About this course:
The purpose of this activity is to provide an overview of the evaluation and treatment of urinary incontinence and its impact on women.
The Evaluation and Management of Urinary Incontinence in Women
The purpose of this activity is to provide an overview of the evaluation and treatment of urinary incontinence and its impact on women.
By the end of this activity, learners will be able to
- classify the most common presentations of stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) in women by their symptom patterns
- explore the evidence-based treatment options for the most common types of urinary incontinence seen in primary care settings
- identify clinical factors indicating a need for referral to a urology specialist
Urinary incontinence (UI) is the involuntary loss of urine and is a common finding in women of all ages. It impacts social functioning and limits activities. The three major uncomplicated UI classifications are stress, urge, and mixed. Women rarely mention their symptoms during healthcare visits, and providers rarely inquire. Providers may unintentionally omit these questions due to multiple competing demands during a time-limited visit. Older patients may consider leaking urine as a normal part of the aging process. More than 78 million adult women in the US have urinary incontinence, and more than 60% of women over 20 report having symptoms (Patel et al., 2022). According to the National Health and Nutrition Survey (NHANES), the incidence of UI is increasing. The cause of the rise is unknown, but it is speculated that an increase in obesity and an aging population are contributing factors (Patel et al., 2022).
Stress urinary incontinence (SUI) is the involuntary loss of urine, which occurs when a woman laughs or sneezes (Anand et al., 2020). SUI is the most common type of incontinence. In 2018, an estimated 50% of women with UI had the SUI subtype (Patel et al., 2022). SUI affects women of all ages. Athletes with SUI often do not seek treatment because of embarrassment, and many subsequently quit their sport because of the social stigma related to urine leakage. Athletes are 177% more likely to experience UI than their sedentary counterparts (Teixeira et al., 2018). Sexual relationships may be deterred due to a woman’s fear of urine loss during intercourse (Duralde & Rowen, 2017). Conditions contributing to SUI in young women are obesity, chronic cough, smoking, diabetes, and childbirth (Pang et al., 2022).
Urge Urinary Incontinence
Urge urinary incontinence (UUI) is a sudden urge to void and the inability to retain urine long enough to get to a toilet (Nandy & Ranganathan, 2022). Throughout the literature, it may also be referred to as overactive bladder (OAB); however, OAB does not necessarily include incontinence (Leron et al., 2018). UUI affects up to 31% of women with UI (Patel et al., 2022). Like SUI, UUI is also bothersome and socially isolating to women (Nandy & Ranganathan, 2022).
Mixed Urinary Incontinence
The final category, mixed urinary incontinence (MUI), describes overlapping symptoms of both SUI and UUI. Usually, one symptom pattern dominates and can drive initial treatment decisions. MUI results from the pathology of both UUI and SUI (Vaughan & Markland, 2020).
Anatomy and Physiology
The process of storing and releasing urine, or micturition, involves sympathetic, parasympathetic, and somatic innervation. The detrusor muscle, a smooth muscle surrounding the bladder, typically stays relaxed when the bladder is filled from the ureters. As the bladder expands, the detrusor muscle sends a signal to the spinal cord and the brain through the cortical micturition center. This signal stimulates an increase in the parasympathetic response and a decrease in the sympathetic response. The change in the parasympathetic and sympathetic systems triggers the bladder to contract and the sphincter to relax. Signals are sent from the spinal cord to the parietal lobe and thalamus, which in turn controls the detrusor muscle. The pontine center of the brain coordinates the signals that allow micturition to occur when socially appropriate. While the signals to the spinal cord stimulate the body to release urine, the pons in the brain is responsible for delaying urination until the woman is near a toilet. Sphincters at the bladder neck between the bladder and the urethra function as “gatekeepers” to keep urine from flowing out of the bladder (Barrett et al., 2019; Conner et al., 2019).
Risk Factors and Etiology
Risk factors for all categories of UI include obesity, a history of vaginal births, urethral trauma, pelvic organ prolapse (POP), and post-menopausal vaginal atrophy. Fifty-four percent of women with UI have POP (Wong & Ramm, 2021). Certain medications, including diuretics, hypnotics, and sedatives, can trigger UI symptoms. Additionally, antispasmodic agents can lead to SUI symptoms. While SUI and UUI are the two main symptom patterns, there are also other causes of urinary incontinence. For instance, neurogenic bladder caused by conditions such as cerebral vascular accident, multiple sclerosis, or spinal cord injury may also lead to incontinence (Conner et al., 2019). However, these are considered complicated UI and are beyond the scope of this continuing education program.
Risk Factors and Etiology of SUI
Patients with SUI report leaking of urine with coughing, sneezing, or any action that increases intra-abdominal pressure (Conner et al., 2019). This occurs whenever “pressure in the abdominal cavity exceeds the ability of the urethral sphincter to counteract external forces and hold urine in” (Wyndaele & Hashim, 2017, p. 289). SUI is also associated with urethral or bladder neck hypermobility (Candoso et al., 2019). Specific risk factors for SUI include atrophy of mucosal epithelium, pelvic floor muscle weakness, perineal trauma, and pelvic surgeries (Conner et al., 2019).
Risk Factors and Etiology of UUI
UUI is a “sudden compelling desire to urinate which is difficult to defer” (Wyndaele & Hashim, 2017, p. 290). Patients often describe specific triggers causing loss of urine, such as the sound of running water or trying to unlock a door to get to the bathroom. There are several theories to explain the biological process causing the sensation of urgency during bladder filling (Leron et al., 2018; Nandy & Ranganathan, 2022; Wyndaele & Hashim, 2017). Experts suggest three bladder processes underlie UUI: detrusor overactivity, poor compliance of the detrusor muscle, and bladder hypersensitivity (Nandy & Ranganathan, 2022). Overactive bladder and UUI overlap and are often discussed together. Overactive bladder is characterized by urgency and may also present with nocturia and urinary frequency but does not always involve loss of urine (Leron et al., 2018; Nandy & Ranganathan, 2022). Risk factors for UUI include bladder infection, vaginitis, bladder stones, tumors, cortical and subcortical lesions (brain lesions), and sacral lesions (Conner et al., 2019).
Symptoms & Risk Factors for UI
Risk factors for UI
Age-related changes to the vaginal epithelium (atrophy)
History of vaginal deliveries
Medications: sedatives, hypnotics, antispasmodics
Urinary tract infection
bladder stones and tumors
Neurological lesions, including cerebrovascular accident
spinal cord transection
Medications: diuretics, narcotics
Risk factors for both UUI and SUI
(Conner et al., 2019)
The workup for symptoms of urinary incontinence begins with a thorough history (see Table 2) and a physical exam. The acronym DIPPERS (delirium, infection, pharmaceutical, psychological morbidity, excess fluid intake, restricted mobility, and stool impaction) serves as a guide for collecting a detailed history of UI to rule out underlying causes (Nandy & Ranganathan, 2022). Attention should be paid to any prior conditions affecting the pelvic, urinary, and renal systems, such as previous surgeries, kidney stones, etc. Assess self-care ability, mobility constraints, and communication issues (aphasia or other language impairment), as these conditions may suggest functional causes of incontinence. Functional incontinence is the inability to get to the bathroom in time to void due to factors other than problems in the urinary system. This type of incontinence should be treated by providing appropriate assistance or devices that address the underlying difficulties (Conner et al., 2019).
In addition to the medical conditions listed above, the obstetric and gynecological histories should be thorough. A history of multiple vaginal deliveries increases a woman’s risk of pelvic floor weakness, POP, and perineal trauma. The gynecological history includes assessing for conditions associated with estrogen deficit, such as menopause. Multiple validated questionnaires are available to assist the nurse when taking a focused history for UI. Examples include the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), and the Urogenital Distress Inventory (UDI; Nandy & Ranganathan, 2022).
A complete voiding history provides valuable information and should include the following: onset of incontinence, the number of voids in a day, the amount of urine leaked, a sensation of incomplete bladder emptying, and the presence of dysuria. The patient may also be screened for nocturia and polyuria. In addition, a fluid intake history should include the types and amounts of fluid the patient consumes. Watch for reports of excessive fluid intake (above 64 ounces per day), caffeine intake, and other bladder irritants (e.g., alcohol, carbonated beverages, and tobacco products; Conner et al., 2019).
Essential Considerations in the History of Patients with UI
Are the symptoms bothersome?
Alpha-adrenergic agonists or antagonists
Calcium channel blockers
Sneezing or coughing
(Conner et al., 2019; Hu & Pierre, 2019; Leron et al., 2018)
Voiding diaries provide further details about symptoms for cases in which the history is unclear. Have the patient record fluid intake, voids, and activity around the time of any leakage for at least three days. If the presence of UI is questionable, a pad test may be done. Have the patient take phenazopyridine hydrochloride HCL (Pyridium) to stain the urine while wearing a sanitary pad or absorbent product. The patient can check the pad periodically for staining from urine loss (Conner et al., 2019).
Information obtained during the history will guide the nurse to key areas in a focused physical exam. A previously healthy woman with no underlying abdominal or neurological conditions may only need an abdominal and pelvic exam. The provider will assess the abdomen for signs of constipation, masses, a distended bladder, or cystitis (Conner et al., 2019). A pelvic examination should be performed to evaluate the strength of the pelvic floor musculature, for POP, and atrophy of the vaginal mucosa (Conner et al., 2019; Vaughan & Markland, 2020). The patient will be placed in the lithotomy position to inspect the perineum. POP can sometimes be visualized by the protrusion of the vaginal walls or uterus at the introitus. After inspection, pelvic floor strength may be assessed manually. Atrophic changes of the vaginal epithelium appear as smooth, pale pink vaginal mucosa. A rectal examination may be indicated to assess for the presence of stool in the rectal vault. Constipation can be a contributing factor to UI. A cardiovascular exam to evaluate for volume overload is essential for patients with underlying cardiovascular disease and risk factors (Conner et al., 2019).
Additional exam techniques may be incorporated to confirm findings. A positive cough stress test occurs when there is evidence of urine loss when the patient is directed to cough while the examiner inspects the urethral meatus. This test can be performed standing or supine; however, to best visualize the urethra, the supine or lithotomy position is the most convenient. The bladder must be at least partially full for the test to be valid (Guralnick et al., 2018). The cotton swab test, typically completed by urology, assesses for urethral hypermobility in a patient with UUI. The urethra is lubricated, and a swab is inserted into the neck of the bladder. If the angle of the swab changes more than 30 degrees during a Valsalva maneuver, the test is considered positive (Harris & Riggs, 2022; Nandy & Ranganathan, 2022, p3).
Most patients with UI will only need a physical exam and a simple urinalysis for evaluation. The urine should be sent for culture and sensitivity if the urinalysis suggests a possible infection. A post-void residual bladder sonogram may be considered when a woman does not respond to first-line interventions or reports obstructive symptoms such as a weak urine stream or urinary hesitancy (Gormley et al., 2012). Other tests that a urological specialist may order include uroflowmetry and a voiding cystourethrogram, but these are not indicated for initial workups and uncomplicated cases (Harding et al., 2022).
Once diagnosed and correctly characterized, the first step in managing incontinence is establishing treatment priorities based on the patient’s care goals and managing expectations. The goals typically include improving quality of life (QOL) by focusing on the patient’s most bothersome symptoms, but rarely is full continence achieved. Tools to assist the assessment of symptom impact may help focus treatment goals and track efficacy, such as the International Consultation on Incontinence Questionnaire, the King’s Health Questionnaire, PFDI, PFIQ, the OAB Questionnaire, and the Patient Global Impression of Improvement (PGII) or Severity (PGIS; Balk et al., 2019).
Treatment of UI should then proceed with nonpharmacological measures and a multidisciplinary approach to managing symptoms. Any aggravating factors that contribute to the symptoms should be removed or controlled. If the medication review reveals drugs that may exacerbate symptoms, the provider may recommend changing the schedule or dosage to see if symptoms decrease. Conditions such as asthma, chronic obstructive pulmonary disease (COPD), and post-nasal drainage should be fully optimized to ameliorate a chronic cough from contributing to SUI (Winkelman & Elkadry, 2021). Additional lifestyle modifications that may benefit those with incontinence include smoking cessation; avoidance of alcoholic, caffeinated, and carbonated beverages; and maintaining a fluid intake of no more than 64 ounces/day. Patients with nocturia symptoms should avoid fluid intake within several hours of their bedtime (Lukacz, 2022).
Another condition associated with increased strain on the pelvic floor is obesity. Weight loss improves UI as much as surgery. One randomized controlled trial comparing a 6-month intensive weight loss program to usual care found a 70% reduction in SUI episodes in the intervention group. The European Association of Urology’s 2022 guidelines include a strong rating for recommending weight loss to patients with UI. The nurse should counsel patients about the efficacy of weight loss for improving their symptoms of UI as well as the overall benefit to general health (Harding et al., 2022).
UI treatment should consist of pelvic floor muscle therapy (PFMT) to strengthen and improve the tone and endurance of the musculature to support the pelvic organs. A recent Cochrane review supported PFMT as a first-line therapy for SUI, UUI, and MUI, a recommendation reinforced by the World Health Organization (WHO, 2017; Todhunter-Brown et al., 2022). PFMT is a safe and effective intervention with high satisfaction rates from women. PMFT is associated with higher cure and improvement rates for SUI over UUI but is effective for all UI symptoms (Dumoulin et al., 2018).
Kegel maneuvers are the most widely known pelvic floor exercise. The first step in teaching a patient to perform a Kegel maneuver is to help her identify the correct muscles to contract. One way to introduce the maneuver is to have the woman squeeze an examining finger placed in the vaginal introitus during a pelvic exam. Teach women to identify the correct muscle by imagining they are trying to hold in urine and flatulence. Ensure that the patient feels a sensation of lift in the pelvic floor with the contraction. It is critical to explain that she must not contract during urination as this can weaken the pelvic floor muscles if done continuously or repeatedly (Cho & Kim, 2021).
Once the woman identifies the correct muscles to contract, she can do five contractions holding each contraction for 1-2 seconds and gradually lengthening to 8-10 seconds. Patients should initially practice the exercises in the prone position and progress to sitting and then to standing as she feels more confident in their pelvic strength. This series should be completed three times daily for 15-20 weeks to see a benefit (Cho & Kim, 2021). Some women may have difficulty performing Kegel exercises correctly and effectively (Armstrong et al., 2019). A referral to a physical therapist specializing in pelvic floor disorders may be needed to improve the efficacy of PFMT (Harding et al.,2022).
Mobile device applications (apps) for UI self-management hold promise as an option for patients to reinforce PFMT exercises. A systematic review of mobile health applications (e.g., Tät®, UrinControl) reported improved SUI symptoms and quality of life scores (Hou et al., 2022). More than 100 apps can be found for different mobile device platforms and often have built-in reminder systems to improve adherence (National Association for Continence [NAFC], n.d.).
In addition, bladder training may be a helpful tool in managing UUI conservatively. The patient’s shortest voiding interval (based on their voiding diary) should be used as a starting point for timed voiding throughout the waking hours. If urgency occurs within this interval, the patient should be encouraged to utilize mental relaxation techniques (i.e., mindful breathing) as well as distraction. To manage bladder contractions, the patient should also be trained in rapid contractions of the pelvic floor muscles (i.e., quick flicks). Once the patient can successfully avoid any leaks for an entire day using this initial interval period, the interval period should be extended the following day by 15 minutes. This interval is continuously lengthened until the patient can void every 3-4 hours without incontinence episodes or urgency (Lukacz, 2022).
Several commercially available products are designed for urine containment. Women may try products designed for menstrual blood flow, but these are not ideal for urine. Menstrual pads are designed to hold a smaller amount of fluid (approximately 10 mL), whereas incontinence pads and disposable underwear are designed to contain up to one liter of urine. Regardless of the cause or type, most patients with incontinence utilize disposable undergarments or pads. In the US, these products are easily accessible but may be expensive over time, insurance plans rarely cover the cost, and these do not address the underlying cause of incontinence. These products can also lead to contact dermatitis or skin breakdown if they are not changed frequently enough. These patients should undergo urodynamic testing to assess bladder storage pressures and avoid consequent renal damage. Indwelling or intermittent bladder catheterization is associated with a high risk for infection. As a result, it is reserved for limited instances with few alternatives (Clemens, 2019; Lukacz, 2022). A systematic review and meta-analysis reported that behavioral treatments, alone or in conjunction with other interventions, are more effective than pharmacological interventions alone (Balk et al., 2019).
Pessaries are devices inserted into the vagina to support prolapsed pelvic organs (see Figure 1). Although forms of pessaries have been used for centuries, modern devices are made of silicone and prescribed and fitted by trained healthcare providers, usually in gynecology or urogynecology practices. Pessaries come in various shapes and sizes depending on specific factors such as uterine shape, the size of the vaginal introitus, and the need for urethral support. They are often recommended for SUI and POP before surgical interventions and for women who wish to avoid surgery. After an initial fitting, a follow-up appointment 1-2 weeks later provides an opportunity to assess for comfort, fit, and symptom improvement. Only annual follow-up is needed for women who can independently remove and insert the device. Pessaries and PMFT have similar long-term results regarding patient satisfaction and symptom control (Vaughan & Markland, 2020; Winkelman & Elkadry, 2021).
A newer product, Poise Impressa™, was designed for SUI. It is a disposable over-the-counter vaginal support (i.e., pessary-like) device to be worn intravaginally. The device looks similar to a tampon and is inserted using a similar applicator but has an internal structure that supports the urethra to prevent leakage during activity. A fitting kit is available for patients to determine which size (S/M/L) provides the best control. This is a potential solution for women with intermittent symptoms during specific activities (e.g., exercise; Poise® Impressa® Bladder Supports, n.d., Winkelman & Elkadry, 2021).
A trial of an antimuscarinic agent or a beta-3 adrenergic agonist may be considered for patients with UUI who do not respond to conservative measures. Several agents with US Food and Drug Administration (FDA) approval for OAB may help with symptoms of UUI. Traditionally, antimuscarinic agents have been common treatments for OAB but are falling out of favor due to recent evidence of cognitive side effects and the risk of dementia (Welk & McArthur, 2020). Side effects may be mitigated if the medication’s extended-release (ER) formulation is given (Nandy & Ranganathan, 2022). These medications block acetylcholine from stimulating the muscarinic receptors, thus reducing smooth muscle contraction within the bladder. This should decrease urgency and increase bladder capacity. These are typically available in a generic version and often lower in cost for most patients. Anticholinergic side effects that can be anticipated include dry mouth, dizziness, constipation, tachycardia/palpitations, and dry eyes. Options include darifenacin (Enablex ER), fesoterodine (Toviaz ER), oxybutynin (Ditropan, which is also available in an OTC transdermal patch that can be applied to the hip, abdomen, or buttock every 3-4 days), solifenacin (Vesicare), tolterodine (Detrol ER), and trospium (Sanctura ER, which should be taken on an empty stomach). The increased risk of cognitive decline (i.e., dementia, Alzheimer’s disease) should be discussed with the patient prior to starting the antimuscarinic (Lukacz, 2021).
Mirabegron (Myrbetriq) and vibegron (Gemtesa) are beta-3 adrenergic agonists approved for OAB symptoms with a lower incidence of anticholinergic side effects. They cause smooth muscle relaxation in the bladder by stimulating the beta-3 adrenergic receptors and appear to be equivalently effective compared to antimuscarinic agents. Typical side effects include headache, rhinorrhea, or GI symptoms (e.g., nausea, diarrhea, constipation). They may also cause urinary retention. Mirabegron (Myrbetriq) may also elevate blood pressure. Mirabegron (Myrbetriq ER) may also be combined with solifenacin (Vesicare) in those with refractory/recurrent symptoms of OAB. Vibegron (Gemtesa) offers the added advantage of being able to crush the pills for ease of administration if needed (Leron et al., 2018; Lukacz, 2021).
There are no FDA-approved medications for SUI; however, some are used off-label as second-line treatments. Duloxetine (Cymbalta), a serotonin-norepinephrine reuptake inhibitor (SNRI), can be offered to women with SUI to decrease incontinence episodes; side effects such as fatigue, insomnia, dizziness, dry mouth, and gastrointestinal (GI) symptoms limit tolerability. Duloxetine (Cymbalta) is contraindicated in liver disease, pregnancy, and breastfeeding. Its use may be most appropriate for patients with concomitant conditions such as depression or chronic pain (Anand et al., 2020; Lukacz, 2022). A standard dose of topical estrogen may improve UI symptoms in post-menopausal women with vaginal atrophy. Patients may not see results for up to 3 months. Studies indicate minimal systemic absorption with no significant cardiovascular or cancer risk increase. Oral (systemic) therapy with estrogen may worsen incontinence and is not recommended (Harding et al., 2022; Lukacz, 2022).
Other management options for SUI include injections and surgery. Periurethral bulking agents are injected cystoscopically. The American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) 2017 guidelines include urethral bulking agents (UBA) as an option for SUI, but long-term data are lacking. For this reason, UBAs are rarely used other than in scenarios where the patient is unwilling or unable to tolerate an invasive procedure or in cases of refractory incontinence. Options are either particulate or nonparticulate and include Durasphere EXP, Macroplastique, Coaptite, and Bulkamid (Morgan, 2022). Surgical options are designed to support the bladder and urethra using synthetic mesh or autologous slings. A mid-urethral sling can be placed during an outpatient procedure with a low risk of complications (Vaughan & Markland, 2020). The AUA/SUFU 2017 guidelines recommend that all women considering surgery be thoroughly counseled about the benefits, risks, and potential outcomes. Pelvic organ prolapse can mask SUI symptoms, so it is important to counsel women that they may notice more SUI after POP repair (Kobashi et al., 2017). A suburethral sling is surgically inserted vaginally and then placed at the bladder neck, midurethra, or proximally to support the urethra. A pubovaginal sling includes a blabber neck and proximal support placed through an abdominal and vaginal incision. Midurethral slings (MUS) are often performed in a tension-free manner via a vaginal approach. Abdominal approaches may also be used to perform laparoscopic procedures such as the Burch or Marshall-Marchetti-Krantz (MMK). These use sutures to suspend the vaginal wall adjacent to the midurethra and bladder neck in a retropubic position. These may be referred to as retropubic colposuspension or urethropexy. A direct comparison (randomized trial) between surgical and conservative therapy (including physiotherapy) found 90% of surgical candidates felt their symptoms had improved versus 64% of conservative candidates. The valid concerns with surgical intervention include an increased risk of morbidity, postoperative voiding complications, and worsened (or new) UUI. Other trials have indicated efficacy rates of 40% for pelvic floor therapy, biofeedback, and pessaries versus 70-80% for surgical interventions (Jelovsek & Reddy, 2022).
If pharmacological interventions fail to improve symptoms of UUI, other options include neuromodulation and onabotulinumtoxinA (Botox). Percutaneous tibial nerve stimulation involves a series of in-office treatments over several months. An implantable sacral neuromodulator device sends electrical signals to the sacral nerve plexus. Another option for UI is onabotulinumtoxinA (Botox) which is injected into the bladder cystoscopically to temporarily paralyze the muscles responsible for causing voiding urgency (Vaughan & Markland, 2020). Unfortunately, surgical procedures for UUI are limited, and evidence of benefit is weak (Kobashi et al., 2017).
Urinary incontinence is a common condition, and nurses should have a working knowledge of the signs, symptoms, and treatment options. Since women may not bring up the subject, it is essential to inquire about symptoms of UI with all female patients. A thorough history and physical exam are the first steps in identifying appropriate treatment options. Conservative measures should include pelvic floor exercises, fluid management, bladder training, and weight management. They are safe, effective, and form the foundation of treatment for women with all types of UI. When needed, patients should be referred to a physical therapist specializing in pelvic floor therapy to maximize the benefit of exercise. Pharmacological options are available, but side effects limit their use; most drugs are only approved for UII and OAB symptoms. Patients who do not improve with conservative measures and first-line medications should be referred to urology specialists for additional treatment options.
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