Female Urinary Incontinence

Educational Objectives

The goal of this program is to improve management of urinary incontinence in women. After hearing and assimilating this program, the clinician will be better able to:

1. Distinguish among causes of bladder dysfunction.
2. Provide appropriate treatment for stress urinary incontinence.
3. Recommend treatment options for overactive bladder.

Summary

Bladder function: the urinary bladder is a muscular organ that stores and releases urine; relaxation of the bladder allows storage; the urinary urethral sphincter closes to prevent leakage during pressure changes; to release urine, the bladder contracts and the sphincter opens; the urinary bladder exhibits a complex interplay between centralized and local reflexes; however, these reflexes can be controlled

Bladder dysfunction: issues related to urine storage include overactive bladder (OAB), neurogenic bladder, and interstitial cystitis (irritated bladder wall); a compromised sphincter with improper closure can cause intrinsic sphincter deficiency; conversely, difficulty emptying the bladder can cause urinary retention, voiding dysfunction, weak bladder, or hypotonic or atonic bladder, with a variety of etiologies, including neurogenic issues; detrusor hyperactivity with impaired contractile function is a clinical diagnosis characterized by bladder spasms that are too weak to allow sufficient emptying; detrusor sphincter dyssynergia is caused by discord between refluxes that occur during bladder emptying; bladder outlet obstruction (BOO) may be caused by a variety of conditions, including prolapse; in addition to the dysfunctions associated with storage and emptying, patients may experience incontinence alone

Urinary incontinence (UI): involuntary evacuation of urine; in the United States, only 1 in 8 individuals who experienced UI have been diagnosed; only 25% of women seek care, with an average wait of 7 yr; the associated high costs ($82.6 billion in 2020) include those for extra dry cleaning, pads, and laundry; UI may affect ≤50% women globally; prevalence increases with age; the type of UI varies with age (stress incontinence being more common at younger ages); at 80 yr of age, one-third of women have UI; common during pregnancy (30%-60%) but often resolves afterward; postpartum pelvic health programs can be helpful; UI is more prevalent at older ages, accounting for ≤10% of nursing home admissions; women are twice as likely as men to have UI, primarily because of pregnancy, childbirth, and menopause; addressing anxiety and depression, which are common among patients with UI, can be mentally and physiologically helpful; individuals with UI struggle with daily activities; reduced physical activity because of UI may compromise health and well-being; in severe cases, individuals cannot work or leave their homes

Types of UI: stress incontinence — urine leakage during coughing, laughing, or sneezing; most commonly related to urethral hypermobility; often caused by damage to the pubourethral ligament during vaginal delivery; may also be caused by compromise of the midurethral sphincter (ie, “lead pipe syndrome”); patients may have >1 etiology; urgency incontinence — characterized by a sudden urge to urinate and inability to hold urine; also referred to as OAB (wet or dry); mixed incontinence — a combination of different types of UI, most commonly stress UI and OAB; overflow incontinence — caused by a weak or obstructed bladder; functional UI — inability to reach the toilet because of physical or mental limitations; transient incontinence — caused by short-lived medical conditions (eg, constipation, bladder irritation, medications, use of sleep aids); total incontinence — complete lack of bladder control, often caused by a fistulous tract

Risk factors for UI: risk increases with age; risk for stress UI is ≈2.5-fold greater after vaginal deliveries, compared with cesarean deliveries; other factors include obesity and weight, functional impairment, genetic predisposition, neurologic conditions (eg, stroke, multiple sclerosis, spinal cord injury, Parkinson disease, severe diabetes), other medical conditions, and sleep disorders; cigarette smoking is a reversible risk factor; history of genitourinary surgery or pelvic irradiation may compromise the bladder; several medicines can contribute to UI, including those used to treat the bladder (eg, anticholinergic agents, β3 agonists, diuretics); triggers include caffeine, alcohol, and sedatives

Evaluation: as women who have UI may not report it, it is important to ask; the 5 required questions for patients on Medicare include inquiry about UI; avoid normalizing UI; the clinician should explain that UI is common but treatable; maintaining a bladder diary can help demonstrate associations between UI and lifestyle and suggest appropriate behavioral modifications; a 2-day bladder diary has been shown to be optimal; urodynamic testing — provides information about bladder function; relatively simple to perform; may be used in cases of mixed incontinence, pelvic surgery, or when simple interventions have caused worsening of UI

Discussing treatment with the patient: the goal should be to identify interventions that are effective for the individual patient; interventions should be advanced from least invasive to more invasive, while taking into account prior trials of treatment; determine the patient’s interest in treatment with medication or physical therapy; primary care physicians can prescribe lifestyle changes, behavioral therapy, pessaries, and medications

Treatment of stress UI: studies show that weight loss, even 10%, produces ≤50% improvement in stress UI; recommend dietary changes and avoiding triggers, eg, alcohol, carbonation, caffeinated beverages (coffee, green and black teas); however, these may be consumed reasonably, at appropriate times; other strategies include avoiding excessive fluid intake; constant thirst suggests an underlying condition, such as diabetes mellitus or diabetes insipidus, and warrants further evaluation; in case of nocturia, consider avoiding fluid intake at night and adjustments to medications to minimize fluid intake

Pelvic floor physical therapy: highly beneficial (helpful for 90% of patients with mild stress UI); a variety of apps guide women in practicing Kegel exercises at home (and improve compliance); if a ≈3-mo trial is unsuccessful, recommend training by a physical therapist; levator dysfunction is prevalent in ≈18% of the population; physical therapists can teach patients how to contract and release the pelvic musculature (much more effectively than self-training)

Pessaries: often used for prolapse; an incontinence ring can be used for stress UI; can be left in place and checked every 3 mo

Surgical interventions: available procedures may take only a few minutes, as an outpatient, and provide immediate resolution to UI; bladder net suspension, an older procedure, is associated with a recurrence rate of 50% to 60%; energy-based treatments — ie, laser treatments (intravaginal and intraurethral) are available but are not currently recommended by any medical society for treatment of UI or prolapse; data have been extrapolated from experience with genitourinary syndrome of menopause; show some promise for UI; midurethral slings — placement is a short procedure (10 min); provides immediate resolution; various types of slings are available; a single-incision sling requires no external incisions; midurethral slings have efficacy of 90%; options include synthetic and biological materials; with the single-incision sling, the risk for erosion is 0% to 2%; with new and modified slings, mesh extrusion occurs at extremely low rates and is simple to treat; periurethral bulking — mid-urethral injection of a bulking agent; indicated for intrinsic sphincter deficiency; prior agents showed efficacy for only 1 to 2 yr (migrated or were eventually absorbed); the newest bulking agent is a water-based hydrogel that remains efficacious ≤7 yr, according to a Stanford study; no reactions have been observed to this new bulking agent; the procedure is quick and simple, and is performed in an outpatient setting; provides immediate improvement and is highly effective for stress UI

Treatment of OAB: according to data from Health and Human Services, found in 1 in 6 women ≥70 yr of age

Conservative treatment: includes weight loss, dietary changes, avoiding triggers, and common-sense strategies; behavioral modification may help to change patients’ responses to bladder symptoms and optimize their voiding function but does not address the underlying problem; can be used in conjunction with treatments directed to the bladder to help optimize function; less effective than for stress UI

Extracorporeal magnetic innervation (EMI): shows effectiveness of ≈50% (20% higher than a placebo effect); requires constant training

Supplements: high-dose vitamin C — studies show some improvement in bladder function and storage incontinence; vitamin D — increased use has been associated with of lower rates of pelvic floor disorders; helpful for bone health, the immune system, heart health, blood glucose levels, and mood regulation; therefore, supplementation may treat various disorders, which, in turn, may improve bladder function or the perception of bladder function; magnesium — a stabilizing supplement that may reduce bladder spasms

Medication: the first-line treatment of OAB; anticholinergic agents — most frequently prescribed for OAB and urgency UI; the effectiveness of all anticholinergics is similar, at ≈70% (40% greater than placebo); agents differ in time of onset and adverse effects; typically, ≈1 mo of use is required for a significant change in bladder function; potential adverse effects are dry mouth, dry eye, blurred vision, and tachycardia; contraindications include gastric retention and narrow-angle glaucoma; β3 agonists — 70% effective and have a different adverse-effect profile; mirabegron is contraindicated in patients with uncontrolled hypertension; vibegron (approved in 2020) is not associated with changes in blood pressure and requires only 2 wk of daily use to produce benefit; antidepressants — used less frequently for UI; imipramine can be used for mixed UI; oxybutynin — not recommended, as it has been directly associated with risk for dementia; compromised cognitive function has been observed with 1 mo of use; among anticholinergic agents, trospium is preferred because it does not cross the blood-brain barrier

Botulinum toxin: when injected into the bladder, onset of effect occurs after ≈3 wk and effects last ≈9 mo; a simple outpatient procedure

Neurostimulation: direct (sacral nerve) or indirect (tibial nerve) stimulation to improve bladder function; percutaneous tibial nerve stimulation — effectiveness is ≈70%, with no adverse effects; the tibial nerve is stimulated using an acupuncture needle; requires 30-min sessions weekly for 12 wk to produce improvement, followed by maintenance of one session every 1 or 2 mo; sacral neuromodulation — one of the best treatments; effectiveness (80%) is equivalent to that of botulinum toxin; an outpatient procedure involving placement of a small wire connected to a battery to provide constant stimulation; previously, the battery life was 3 to 5 yr but is currently 10 to 20 yr and is safe for magnetic resonance imaging; produces immediate improvement; tibial implants — a device is implanted at the ankle; dual incontinence — neurostimulation may effectively treat patients with fecal and UI

Readings

Alsulihem A, Corcos J. The use of vaginal lasers in the treatment of urinary incontinence and overactive bladder, systematic review. Int Urogynecol J. 2021;32(3):553-572. doi:10.1007/s00192-020-04548-2; Aoki Y, Brown HW, Brubaker L, et al. Urinary incontinence in women [published correction appears in Nat Rev Dis Primers. 2017 Nov 16;3:17097]. Nat Rev Dis Primers. 2017;3:17042. Published 2017 Jul 6. doi:10.1038/nrdp.2017.42; Demaagd GA, Davenport TC. Management of urinary incontinence. P T. 2012;37(6):345-361H; Dufour S, Wu M. No. 397 - Conservative care of urinary incontinence in women. J Obstet Gynaecol Can. 2020;42(4):510-522. doi:10.1016/j.jogc.2019.04.009; Duong V, Iwamoto A, Pennycuff J, et al. A systematic review of neurocognitive dysfunction with overactive bladder medications. Int Urogynecol J. 2021;32(10):2693-2702. doi:10.1007/s00192-021-04909-5; Lau HH, Davila GW, Chen YY, et al. FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence. Int J Gynaecol Obstet. 2023;161(2):367-385; Locher JL, Goode PS, Roth DL, et al. Reliability assessment of the bladder diary for urinary incontinence in older women. J Gerontol A Biol Sci Med Sci. 2001 Jan;56(1):M32-5; Hutchinson A, Nesbitt A, Joshi A, et al. Overactive bladder syndrome: Management and treatment options. Aust J Gen Pract. 2020 Sep;49(9):593-598; Welk B, Baverstock RJ. The management of mixed urinary incontinence in women. Can Urol Assoc J. 2017 Jun;11(6Suppl2):S121-S124; Wing RR, West DS, Grady D, et al; Effect of weight loss on urinary incontinence in overweight and obese women: results at 12 and 18 months. J Urol. 2010 Sep;184(3):1005-10.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Santos was recorded at Riding the Waves of Primary Care 2023, held in Waimea, HI, November 6-10, 2023, and presented by Providence Regional Medical Center Everett. For information about upcoming CME activities from this presenter, please visit https://cmetracker.net/prov. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

IM711601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.