I URINARY INCONTINENCE ^684

Urinary incontinence, the involuntary leakage of urine, is a common condition caused by a variety of factors and may result in an assortment of urinary symptoms. The prevalence of incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in the elderly.

Etiology

Among women who experience urinary incontinence, the differential diag­nosis includes genitourinary and nongenitourinary conditions (see Box 4-10). Some conditions that cause or contribute to urinary incontinence are potentially reversible (see Box 4-11). The relative likelihood of each condi­tion causing incontinence varies with the age and health of the individual. Detrusor abnormalities and mixed urinary incontinence symptoms are more common among older, noninstitutionalized women with incontinence, whereas stress incontinence is more common among younger, ambula­tory women. More severe and troublesome urinary incontinence probably occurs with increasing age, especially in women older than 70 years.

Evaluation and Diagnosis

The history and physical examination are the first and most important steps in evaluation of patients with urinary incontinence.

Box 4-10. Differential Diagnosis of Urinary Incontinence in Women ^___

Genitourinary Etiology

• Filling and storage disorders

— Urodynamic stress incontinence

— Detrusor overactivity (idiopathic)

— Detrusor overactivity (neurogenic)

— Mixed types

• Fistulae

— Vesical

— Ureteral

— Urethral

• Congenital

— Ectopic ureter

Nongenitourinary Etiology

• Functional

— Neurologic

— Cognitive

— Psychologic

— Physical impairment

• Environmental

• Pharmacologic

• Metabolic

Modified from Urinary incontinence in women.

Urologic, bowel, medical, surgical, gynecologic, neurologic, and obstet­ric histories as well as a complete list of the patient’s medications (includ­ing nonprescription medications) should be obtained. In addition to patient history evaluation, a 3-day or 7-day bladder diary and pad counts are considered a practical and reliable method of obtaining informa­tion on voiding behavior and incontinence severity. A bowel history is

Box 4-11. Common Causes of Transient Urinary Incontinence ^

• Urinary tract infection or urethritis (including from sexually transmitted infections)

• Atrophic urethritis or vaginitis

• Drug adverse effects

• Pregnancy

• Increased urine production

— Metabolic (hyperglycemia, hypercalcemia)

— Excess fluid intake

— Volume overload

• Delirium

• Restricted mobility

• Stool impaction

• Psychologic

Data from Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985;313:800-5.

important because anal incontinence and constipation are relatively more common in women with urinary incontinence and pelvic organ pro­lapse. Certain medical and neurologic conditions (such as diabetes, stroke, and lumbar disc disease) may cause urinary incontinence. A history of hysterectomy, vaginal repair, pelvic radiotherapy, or retropubic surgery should alert the physician to possible effects of prior surgery on the lower urinary tract.

After a history is obtained, patients with urinary incontinence should undergo a physical examination (of the abdomen, pelvis, and rectum), neurologic examination (of the lower thoracic, lumbar, and sacral nerves), direct observation of urine loss (ie, cough stress test), measurement of postvoid residual volume, and urine dipstick test (with urinalysis and a urine culture as indicated), with initial therapy based on these findings. If the patient has symptoms of dysuria, increased urgency, and frequency of acute onset and has urine dipstick test results positive for leukocyte esterase or nitrites, antibiotic treatment is appropriate, and the patient can be reevaluated in several weeks.

A preliminary diagnosis can be made with simple office and laboratory tests, with initial therapy based on these findings. A trial that assessed the outcomes of mid-urethral surgery in women with uncomplicated stress- predominant urinary incontinence revealed no difference in outcomes in women undergoing only a basic office evaluation versus women under­going such an evaluation with the addition of urodynamic testing; thus, many women may be spared an expensive and uncomfortable evaluation.

If complex conditions are present, the patient does not improve after initial therapy, or surgery is being considered, definitive specialized studies may be necessary. Supplementary evaluation may include the following:

• Blood testing (evaluation of blood urea nitrogen, creatinine, glucose, and calcium)

• Urodynamic testing (uroflowmetry, cystometry, multichannel urodynamics)

• Cystourethroscopy

• Imaging (eg, radiography, ultrasonography, magnetic resonance imaging)

Management

Many individuals with mild symptoms of urinary incontinence depend on barrier management. For women who desire treatment, physicians should offer conservative therapy as first-line treatment for stress urinary incontinence (including behavioral therapy and pessary use) as well as for urgency urinary incontinence (medications, behavioral therapy, bladder training, and some neuromodulation techniques). Surgery is indicated for the treatment of stress urinary incontinence when conservative treatments have failed to satisfactorily relieve the symptoms and the patient wishes further treatment in an effort to achieve continence.

Nonsurgical Interventions

Behavioral therapy—including pelvic floor muscle exercises, bladder training, prompted voiding, fluid management, and stress and urgency strategies—improves symptoms of stress, urge, and mixed incontinence and can be recommended as a conservative treatment in many women. Pelvic floor muscle training appears to be an effective treatment for adult women with stress, urge, and mixed incontinence.

Pharmacologic agents, such as oxybutynin, tolterodine, and others, may have some beneficial effect on symptoms of overactive bladder. The use of sacral and posterior tibial nerve neuromodulation, or intradetru­sor injections of botulinum toxin may be considered for those women with urge urinary incontinence refractory to medical therapy, behavioral therapy, or both.

Surgical Interventions

Many surgical treatments have been developed for stress urinary incon­tinence, but only a few—retropubic colposuspension and sling (pubo- vaginal and mid-urethral) procedures—have supporting evidence for recommendations. Long-term data suggest that Burch colposuspension and mid-urethral sling procedures have similar objective cure rates; pubo- vaginal slings have a slightly higher cure rate than the Burch procedure but are associated with more complications. Because of their feasibility as an outpatient procedure, their relative ease of performance, and comparable cure rates with few complications, standard full-length mid-urethral slings (retropubic and transobturator) have evolved into an acceptable first- line surgical option. Recent meta-analyses suggest that outcomes from single-incision mini-slings may not have the same effectiveness. Selection of treatment should be based on patient characteristics, evolving evi­dence regarding long-term cure and complication rates, and the surgeon’s experience.

Bibliography

Abdel-Fattah M, Ford JA, Lim CP, Madhuvrata P. Single-incision mini-slings ver­sus standard midurethral slings in surgical management of female stress urinary incontinence: a meta-analysis of effectiveness and complications. Eur Urol 2011;60: 468-80. [PubMed]

Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med 2012;366:1028-37. [PubMed] [Full Text]

Hunskaar S, Arnold EP, Burgio K, Diokno AC, Herzog AR, Mallett VT.

Nager CW, Brubaker L, Litman HJ, Zyczynski HM, Varner RE, Amundsen C, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. Urinary Incontinence Treatment Network. N Engl J Med 2012;366:1987-97. [PubMed] [Full Text]

Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. Pelvic Floor Disorders Network. JAMA 2008;300:1311-6. [PubMed] [Full Text]

Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol 2004;104:607-20. [PubMed] [Obstetrics & Gynecology]

Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985;313:800-5. [PubMed]

Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, et al. Retropubic versus transobturator midurethral slings for stress incontinence. Urinary Incontinence Treatment Network. N Engl J Med 2010;362:2066-76. [PubMed] [Full Text]

Subak LL, Brubaker L, Chai TC, Creasman JM, Diokno AC, Goode PS, et al. High costs of urinary incontinence among women electing surgery to treat stress incontinence. Urinary Incontinence Treatment Network. Obstet Gynecol 2008;111: 899-907. [PubMed] [Obstetrics & Gynecology]

The role of cystourethroscopy in the generalist obstetrician-gynecologist practice. ACOG Committee Opinion No. 372. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:221-4. [PubMed] [Obstetrics & Gynecology]

Urinary incontinence in women. ACOG Practice Bulletin No. 63. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;105:1533-45. [PubMed] [Obstetrics & Gynecology]

Resources

American College of Obstetricians and Gynecologists. Urinary incontinence. Patient Education Pamphlet AP081. Washington, DC: American College of Obstetricians and Gynecologists; 2010.

American College of Obstetricians and Gynecologists.

American Urogynecologic Society. Available at: http://www.augs.org. Retrieved September 20, 2013.

Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inac­tive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD005654. DOI: 10.1002/14651858. CD005654.pub2. [PubMed] [Full Text]

Duthie JB, Vincent M, Herbison GP, Wilson DI, Wilson D. Botulinum toxin injec­tions for adults with overactive bladder syndrome. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD005493. DOI: 10.1002/14651858.CD005493. pub3. [PubMed] [Full Text]

Food and Drug Administration. Update on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse: FDA safety com­munication. Silver Spring (MD): FDA; 2011. Available at: http://www.fda.gov/med- icaldevices/safety/alertsandnotices/ucm262435.htm. Retrieved August 15, 2013.

Food and Drug Administration. Urogynecologic surgical mesh implants. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/Implants andProsthetics/UroGynSurgicalMesh/default.htm. Retrieved September 30, 2013.

Glazener CMA, Lapitan MCM. Urodynamic studies for management of urinary incontinence in children and adults. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD003195. DOI: 10.1002/14651858.CD003195.pub2. [PubMed] [Full Text]

Goode PS, Burgio KL, Richter HE, Markland AD. Incontinence in older women. JAMA 2010;303:2172-81. [PubMed] [Full Text]

Hartmann KE, McPheeters ML, Biller DH, Ward RM, McKoy JN, Jerome RN, et al. Treatment of overactive bladder in women. Evidence Report/Technology Assessment No. 187. AHRQ Pub. No. 09-E017. Rockville (MD): Agency for Healthcare Research and Quality; 2009. Available at: http://www.ahrq.gov/research/findings/evidence- based-reports/bladder-evidence-report.pdf. Retrieved September 20, 2013.

Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling opera­tions for stress urinary incontinence in women. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006375. DOI: 10.1002/14651858.CD006375. pub2. [PubMed] [Full Text]