ACP Guideline on Nonsurgical Management of Urinary Incontinence in Women

Selected by Pietro Cazzola

Incontinenza urinariaUrinary incontinence (UI), the involuntary leakage of urine, is one of the most common medical conditions for women across the life cycle. Women often suffer in silence and may be reluctant to discuss their symptoms with their physicians. Qaseem and colleagues in the newly published American College of Physicians (ACP) clinical practice guidelines for UI afford us evidence-based non-surgical recommendations to assist our patients and an opportunity to review the common types of UI, the diagnostic tools, and the treatment options.
The three major types of UI are stress, urge, or a combination of both (referred to as mixed). Stress incontinence is most common in younger women, while urge incontinence is most common in older women. The diagnosis of UI can largely be made in the primary care physician’s office with the history and physical examination providing most of the diagnostic information. A commonly used, quick questionnaire is the 3IQ, which was developed by Brown and colleagues.1 It can be completed by the patient in less than a minute and helps to guide the clinician regarding the type of incontinence the patient may be experiencing. 

1. During the last 3 months, have you leaked urine (even a small amount)?

  1. Yes (continue to question 2)
  2. No (questionnaire completed)

2. During the last 3 months, did you leak urine (check all that apply):

  1. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
  2. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?
  3. Without physical activity and without a sense of urgency?

3. During the last 3 months, did you leak urine most often (check only one):

  1. When you performing some physical activity, such as coughing, sneezing, lifting, or exercise?
  2. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?
  3. Without physical activity and without a sense of urgency?
  4. About equally as often with physical activity as with a sense of urgency?

Response to #3 and Type of Incontinence:

A = Stress only or mostly stress
B = Urge only or predominantly urge
C = Other cause
D = Mixed

Other important information to gather from the history is whether the incontinence is temporary or chronic. There are multiple reversible causes for temporary incontinence. Identifying and treating these temporary factors, such as infection, mental status changes, medications, hyperglycemia, constipation or stool impaction, and atrophic vaginitis can improve the patient’s symptoms and quality of life without costly and extensive intervention. 

A thorough physical examination, including a cough stress test and a post-void residual (PVR) urine may also be helpful. Low PVR volumes (<50 mL) are usually seen in stress, urge, and mixed UI, while large volumes (>200 mL) are seen in overflow incontinence, which is rarer. PVR is ideally measured noninvasively with office ultrasound. Urethral catheterization is an alternative, but this technique poses increased risk for infection and trauma. If PVR measurement is not possible in the primary care setting and the cause and type of the incontinence is not readily identified, referral for urodynamic evaluation can be considered. A cough stress test can be done in the office supine or standing while asking the patient (with a full bladder) to cough and assessing for urine leakage. If the leakage is immediate after coughing, this is most indicative of stress incontinence.

Laboratory testing for evaluation of incontinence should include urinalysis and creatinine measurement. A urinalysis is helpful to evaluate for infection, hematuria, proteinuria, and glycosuria. An elevated creatinine could indicate urinary retention or obstruction.

The goal of treatment is continence or ≥50% reduction in frequency of UI symptoms. A patient’s voiding diary can be useful to assess management and treatment efficacy.

Type 

Description

Diagnosis

Treatment (Nonsurgical)*

Stress

Weakness of the urethral sphincter; urine leakage occurs with cough, sneezing, or activity

History, physical examination, cough stress test, urinalysis, creatinine

Pelvic floor muscle training (PFMT)

Avoiding medications

Urge

Detrusor overactivity; frequent urgency to empty bladder

History, physical examination, urinalysis, creatinine

Bladder training

Medication (if bladder training is unsuccessful)+

Mixed

Combination of stress and urge

History, physical examination, urinalysis, creatinine

PFMT with bladder training

*Weight loss and exercise recommended in all obese women with UI

+Anticholinergics (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) should be selected for patient based on benefit, adverse effects, tolerability and cost. Limit or avoid use in elderly patients. OnabotulinumtoxinA is approved for use in urge incontinence.

UI is a common medical condition with a significant impact for patients and the healthcare system. Patients often do not readily discuss these concerns with their physicians. Clinicians can help patients feel comfortable discussing these incontinence issues by including questions regarding UI in the review of systems during the annual exam or a relevant focused visit. The 3IQ can be useful for a quick assessment. Treating patients early and effectively can improve the overall quality of life and prevent future complications due to chronic symptoms. Referral to an urologist or urogynecologist should be considered in the presence of hematuria, obstruction, recurrent urinary tract infections, nonresponse to treatment, prolapse, or pelvic pain with incontinence.

References

  1. Brown JS, Bradley CS, Subak LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144(10):715-723.

Recommended Reading

  1. Khandelwal C, Kistler C. Diagnosis of urinary incontinence. Am Fam Physician. 2013;87(8):543-550.
  2. Hersh L, Salzman B. Clinical management of urinary incontinence in women. Am Fam Physician. 2013;87(9):634-640.

Tricia C Elliott