Urinary Incontinence

UI is a common problem across all demographics & places a considerable medical, psychosocial & economic burden on individuals & healthcare systems. It can be defined as involuntary loss of urine experienced during bladder storage phase.Though not life-threatening, it can lead to social isolation, loss of confidence, depression, avoidance of intimacy, and reduced family interaction, severely impacting quality of life.

Types:

Stress Urinary Incontinence (SUI)-Increased intraabdominal pressure leads to incontinence
Urgency Urinary Incontinence (UUI)-Strong urge to void immediately
Mixed Urinary Incontinence- combination of SUI & UUI

Others:

Overflow incontinence- overdistended bladder leading to dribbling
Functional incontinence-Incontinence due to cognitive, functional or mobility impairments in presence of intact lower urinary system. E.g. DM, Infection, pharmacological.
True incontinence- Incontinence due to abnormal connection between urinary and genital tract.

Epidemiology & Demographics:

Prevalence:
- Stress UI: 42–55%
- Urge UI: 7–12%
- Mixed UI: 24–44%
  (Elving, Bortolotti)

Age Distribution:

UI demonstrates a bimodal distribution:

First peak around menopause (~30%)
Second peak after age 70 (30–40%

Stress UI (SUI): More common in young and middle-aged women

Mixed UI and Overactive Bladder (OAB): Predominantly in older adults

Risk factors for UI:

Age: Increasing age is strongly associated with UI, especially postmenopausal women and the elderly.
Race/Ethnicity: Some studies suggest variations in prevalence by race
Parity: Higher number of vaginal births increases risk.
Smoking: Associated with chronic cough and pelvic floor weakening.
Body Mass Index (BMI): Obesity increases intra-abdominal pressure, worsening UI.
Diabetes Mellitus: Associated with neuropathy affecting bladder function.
Hysterectomy: Can affect pelvic floor support and nerve supply.
Family History: A positive maternal and/or sibling history increases risk (Relative Risk ~3x).

Assessing urinary incontinence:

Initial Evaluation of Urinary Incontinence

The initial evaluation of urinary incontinence (UI) should begin with a comprehensive clinical assessment comprising a detailed history and physical examination. The goal is to:

Classify the type of incontinence: stress, urge/overactive bladder, or mixed UI
Identify predisposing or precipitating factors that may require further investigation or targeted treatment

Symptom Scoring and Quality-of-Life Assessment

Utilize validated symptom and quality-of-life questionnaires specific to urinary incontinence, particularly when initiating or evaluating therapies.
These tools help assess the severity of symptoms, impact on daily activities, and response to treatment.

Focused History

A detailed history should include the following components:

a. Incontinence-specific history

Type of leakage (stress, urgency, mixed)
Duration of symptoms

Severity of incontinence (frequency and amount of leakage, number of pads used daily including weight & size)

Precipitating or aggravating factors (e.g. coughing, sneezing, urgency)
Previous evaluations or investigations
Prior treatments and their outcomes
Impact of incontinence on daily life and quality of life

b. Associated pelvic and urinary symptoms

Sensation of vaginal bulge or pelvic pressure (suggestive of pelvic organ prolapse)
Urinary urgency, frequency, nocturia
Hematuria (macroscopic or microscopic)
Recurrent urinary tract infections (UTIs)
Voiding difficulties (hesitancy, weak stream, incomplete emptying)
Bowel symptoms: anal incontinence or defecatory dysfunction
sexual dysfunction

c. Fluid habit: Amount and type of fluid intake including Intake of bladder irritants like tea, coffee, alcoholic, carbonated drinks, acidic foods

d. Obstetric / gynecologic / surgical history: number of deliveries with labour duration, mode of delivery, birth weights of children, year of delivery, intrapartum complications (e.g., obstetric anal sphincter injury, peri-urethral lacerations, wound breakdown), post-partum urinary symptoms (e.g., urinary retention or stress UI)

Medical conditions like endocrine disorders (i.e.complicated and uncontrolled diabetes, diabetes insipidus, neurological conditions (i.e., stroke, Parkinson’s disease, multiple sclerosis, spinal cord injury), urological conditions (i.e.urolithiasis, recurrent urogenital infections, bladder cancer), respiratory dysfunctions with chronic cough (i.e., chronic obstructive pulmonary disease

medications: Drug history of medications like intake of diuretics and alpha agonist

Psychiatric disorders such as depression, dementia and anxiety can contribute to abnormal voiding patterns.87

past surgeries and radiotherapy

Physical Examination:

A thorough general, physical, neurological & pelvic examination should be done:

General evaluation includes BMI, edema, physical dexterity and mobility, mental status, cognitive impairment and an objective demonstration of SUI with a full bladder.

Abdominal Exam:

Palpation for pelvic or abdominal masses, bladder distention or tenderness

b. Pelvic Examination

Inspect for pelvic organ prolapse, atrophic vaginitis, active vaginal infection, or periurethral pathology
cough test or Valsalva maneuver to objectively demonstrate stress UI with a full bladder.
Assess for urethral hypermobility, periurethral cysts, or other structural abnormalities

c. Pelvic Floor Assessment

Digital vaginal examination to assess pelvic floor muscle tone and contraction

d. Neurological and Extremity Exam

Basic neurological assessment, including cognitive function if indicated
Evaluate lower extremities for edema, which may contribute to nocturia or overflow symptom
Neurologic (In cases of associated neurological symptoms, test anal wink reflex, rectal sphincter tone, and ability to contract the anal sphincter, bulbocavernosus reflex, and perineal sensation)

5. Bladder Diary (Voiding Diary)

A 3-day bladder diary is recommended by NICE to document:
- Fluid intake patterns
- Voiding frequency and volumes
- Daytime and nighttime urinary output
- Episodes and circumstances of incontinence
Encourage patients to include both work and leisure days to capture variability in daily routine.

In most cases, a thorough history and physical exam are sufficient to diagnose the subtype of incontinence.

6. Initial Investigations

a. Urinalysis

Dipstick urinalysis to screen for:

Urinary tract infection (UTI)

Microhematuria

If symptomatic or if dipstick is positive, urine culture.

b. Postvoid Residual (PVR) Volume: To rule out retention or overflow incontinence

By using bladder ultrasound or in-and-out catheterization

<50 mL: Normal

>200 mL: Abnormal

c. Pad Test (Optional)

Semi-objective method to quantify urine loss
Weigh perineal pad before and after a set period of wear (usually 1 hour or 24 hours)

Urodynamics / advanced testing

It may be appropriate to perform cystoscopy in patients with concern for lower urinary tract abnormalities.

urge-predominant mixed urinary incontinence or urinary incontinence in

which the type is unclear

where the initial assessment does not provide a diagnosis,

mismatch between subjective and objective measures,

significant voiding dysfunction, elevated PVR,

• anterior or apical prolapse

a history of previous surgery for stress urinary incontinence.

“Red flags” / features needing specialist referral

High PVR or significant voiding dysfunction
- Failed conservative treatment
- Persisting bladder or urethral pain

Associated faecal incontinence
- Suspected neurological disease
- Suspected urogenital fistulae
- Previous continence surgery
- Previous pelvic cancer surgery, pelvic radiation therapy.

SUI:

Stress incontinence (SUI) is the complaint of involuntary urine leakage in association with coughing, sneezing or physical exertion.

(Source: International Continence Society (ICS) standard definition)

Genuine stress incontinence (GSI) is defined, according to the international continence society (ICS) as involuntary urethral loss of urine when the intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. The diagnosis of GSI should be made following urodynamic assessment only.

PATHOGENESIS:

Main defects responsible for SUI are:

Hypermobility of urethra (80%)

Due to distortion of the normal urethro-vesical anatomy by mechanical injury to the support of bladder neck during old age, child -birth.

Descent of the bladder neck and proximal urethra which normally lies above the urogenital diaphragm, prevents rise of intraurethral pressure during straining

Intrinsic sphincter defect (20%): due to pelvic irradiation, trauma, surgery.

Management of Stress Urinary Incontinence:

A. Conservative Management

1. Lifestyle Modification

Weight loss: Particularly effective if BMI >30
Smoking cessation
Fluid management

2. Pelvic Floor Muscle Training (PFMT)

First-line therapy for women with SUI
Recommended: At least 8 contractions, three times daily for 3+ months (NICE)
Subjective cure rate: ~30–40%
Objective cure rate: ~50%
Continued exercises encouraged if beneficial

3. Adjunct Therapies

Biofeedback and/or electrical stimulation: Electrical stimulation and/or biofeedback should be considered for women unable to identify and adequately contract pelvic floor muscles to aid motivation and adherence to therapy.

B. Pharmacological Management

1. Topical Vaginal Estrogen

Improves urethral mucosal coaptation and pelvic tissue tone
Particularly useful in postmenopausal women with atrophic changes
Response rate: ~50%

2. Duloxetine

A serotonin-norepinephrine reuptake inhibitor (SNRI) that enhances urethral sphincter tone via increased pudendal nerve activity
Dose: 40 mg twice daily for 3 months
Licensed in the EU for moderate to severe SUI, not FDA-approved
Side effects: Nausea, dizziness, dry mouth, fatigue; discontinuation in ~10% of patients
Not recommended as first-line by NICE but may be considered for those unfit or unwilling to undergo surgery

3. Imipramine (Tricyclic Antidepressant)

SNRI effect may help reduce leakage by decreasing detrusor contractility and increasing urethral resistance
Dose: 25 mg TID (or 10 mg at night for elderly)
Considered in select patients; not a first-line agentC. Vaginal Devices

Non-surgical mechanical aids that entails introducing devices into the vaginal canal which exert a mechanical force on the urethra, in turn increasing urethral outlet resistance.

Examples: Continence pessaries, vaginal inserts, urethral plugs
May be suitable for women who are poor surgical candidates or those desiring non-invasive options

Effectiveness may be reduced in cases of prior pelvic surgery or anatomical variation such as wide urethra or decreased bladder capacity.

Surgical Management

Indicated for moderate-to-severe SUI or when conservative and medical therapies fail. Procedure choice depends on urethral mobility, presence of ISD, patient comorbidities, and surgical history.

1. Midurethral Sling (MUS)

Considered the standard of care globally

Types:
- Retropubic (TVT) – success rate 51–81%
- Transobturator (TOT) – success rate 43–95%

No clear difference in efficacy, but complications differ:

TVT: Higher risk of bladder perforation and voiding issues

TOT: Less invasive, lower risk of bladder injury; may cause groin pain

Complications: Mesh erosion, hematoma, urinary retention, de novo urgency

2. Autologous Pubovaginal Sling

Uses fascia from the rectus abdominis or fascia lata
Especially useful in patients with:
- Prior mesh complications or surgery failure
- ISD
- Desire to avoid synthetic mesh
Success rate: 85–92%
May have higher rates of postoperative storage symptoms
SISTEr trial: Demonstrated superiority over Burch colposuspension in effectiveness and retreatment rates

3. Burch Colposuspension

Long-standing retropubic procedure with high long-term success (85–90%)
Recommended particularly for urethral hypermobility
Involves suturing the paravaginal fascia to Cooper’s ligament
Gold-standard open approach, but less commonly performed with the advent of slings

4. Bulking Agents

Injection of agents ( collagen, carbon-coated beads) into periurethral tissue to enhance coaptation
Benefits:
- Minimally invasive
- Suitable for frail or elderly patients unfit for surgery
Limitations:
- Lower long-term efficacy than slings
- Require repeat injections
- Side effects: transient urinary retention, de novo urgency

5. Artificial Urinary Sphincter (AUS)

Reserved for:

Intrinsic sphincter deficiency

Patients with failed prior surgeries

High subjective success (~90%) but associated with:

Erosion rates: 7–29%

Mechanical failure requiring revision

Typically used in highly selected cases

OAB:

Overactive Bladder (OAB) is a symptom complex consisting of:

Urgency (strong desire to void)
With or without urgency incontinence
Often accompanied by frequency and nocturia
In the absence of urinary tract infection or other identifiable pathology

OAB is common in both sexes, with increasing prevalence with age. Most patients have a combination of OAB symptoms. (Evidence strength Grade B)

Questions about urinary symptoms associated with OAB should be subdivided into

Storage problems (frequency, urgency, nocturia, incontinence),

Voiding symptoms (hesitancy, straining, poor and intermittent flow),

Post-micturition symptoms (sensation of incomplete emptying, post-micturition dribble), and other symptoms (nocturnal enuresis, dysuria).

bladder/renal ultrasound (Evidence strength Grade C), cystoscopy (Evidence strength

Grade C), CT/MRI (Evidence strength Grade C), and UDS (Evidence strength Grade A) are not recommended in the initial assessment of the uncomplicated OAB patient.

First-line treatment:

Llifestyle changes, behavioural therapies and patient education:

They are non-invasive and reversible, however require a significant time commitment and effort with regular follow-up to achieve success. combined with other OAB treatments and should form part of any treatment plan, have little or no morbidity.

Lifestyle changes:

Dietary modifications and fluid management:

Modifications of fluid intake and reduction or elimination of caffeinated and alcoholic beverages, as well as aspartame from the diet. Restricting fluid intake 2‒4 hours before bedtime, or after 6 pm decreases nocturia and night time incontinence.

Weight reduction- body mass index greater than 30kg/m² is at increased risk for the onset of OAB symptoms. Weight loss has been shown to improve OAB symptoms, even 5% reduction in weight decreases incontinence episodes by 50%.

management of bowel regularity/ constipation

optimization of other comorbidities ( diabetes, CHF, OSA) can be effective (Evidence strength Grade B/C)
Cessation of Smoking

Physical exercise: Regular physical activity is shown to strengthen the pelvic floor muscles, which can decrease OAB symptoms.170

Behavioural therapy: includes two main treatments, bladder training (BT) and pelvic floor muscle therapy (PFMT). A minimum period of 3 months has to be observed

Bladder Training : includes the use of bladder diaries, bladder control strategies, timed voiding, prompted or scheduled voiding, or delayed voiding.

The main strategy is implementing a voiding schedule and lengthening the intervals between voids until a normal pattern is established. (timed voiding) They are increased by 15‒30 minutes each week, depending on patient compliance and tolerance, until a voiding interval of 3‒4 hours is achieved

They can also perform 6‒10 quick pelvic floor muscle (PFM) contractions, which prevent the sphincter from relaxing when the urge is present

PFMT: tightening the pelvic floor muscle results in closing and lifting sensation without tensing the leg, buttock, or abdominal muscles may also include urgency suppression, control strategies, and biofeedback. In general, there is good literature to support the use of BT and PFMT in patients with OAB (Level of evidence 1b, Grade B)

The PFMT regimen consists of repeating the contraction for 10 seconds, 15 times in a row with equal breaks

of 10 seconds a total of three times a day, total 45 PFM contractions in a day.

Urgency control and suppression techniques: teaching the patient to control urgency by performing general relaxation, such as slow, deep breathing. This can decrease the intensity and urgency

Patient education: empowers patients and engages them in their treatment plan.

Second-line treatment (pharmacological management):

Anti muscarinic agents:

Oxybutynin (immediate release [IR],extended release [ER], transdermal),

Tolterodine (IR, ER),

Darifenacin, Trospium (IR), Solifenacin, Propiverine, an Fesoterodine

Beta-3 adrenoceptor agonist (primarily mirabegron) (Evidence strength Grade A).

The lowest recommended dose should first be prescribed, followed by dose increases in order to obtain the best clinical improvement while monitoring for adverse events (Evidence strength Grade B). It may take at least 4 weeks to see the improvements.

If initial drug is not tolerated or does not provide adequate symptom relief, should offer an alternative medication, preferably with a different mechanism of action

(Expert opinion).

Immediate release formulations of AMs should be avoided if other formulations are available (Evidence strength Grade A).

Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines.

Patients who remain incontinent after the initial treatment with an AM could be offered combination treatment with solifenacin and mirabegron (Evidence strength Grade C).

beta-3 adrenoceptor agonist (primarily mirabegron:

They have an antagonistic action on muscarinic receptors throughout the body, but improve OAB symptoms by blocking the M2 and M3 receptors in the bladder and urothelium, and therefore affect both involuntary detrusor contraction and increased sensory afferent signalling.

Offer follow up after 4 weeks, if well tolerated & satisfactory improvement, a review in primary care every 12 months, or every 6 months if aged over 75.

Desmopressin: may be considered in nocturia in women with urinary incontinence or overactive bladder who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension

Third-line treatment:

Botulinumtoxin A: Can be used in patients where 1^st and 2^nd line OAB treatment have failed after MDT review.

It is a neurotoxin produced by Clostridium botulinum, which prevents acetylcholine release from presynaptic membrane and failed neuromuscular transmission

Dose: 100 units (U) distributed by 20 injection points above the trigone (0.5 ml per injection point).

. Commonest side effects are UTI and voiding dysfunction including retention that may necessitate self-catheterization.

Review at 12 weeks, if there is good symptom relief, offer repeat treatment as necessary. If inadequate symptom relief, consider increasing subsequent doses of botulinum toxin type A to 200 units and review within 12 weeks

PTNS, SNM: Per cutaneous tibial nerve stimulation (PTNS):

Offer percutaneous sacral nerve stimulation to women after local or regional MDT

review if their overactive bladder has not responded to non-surgical management

including medicines and their symptoms have not responded to botulinum toxin type A or they are not prepared to accept the risks of needing catheterisation associated with botulinum toxin type A

Procedure: By inserting a needle on lower leg in posterior aspect of tibia, about 2 finger breadth above medial malleolus. This is done in OPD-basis and multiple sessions of stimulation is required

SNM :

SNM is considered as more invasive and higher-risk than other third-line treatment, but a suitable option for patients with OAB symptoms refractory to preferred treatment options (Evidence strength Grade B). (indwelling or CIC), and likelihood of repeat injections to maintain symptom improvement.

Additional treatment (indwelling catheters, augmentation cystoplasty, urinary diversion)

are rare long-term management strategies for OAB

Can be done in patients with complicated and refractory OAB as last resort only after careful consideration of the likely benefits and risks. (Evidence strength Grade D)

Augmentation cystoplasty:

Distal ileum is used to treat small capacity, low-compliant bladders that may follow chronic infections, radiation, or chronic inflammation from interstitial cystitis rather than true OAB patients

Common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder need self-catheterisation, UTI and urinary retention, small risk of malignancy occurring in the augmented bladder. Life-long follow-up is required.

Urinary diversion:

Considered only when non-surgical management of OAB has failed, and if botulinum toxin type A, percutaneous sacral nerve stimulation and augmentation cystoplasty are not appropriate or are unacceptable to her. Provide life-long follow-up.

OAB Treatment Summary

Step	Intervention
First-line	Lifestyle changes, bladder training, PFMT
Second-line	Antimuscarinics / Mirabegron
Third-line	BTXA, PTNS, SNM
Last resort	Augmentation cystoplasty / Urinary diversion

Flowchart: Evaluation and Management of Stress Urinary Incontinence (SUI)

             +----------------------------+

             |   Patient presents with    |

             |  symptoms of urine leakage |

             | during exertion/coughing   |

             +------------+---------------+

             +----------------------------+

             |   Detailed clinical history|

             |    & physical examination  |

             +------------+---------------+

             +----------------------------+

             |  Confirm SUI (no urgency,  |

             |  no significant voiding    |

             |     dysfunction)           |

             +------------+---------------+

             +----------------------------+

             |     Initial management     |

             +------------+---------------+

             | Conservative Measures:      |

             | - Weight loss (if BMI>30)   |

             | - Lifestyle changes         |

             | - Pelvic Floor Exercises    |

             | - Biofeedback if needed     |

             +----------------------------+

             | Symptom improvement?       |

             +---------+------------------+

                       | Yes                     No

                       v                         v

            +------------------+      +------------------------------+

            | Continue therapy |      | Consider medical treatment:  |

            +------------------+      | - Vaginal estrogen           |

                                      | - Duloxetine (if eligible)   |

                                      | - Vaginal pessary/device     |

                                      +--------------+---------------+

                                      +------------------------------+

                                      | Failure or severe symptoms?  |

                                      +--------------+---------------+

                               +---------------------------------------------+

                               |      Evaluate for surgical eligibility      |

                               +----------------------+----------------------+

                            +----------------------------------------------+

                            | Surgical options:                            |

                            | - Midurethral Sling (TVT/TOT)                |

                            | - Autologous Pubovaginal Sling              |

                            | - Burch Colposuspension                     |

                            | - Bulking agents (if unfit for major surgery)|

                            | - Artificial sphincter (last resort)         |

Compiled By

Dr. Hasina Sultana

Contributors

1. Prof Dr Fawzia Hossain
2. Dr Maniza Khan
3. Dr Taslima Akhter
4. Dr Amena Fardous
5. Dr Aklima Zakaria
6. Dr Seeham Saif
7. Dr Georgia Hoque
8. Dr Tasrina Akhter
9. Dr Soma Podder
10. Dr Tawhida Behum
11. Dr Ferdousi Chowdhury
12. Dr Sumaiya Binte Asif