Urinary Incontinence in Women: Evaluation and Management Jocelyn S
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Urinary Incontinence in Women: Evaluation and Management Jocelyn S. Hu, MD, Bayne-Jones Army Community Hospital, Fort Polk, Louisiana Elyse Fiore Pierre, MD, Winn Army Community Hospital, Fort Stewart, Georgia Urinary incontinence is a common problem among women worldwide, resulting in a substantial economic burden and decreased quality of life. The Women’s Preventive Services Initiative is the only major organization that recommends annual screening for urinary incontinence in all women despite low to insufficient evidence regarding effectiveness and accuracy of methods. No other major organization endorses screening. Initial evaluation should include determining whether incon- tinence is transient or chronic; the subtype of incontinence; and identifying any red flag findings that warrant subspecialist referral such as significant -pel vic organ prolapse or suspected fistula. Helpful tools during initial evaluation include incontinence screening questionnaires, a three-day voiding diary, the cough stress test, and measurement of postvoid residual. Urinalysis should be ordered for all patients. A step-wise approach to treatment is directed at the urinary incontinence subtype, starting with conservative management, esca- lating to physical devices and medications, and ultimately referring for surgical intervention. Pelvic floor strengthening and lifestyle modifications, including appropriate fluid intake, smoking cessation, and weight loss, are first-line recom- mendations for all urinary incontinence subtypes. No medications are approved by the U.S. Food and Drug Administration for treatment of stress incontinence. Pharmacologic therapy for urge incontinence includes antimuscarinic medications and mirabegron. Patients with refrac- tory symptoms should be referred for more invasive management such as mechanical devices, injections of bulking agents, onabotulinumtoxinA injections, neuromodulation, sling procedures, or urethropexy. (Am Fam Physician. 2019; 100(6):339- 348. Copyright © 2019 American Academy of Family Physicians.) Illustration by Scott Bodell Scott by Illustration Urinary incontinence (UI), defined as any complaint of ratio of 1.27 (95% CI, 1.13 to 1.42).10 Another study found involuntary loss of urine,1 is a common issue, with a preva- that UI was associated with a 24% increased risk of all-cause lence of 51% among adult women in the United States.2 Over mortality among older institutionalized adults.11 half of affected women report that their UI symptoms are bothersome.3 This results in a substantial economic burden, Classification up to $65 billion annually.4 Comorbidities include decreased UI can be transient or chronic. Transient UI arises sud- quality of life (QOL) and productivity; increased anxiety denly, lasts less than six months, and can be reversed if the and depression; increased urinary tract and skin infections; underlying cause is addressed.12 Chronic UI is differentiated increased risk for falls and nonspine, nontraumatic frac- into stress, urge, mixed, overflow, or functional subtypes. tures in older women; and increased caregiver burden.5-9 Stress UI caused by urethral sphincter weakness or urethral A large meta-analysis of the relationship of UI to mortality hypermobility results in predictable loss of urine with activ- found that UI is associated with a pooled, adjusted hazard ities that increase intra-abdominal pressure (e.g., exercising, sneezing, laughing). Stress UI affects 25% to 45% of women older than 30 years.13 CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz on Urge UI related to detrusor overactivity causes invol- page 336. untary loss of urine associated with urgency as well as Author disclosure: No relevant financial affiliations. increased urinary frequency or nocturia. Patients typi- Patient information: A handout on this topic is available at cally lose urine on the way to the toilet. Prevalence ranges https:// family doctor.org/condition/urinary-incontinence/. from 9% of women in their forties to 31% of women in their seventies.13 Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- ◆ 339 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Septembermercial use 15, of 2019 one individual Volume user 100, of Number the website. 6 All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyright questionsAmerican and/or Family permission Physician requests. URINARY INCONTINENCE FIGURE 1 1. During the past three months, have you leaked urine (even 3. During the past three months, when did you leak urine a small amount)? most often? (choose only one) l Yes l A. When you were engaged in physical activity (e.g., coughing, sneezing, lifting, exercising) l No (questionnaire completed) l B. When you had the urge or feeling that you needed 2. During the past three months, when did you leak urine? to empty your bladder but you could not get to the toilet fast enough (choose all that apply) C. Without physical activity and without a sense of A. When you were engaged in physical activity l l urgency (e.g., coughing, sneezing, lifting, exercising) D. About equally as often with physical activity as with B. When you had the urge or feeling that you needed l l a sense of urgency to empty your bladder but you could not get to the toilet fast enough l C. Without physical activity and without a sense of urgency Definitions of the type of urinary incontinence are based on responses to question three. Response to question three Type of incontinence A. Most often with physical activity Stress only or stress predominant B. Most often with the urge to empty the bladder Urge only or urge predominant C. Without physical activity or sense of urgency Other cause only or other cause predominant D. About equally as often with physical activity and sense of urgency Mixed The 3 Incontinence Questions. Adapted with permission from Brown JS, Bradley CS, Subak LL, et al.; Diagnostic Aspects of Incontinence Study Research Group. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence.Ann Intern Med. 2006; 144(10): 716, with additional information from reference 13. Mixed UI has components of stress and urge UI and has QOL, and function.19 No other major organization rec- a prevalence of 20% to 30%. Overflow UI accounts for 5% ommends screening for UI. The National Committee for of chronic UI because of detrusor underactivity or bladder Quality Assurance lists Management of Urinary Inconti- outlet obstruction, which leads to urinary retention and nence in Older Adults as a Healthcare Effectiveness Data subsequent leakage.13 Patients may strain to pass urine or and Information Set measure based on responses to the have a sensation of incomplete emptying. Functional UI Medicare Health Outcomes Survey. The measure does not occurs when there are barriers to toileting, such as cognitive require universal screening; it is scored on the percentage of impairment, physical frailty, or immobility. The number of members who reported having urine leakage in the past six patients affected by functional UI is unclear.1,13 months and have discussed their symptoms and treatment options with a health care professional.20 The 3 Incontinence Risk Factors Questions (Figure 113,21), the International Consultation Well-established risk factors for UI include increasing age, on Incontinence Questionnaire Urinary Incontinence Short parity, obesity, history of hysterectomy, and increasing Form (Figure 222),23,24 and the Revised Urinary Incontinence medical comorbidity. Other risk factors include diuretic Scale (available at www.mdcalc.com/revised-urinary- use, poor overall health, and high impact exercise.14-16 Vag- incontinence-scale-ruis)25 have good sensitivity, validity, inal deliveries are associated with an increased risk of UI, and are easily completed in a primary care setting to screen but evidence is mixed regarding whether cesarean deliveries for UI symptoms and the effect that UI has on QOL. have a prolonged protective effect.17,18 History Screening A thorough history can often distinguish between tran- The Women’s Preventive Services Initiative recommends sient and chronic UI, as well as the subtype of chronic UI. annually screening for women of all ages, including ado- The mnemonic TOILETED (thin, dry vaginal and urethral lescents, for UI despite low-quality evidence for accuracy epithelium; obstruction [stool impaction/constipation]; of screening methods and insufficient evidence regarding infection; limited mobility; emotional [psychological dis- the effectiveness of screening in improving symptoms, orders]; therapeutic medications; endocrine disorders; 340 American Family Physician www.aafp.org/afp Volume 100, Number 6 ◆ September 15, 2019 URINARY INCONTINENCE SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating Comments A validated incontinence screening questionnaire should be C Expert opinion and consensus guidelines used to help categorize the type of UI.21 The cough stress test has excellent intertest reliability, C Expert opinion and consensus guidelines sensitivity, and specificity and should be used