Urinary incontinence in women

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Behavioural approaches and lifestyle changes are the preferred initial treatment for urinary incontinence. Reducing weight in women who are overweight or obese (BMI >25) can improve symptoms.[33][60][71][72] Optimising volume of fluid intake and modifying the timing of intake may reduce symptoms, as well as altering fluid type (e.g., minimising caffeinated, alcoholic, and carbonated drinks).[11][60] Improvement of pelvic muscle function and bladder retraining, where appropriate, is beneficial.[71] [ ]

Incontinence management strategies include products (e.g., diapers, pads, liners) to help patients to cope better with or tolerate urinary incontinence. Such products do not treat or prevent incontinence but may reduce adverse sequelae of incontinence, such as urine dermatitis.[60]

For stress incontinence, pharmacotherapy (in some cases) and surgery can be considered.

For urgency incontinence, additional treatment may include pharmacotherapy, neuromodulation, or botulinum toxin type A.

For mixed incontinence, treatment should be determined by the predominant symptoms or according to urodynamic test results. That is, if symptoms primarily suggest stress incontinence (e.g., involuntary urine leakage on effort, exertion, sneezing, or coughing), or urodynamic testing reveals a diagnosis of stress incontinence, patients should be treated as for stress incontinence; if symptoms primarily suggest urgency incontinence (e.g., involuntary urine leakage accompanied by or immediately preceded by urgency), or urodynamic testing reveals a diagnosis of detrusor overactivity, patients should be treated as for urgency incontinence. Treatment for mixed urinary incontinence begins with conservative management directed towards the most bothersome component of the symptom spectrum and progresses to more invasive therapy if required.[73][74]

Patients with overactive bladder symptoms should be assessed for comorbid conditions that may contribute to urinary incontinence (e.g., constipation, obesity, diabetes mellitus, pelvic organ prolapse) and educated on the role that management of these conditions can have on bladder symptoms.[60]

Behavioural techniques and lifestyle changes

Behavioural approaches and lifestyle changes are the preferred initial treatment for urinary incontinence. They should be offered to motivated patients who do not want surgery or do not want to become dependent on drugs or external devices.

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.[11][33][60][71][72][75] Symptoms may be reduced by optimising volume of fluid intake, modifying the timing of intake and altering fluid type (e.g., minimising caffeinated, alcoholic, carbonated drinks).[11][60]

Behavioural approaches (e.g., education, bladder training, scheduled voiding, pelvic floor exercises) can improve detrusor control and pelvic muscle function and reduce the number of incontinence episodes.[1][60][71] [ ] When used in combination with drug therapy, behavioural therapy has been shown to improve results by decreasing the frequency of urgency-incontinence events.[76][77]

Behavioural approaches suitable for women with urgency incontinence include bladder retraining and prompted voiding.[63][78]

Scheduled/prompted voiding is used to teach patients to initiate micturition themselves. It can be used in all patients, but is often used in patients with dementia or cognitive impairment, and in those in nursing homes.[79] It is recommended for patients who can learn to recognise bladder fullness or can ask for help when prompted.
Bladder training (bladder drills/timed voiding) involves techniques to distend the bladder (e.g., adjusting fluid intake) or delayed voiding.[71]

Behavioural treatments for stress incontinence include pelvic muscle exercises (Kegel exercises) and vaginal devices.[71][78][80] [ ]

Pelvic muscle rehabilitation: pelvic muscle exercises (Kegel or pelvic floor muscle exercises) strengthen the voluntary peri-urethral and paravaginal muscles.[81] These may be combined with bladder training, biofeedback, or functional electrical stimulation.
Vaginal devices such as incontinence pessaries or tampons are devices that mechanically support the bladder neck without hindering pelvic floor function.[82] However, data to support mechanical devices are inconclusive.[83]
Biofeedback is an educational method that uses electronic or mechanical instruments to convey information to patients about physiological processes. The information is relayed back to the patient via visual, auditory, or tactile signals.[84] It can be used as an adjunct to pelvic floor exercises.[71]

Pelvic floor muscle training (PFMT) with bladder training is recommended in women with mixed urinary incontinence.[63][78] Furthermore, PFMT can cure or improve symptoms of stress urinary incontinence and other types of urinary incontinence, although long-term efficacy is yet to be determined.[81]

Electrical stimulation is a technique to electrically stimulate the pudendal nerve and pelvic floor muscles, and is delivered via a probe placed vaginally or rectally. A significant improvement in symptoms of stress and urgency incontinence has been shown.[85] Electrical stimulation may be as beneficial as pelvic floor therapy and some pharmacotherapies, and can be used in conjunction with other therapies.[86] Anticholinergic therapy in combination with electrical stimulation or bladder training can significantly reduce frequency of urination.[87]

Pharmacological agents for stress incontinence

Pharmacotherapy is less effective than behavioural treatments in stress incontinence and not routinely recommended.[77][78] In stress incontinence caused by urethral sphincter insufficiency, treatment with an alpha-blocker (e.g., pseudoephedrine) may be considered if there are no contraindications.[88] This is also useful in patients who are considered a high surgical risk.[89] Duloxetine is a serotonin-noradrenaline reuptake inhibitor (SNRI) with alpha agonist properties, which although not approved for stress incontinence therapy in the US, has been widely studied and used in other countries.[90] Vaginal oestrogen can be added if the patient is post-menopausal. Oestrogen in the form of a cream, vaginal tablets, or a vaginal ring can be used to supply local oestrogen to poorly oestrogenised vaginal and urethral tissue.[7][80][91] Imipramine is no longer recommended for treatment of urinary incontinence.[63]

Surgical treatment for stress incontinence

Surgery is indicated if conservative treatment fails or patient requests more definitive therapy.[92] Factors associated with surgical failure include symptomatic detrusor overactivity, prior surgery, obesity, chronic cough, hypo-oestrogenism, older age, previous radiotherapy, strenuous physical activity, and poor nutrition.[93]

If the primary defect is urethral hyper-mobility or displacement, then sling procedures, including retropubic, transobturator, or single-incision slings (also known as mini-slings), and retropubic suspension (e.g., Burch colposuspension) can be performed. [ ] Needle bladder neck suspension and anterior vaginal repairs are not recommended as surgical options for stress incontinence due to demonstrated lower success rates.[94] [ ]

In mid-urethral sling procedures, a thin strip of polypropylene mesh is placed at the mid urethra to compensate for inefficiency of the pubourethral ligaments.[95] A meta-analysis reported superiority of mid-urethral sling procedures over Burch colposuspension in subjective and objective cure rates for stress urinary incontinence.[96] Modifications of the approach to sling placement including top-down and transobturator have been developed and are currently being used. The transobturator approach has the added benefit of avoiding the retropubic space and therefore having decreased risk of causing bladder perforation.[95][97] [ ] At 12 months postoperatively, retropubic and transobturator mid-urethral slings appear equivalent in efficacy.[95][98] However, regardless of the route, transobturator or retropubic, mid-urethral slings have been shown to be effective in the short and medium term, with increasingly favourable long-term data.[95][99] There is some evidence that retropubic slings have a higher subjective cure rate and decreased need for repeat surgery after 5 years.[100] Overall, mesh removal rates for mid-urethral mesh slings have been estimated to be 3.3%.[101] An advance in the surgical treatment of stress incontinence has been the introduction of the single-incision sling (mini-sling).[102] Although these single-incision slings are less invasive, without external skin incisions, their long-term effectiveness and durability are unknown.[103] The subjective cure rate of the single-incision sling is comparable to tension-free vaginal tape at 1 year, but it may have higher postoperative incontinence rates.[104][105]
Placement of mid-urethral slings in women with concomitant stress incontinence and prolapse is also of importance. These women have less symptomatic stress incontinence after prolapse repair when a concomitant mid-urethral sling is performed. For example, one study found that 17% of women who underwent prolapse repair needed an additional sling.[106]
Alternatives to polypropylene mesh include autograph and allograph fascial slings. The fascial sling can be used in patients with prior polypropylene mesh failures, mesh complications, or in patients who decline mesh products.[107] Traditionally these slings are placed at the bladder neck and have been shown to have patient satisfaction rates as high as 83% at 5 years.[108] The fascial sling is seen as less favourable by some surgeons due to the associated morbidity.[107]
In the UK, concern regarding the use of types of mesh in urogynaecological surgery resulted in a pause in the use of these for treatment of both pelvic organ prolapse and stress urinary incontinence. The 2019 National Institute for Health and Care Excellence guidance on urinary incontinence and pelvic organ prolapse advises discussion with women on the likely effectiveness of surgical procedures and the risk of complications.[63] A retropubic mid-urethral mesh sling is included as an option for surgical treatment of stress incontinence, albeit within a tight set of criteria.[63] The guidance includes patient decision aids to support women in making informed decisions.[63]

Surgical procedures for stress incontinence with intrinsic sphincter deficiency include sling procedures, peri-urethral bulking injections, and artificial sphincter placement.[63][93]

Pharmacological agents for urgency incontinence

Pharmacological agents may improve detrusor overactivity by inhibiting the contractile activity of the bladder. Drugs used include anticholinergics and beta-3-adrenergic receptor agonists.[60]

Anticholinergics are the most frequently prescribed drug for urgency incontinence. They act by blocking muscarinic receptors on the detrusor muscle, which are stimulated by acetylcholine. Mirabegron, a beta-3-adrenoceptor agonist, has shown significant reductions in incontinence and micturations compared with placebo, without anticholinergic adverse effects.[109] Further data suggest that mirabegron has better long-term adherence, up to 38% at one year, compared with anticholinergics.[110][111] Vibegron has increased efficacy when compared to mirabegron.[112]

For urgency incontinence with overactive bladder (detrusor overactivity), a beta-3 agonist (e.g., mirabegron, vibegron) or an anticholinergic (e.g., oral oxybutynin, tolterodine, darifenacin, solifenacin, trospium, fesoterodine) are the primary treatment options.[7][60][63][113][112] If these treatments are ineffective, transdermal oxybutynin may be used.[114][115]

Caution is recommended when using anticholinergics in older or frail patients, and use should be avoided in patients with dementia, cognitive impairment, or delirium.[60][116][117][118] These drugs should also only be used with extreme caution in patients who have narrow-angle glaucoma, impaired gastric emptying or a history of urinary retention.[60] Oxybutynin is of particular concern, as it has a higher incidence of adverse effects than other anticholinergics.[63] For these reasons, some experts have recommended a trial of a beta-3 agonist before using anticholinergics in patients with overactive bladder.[119] Propantheline is no longer recommended for treatment of urinary incontinence.[63]

Procedures for urgency incontinence

Neuromodulation is a treatment used in the management of overactive bladder (detrusor overactivity) refractory to pharmacotherapy.[60][120] It can be delivered percutaneously to target the afferent input of the posterior tibial nerve, or via the sacral nerve directly.[60] Tibial nerve neuromodulation has demonstrated success rates as high as 71% in patients who complete the 12-week therapy.[121][122] A 56% to 71% improvement in overactive bladder symptoms (urgency, frequency, and incontinence) has been maintained at 5 years after sacral neuromodulation therapy.[123]

Injection of botulinum toxin type A into the bladder wall has also been shown to be effective for detrusor overactivity and significantly decreases the number of episodes of urge incontinence.[124] This may be considered as an alternative to neuromodulation if pharmacotherapy is unsuccessful.[60] Patients who failed one or more anticholinergics have been successfully treated with botulinum toxin type A.[125] In one study comparing botulinum toxin type A versus sacral neuromodulation treatment among women with refractory urgency urinary incontinence, urgency incontinence episodes decreased from 3.9 to 3.3 episodes per day respectively (P=0.01).[126] However, the clinical significance of these results have yet to be determined.

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