Introduction
Risk factors
Assessing the patient
Examination
Investigations
Introduction
Management

 

Introduction

‘Stress’ urinary incontinence is the involuntary small volume leakage of urine on effort, exertion, sneezing or coughing.1 When co-existing with ‘urge’ symptoms it is called ‘mixed’ urinary incontinence. Fifty percent of incontinent women have pure stress incontinence,2 and it is the most common subtype in men who have had prostate surgery.3

 

Risk factors

AGE: The prevalence of urinary incontinence in women increases with age, but stress incontinence is more prevalent in 45-69 year olds.2 This may be due to pure stress incontinence declining with age, whilst mixed and urge incontinence types become relatively more common.

OBESITY: Obesity raises intra-abdominal pressure. The prevalence of urinary incontinence increases with obesity, particularly for severe mixed and stress incontinence.2

EXERCISE: High impact physical activity increases the risk of stress incontinence during activity,2,4 but there is no evidence that high impact activity predisposes to the development of stress incontinence in future life.5

PREGNANCY: There is a proportional increase in the relative risk of stress incontinence with increasing parity.6 Urinary incontinence prevalence rises through the trimesters.3 Multiple vaginal deliveries are associated with an increased risk of pelvic organ prolapse, which has a strong association with stress incontinence.3

PROSTATE SURGERY: Stress incontinence is primarily associated with radical prostatectomy surgery. The majority of men experience incontinence immediately following radical prostatectomy, but this is normally transient and improves over time.3 There is a low risk of stress incontinence post transurethral resection of the prostate (TURP) with late iatrogenic stress incontinence occurring in less than 0.5% of men.1

            

Assessing the patient

Asking “do you lose urine during physical exertion, lifting, coughing, laughing or sneezing?” is key to identification.8

History should include: precipitating factors, onset and duration of symptoms, previous surgery or trauma, any congenital abnormalities, neurological disease, illnesses such as respiratory conditions.

In female patients, a menstrual, obstetric, sexual and bowel function history should be documented. This helps identify associated factors such as grand multiparity, difficult vaginal deliveries and large birthweight babies, as well as concomitant symptoms of faecal incontinence and pelvic organ prolapse.

In male patients, stress urinary incontinence is unusual without a history of previous trauma or undergoing prostatic/pelvic surgery.

The holistic assessment of the impact of incontinence symptoms on quality of life should be undertaken. Women are more likely than men to report urinary incontinence and urinary incontinence decreases quality of life for both men and women.9 However, there is some evidence to suggest that the presence of urinary incontinence in men may have a greater emotional and social impact on quality of life compared with women.9

 

Examination

As well as a general examination, specific areas should be examined including:

Abdominal examination: Looking for previous surgical scars, urinary retention, masses and abdominal striae.

Gynaecological examination: The perineum and genital regions should be inspected identifying atrophy and excoriation, features of prolapse or erythema due to incontinence and the wearing of pads.

Pelvic examination: Voluntary pelvic floor muscle contraction should be evaluated by digital vaginal palpation.           

Terminology of pelvic floor muscles is shown in Table 1.3

 

Table 1: Terminology of pelvic Floor Muscles

a) Normal pelvic floor muscles: Can voluntarily and involuntarily contract and relax.

b) Overactive pelvic floor muscles:  Do not relax, or may even contract when relaxation is functionally needed, for example, during micturition or defecation.

c) Underactive pelvic floor muscles: Cannot voluntarily contract when appropriate.

d) Non-functioning pelvic floor muscles: no action palpable.

 

Women with urinary incontinence may have a pelvic organ prolapse. In a proportion of women, urinary incontinence will be obvious, but in some patients the prolapse may hide urinary leakage due to urethral bending (‘occult’ stress incontinence). In these patients, urine leakage only occurs when the prolapse is reduced, highlighting the importance of examination.

 

Investigations

Urinalysis should be performed on all patients to exclude other significant pathology such as urinary tract infections and conditions which need onward referral (see table 2).10,11

Ask patients to complete a bladder diary for a minimum of three days.10,11 This helps identify if the patient has pure stress incontinence or has an additional urge element. It also allows the impact of any treatment to be monitored. A bladder diary that patients can access has been produced by the British Association of Urological Surgeons.12

The use of imaging is not recommended for the initial assessment. Ultrasound should only be used for the routine assessment of residual urine volume in patients with recurrent urinary tract infections; voiding difficulty, including where treatment may have worsened or caused voiding problems or ‘complicated’ incontinence (incontinence associated with pain, haematuria, recurrent infection, voiding symptoms, prostate irradiation or radical pelvic surgery).10,11

            

Management

In patients with all types of urinary incontinence, Table 2 lists the indications for referral to specialist services.3,10

                                     

Table 2: Indications for referral to specialist services 

Recurrent or persistent urinary tract infections

Haematuria (visible or microscopic)

Persisting bladder or urethral pain

Clinically benign pelvic mass

Associated faecal incontinence

Suspected neurological disease

Symptoms of voiding difficulty

Suspected urogenital fistulae (constant leakage)

Previous continence surgery

Previous pelvic cancer surgery or radiation therapy

Vaginal prolapse that is at or below the introitus

          

Treatment should focus on improving quality of life and patient expectations should be identified. Initial treatments focus on conservative management and primarily involve pelvic floor exercises. If there is ‘mixed’ urinary incontinence, treat the most bothersome symptom first.

For all types of incontinence:

  • Advise women who have a BMI>30kg/m2 to lose weight10
  • Absorbent products should not be considered as an initial definitive treatment10

For the ‘urge’ incontinence element of ‘mixed’ urinary incontinence:

  • Review fluid intake10
  • Recommend a trial of alcohol and caffeine reduction10
  • Offer bladder training for a minimum of 6 weeks.10 The aim of bladder training is to teach patients to delay voiding when they feel the urge to go. The British Association of Urological Surgeons have produced a bladder training guide for patients13

For ‘stress’ incontinence:

  • Optimise respiratory conditions to prevent coughing
  • Pelvic floor muscle training

In women, a routine digital vaginal assessment to confirm pelvic floor muscle contraction should occur before the use of supervised pelvic floor muscle training.10 NICE guidance recommends offering a trial of at least 3 months’ duration before specialist referral.10 Pelvic floor muscle training should consist of at least 8 contractions performed 3 times per day.10 Patients should be advised to undertake both slow contractions and fast contractions. This encourages pelvic floor muscle stamina, but also increases reactivity. Advise patients to hold the squeeze for as long as possible (up to 10 seconds) and then relax (slow contraction) and after a set of these, to pull their pelvic floor muscles up quickly and relax them immediately for a set of fast contractions.14The training should be continued, if beneficial, as the effect wears off when the exercises stop.15 Pelvic floor muscle training has a success rate of 50-70% if supervised by a continence adviser or physiotherapist.16 Women in their first pregnancy should be offered pelvic floor muscle training as a preventative strategy for stress incontinence.10

A Cochrane review found there was no significant benefit at 12 months for men who received post prostatectomy pelvic floor muscle training.17 However, preoperative pelvic floor muscle training speeds recovery of continence.1

 

Medications

Duloxetine does not cure stress incontinence, but can improve symptoms in women. NICE guidance does not recommend as a first line treatment for women, but it may be offered as second line therapy for women who are either unsuitable or do not wish to have surgery.1 Duloxetine plus pelvic floor muscle training significantly improves urinary incontinence in men who have undergone prostatectomy, but the effects are not long lasting.19 Duloxetine should be started at a low dose and titrated, as most studies have shown a high withdrawal rate due to nausea, dizziness and sedation which should be discussed with the patient.11 The recommended dose is 40mg twice daily. After 2-4 weeks of treatment, patients should be reviewed to evaluate the benefit and tolerability of duloxetine. Some patients may benefit from a starting dose of 20 mg twice daily for two weeks before increasing to the recommended dose of 40mg twice daily to reduce risk of side effects. The efficacy of duloxetine has not been evaluated for longer than 3 months in placebo controlled studies and the benefit of treatment should be reassessed at regular intervals.20

            

Pessaries

Pessaries can be tried as a conservative intervention to help treat prolapse symptoms with stress urinary incontinence.21

            

Surgery (Women)

Patients who fail first line conservative measures can be referred for surgical assessment.  

If stress incontinence is the predominant symptom in women with mixed urinary incontinence, the benefit of conservative management including medications for urge symptoms should be discussed before referring for surgery.10 As reported in recent press coverage, mesh tape procedures are not presently being performed in Scotland and mesh surgery in the rest of UK is under review by NICE (guidance due in 2019).

Surgery (Men)

There is usually a progressive return of continence up to one year after prostatectomy. In general, invasive continence interventions are delayed until one year after surgery.3

 

Dr Helen Wood
Specialist Registrar, Geriatric and General Medicine, Severn Deanery

 


References

1. Abrams P et al. Urology 2003;61:37-49

2. Hannestad YS et al. BJOG: An International Journal of Obstetrics & Gynaecology 2003;110:247-254

3. International Consultation on Urological Diseases. http://www.icud.info/incontinence.html  [Last accessed April 2018]

4. Nygaard IE et al. Obstet Gynecol 1994;84(2):183-7

5. Nygaard IE. Obstet Gynecol 1997;90(5):718-22

6. Rortveit G at al. Obstet Gynecol 2001;98(6):1004–1010

7. Rasswiler J et al. European Urology. 2006;50(5):969-980

8. Holroyd-Leduc J, Tannenbaum C, Thorpe H, et al. JAMA 2008:299(12):1446-1456 


9. Tennstedt SL, Chiu GR, Link CL, Litman HJ, Kusek JW, McKinlay JB. Urology 2010;75(1):27

10. National Institute for Health and Care Excellence. Urinary Incontinence in women: management. NICE Guideline (CG 171). NICE, 2013. nice.org.uk/guidance/ cg171 [Last accessed April 2018]

11. European Association of Urology Guidelines on Urinary Incontinence.  http://uroweb.org/wp-content/uploads/20-Urinary-Incontinence_LR1.pdf  [Last accessed April 2018].

12. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Input%20output%20chart.pdf [Last accessed May 2018]

13. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Bladder%20training.pdf [Last accessed May 2018]

14. https://www.bladderandbowel.org/help-information/resources/pelvic-floor-exercises/ [Last accessed May 2018]

15. Bowker LK et al. Oxford Handbook of Geriatric Medicine. Third Edition. Oxford: OUP, 2018

16. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/SUI%20options.pdf  [Last accessed April 2018]

17. Anderson CA at al.  Cochrane Database of Systematic Reviews 2015

18. Centemero A, Rigatti L, Giraudo D et al. Eur Urol 2010;57:1039–1043

19. Filocamo, MT, Li Marzi V, Del Popolo, G. et al. Eur Urol 2007;51:1559–1564

20. https://www.medicines.org.uk/emc/product/5561/smpc [Last accessed May 2018]

21. Jones KA, Harmanli O. Reviews in Obstetrics and Gynecology. 2010;3(1):3-9