr Sarah Gray and Dr Hannah Short for their valued help in the preparation of this article.