Urinary Incontinence in Women

Nearly 50% of adult women may experience urinary incon- tinence, the involuntary loss of urine.1 This condition in- creases with age, affecting 10% to 20% of all women and
up to 77% of elderly women residing in nursing homes.2-7 Variabil- ity in case definition affects prevalence rates.8 The most current epi- demiologic data suggest an overall prevalence of 17% inwomen older than 20 years and 38% in women older than 60 years.5,7 Recent re- ports indicate that 37.5% of young women (30-50 years) in a pri- mary care setting report stress incontinence.9 According to the 2009-2010 National Ambulatory and Hospital Medical Care Sur- vey, an estimated 6.8 million women had a primary diagnosis or chief complaint of urinary incontinence; 15.3% were treated in a primary care setting.10 Despite this high prevalence, incontinence remains underdiagnosed and undertreated. Only 25% of affected women seek care, and of those, less than half receive treatment.11 Un- treated incontinence is associated with falls and fractures, sleep dis- turbances, depression, and urinary tract infections.12-14 Older women with lower urinary tract symptoms, including urinary incontinence,

History

Many women do not volunteer incontinence symptoms to their pri- mary care provider because of embarrassment, lack of knowledge, or misconception about treatment.15,16 Once incontinence is de- tected, the clinician should determine symptom severity and de- sire for treatment as early as possible. A general principle of care is the need to balance diagnostic certainty with the risk or invasive- ness of therapy. In all women, the clinician should identify and treat reversible causes such as urinary tract infection, excessive fluid in- take (>2 L/day), use or timing of medications that may worsen in- continence (ie, diuretics), and comorbid conditions contributing to incontinence (obesity, constipation, sleep apnea, tobacco use, de- mentia, and depression). The Box outlines signs or symptoms sug- gesting serious underlying pathology, such as cancer or serious neu- rologic disease, that should prompt immediate referral to an incontinence specialist.
Most women do not require an extensive preliminary evalua- tion of urinary incontinence because initial noninvasive treatments may be begun without clear differentiation between the 2 most com- mon urinary incontinence subtypes, stress and urgency inconti- nence. The history should focus on the onset, duration, severity, fre- quency and effect on quality of life. Figure 1 displays 3 simple items in a validated questionnaire to help clinicians discern the common incontinence subtypes. Briefly, the questionnaire describes vari- ous life situations and asks participants whether they experienced urinary incontinence during the past 3 months (even a small amount), whether they experienced involuntary urinary leaking, and when they experienced it most often.17
Stress incontinence is characterized by involuntary loss of urine with increases in abdominal pressure such as exercise or coughing. The main etiology is a poorly functioning urethral closure mecha- nism and is associated with loss of anatomic support or trauma from vaginal childbirth, obesity, and situations that repetitively increase intra-abdominal pressure, such as chronic constipation, heavy lift- ing, and high-impact exercise.18-23 Urgency incontinence is charac- terized by a sudden compelling desire to pass urine that is difficult to defer.24 Affected women experience little warning before incon- tinence episodes and an increase in urinary frequency both day and night. In most women, urgency incontinence is idiopathic. How- ever, it is common in a subset of women with systemic neurologic conditions (eg, Parkinson disease, multiple sclerosis, pelvic or spi- nal nerve injury). Overflow incontinence symptoms are similar to those of stress and urgency incontinence, but this type of inconti-

Examination

Guidelines from international and specialty organizations are largely consistent in their recommendations for the initial incontinence evaluation, which includes history, physical examination, urinary tract infection testing, urinary stress testing, and assessment of post- void residual.29-34 Urinalysis should be used to identify urinary tract infection and detect hematuria, pyuria, or glycosuria because these may represent comorbid conditions associated with incontinence. When history taking and urinalysis do not provide a clear etiology of incontinence symptoms, a written voiding diary recording quan- tity and timing of fluid intake and urine output during 1 to 3 days can provide information about potential modifiable factors associated with incontinence episodes. Figure 2 displays diaries of common ab- normal voiding patterns. Improved fluid intake patterns can re- duce urgency and frequency symptoms in women who infre- quently drink large volumes of liquids. More frequent, regular voiding can reduce symptoms in women who have infrequent, large- volume voids.

Pelvic examination is recommended when findings, such as de- tection of a pelvic mass, would alter the planned intervention or in- fluence treatment selection. In postmenopausal women, clinicians should look forvaginal atrophy, which can effectively be treated with vaginal estrogen. Pelvic examination may identify conditions requir- ing prompt referral (Box). In addition, clinicians should look for pel- vic organ prolapse beyond the vagina because it is associated with a higher risk of urinary retention. For these patients, referral to a spe- cialist for treatment addressing both prolapse and incontinence may be warranted. Clinicians can assess pelvic floor muscle integrity and