Urinary Incontinence

Introduction

Urinary incontinence (UI) is the complaint of involuntary leakage of urine.

• The urethral sphincter, a combination of smooth and striated muscles within and external to the urethra, maintains adequate resistance to the flow of urine from the bladder until voluntary voiding is initiated
• Urethral underactivity is known as stress UI (SUI) and occurs during activities such as exercise, lifting, coughing, and sneezing. The urethral sphincter no longer resists the flow of urine from the bladder during periods of physical activity.

Clinical Presentation

• Signs and symptoms of UI depend on the underlying pathophysiology. Patients with SUI generally complain of urine leakage with physical activity, whereas those with UUI complain of frequency, urgency, high-volume incontinence, and nocturia and nocturnal incontinence.
• Urethral overactivity and/or bladder underactivity is a rare but important cause of UI. Patients complain of lower abdominal fullness, hesitancy, straining to void, decreased force of stream, interrupted stream, and sense of incomplete bladder emptying. Patients can also have urinary frequency, urgency, and abdominal pain.

Diagnosis

• A complete medical history, physical examination (i.e., abdominal examination to exclude distended bladder, pelvic examination in women looking for evidence of prolapse or hormonal deficiency, and genital and prostate examination in men), and brief neurologic assessment of the perineum and lower extremities are recommended.
• For SUI, the preferred diagnostic test is observation of urethral meatus while the patient coughs or strains.
• For UUI, the preferred diagnostic tests are urodynamic studies. Perform urinalysis and urine culture to rule out urinary tract infection.
• For urethral overactivity and/or bladder underactivity, perform digital rectal examination or transrectal ultrasound to rule out prostate enlargement. Perform renal function tests to rule out renal failure.

Treatment

• Goals of Treatment: Restoration of continence, reduction in the number of UI episodes, and prevention of complications

Nonpharmacologic Treatment

• Nonpharmacologic, nonsurgical treatment (e.g., lifestyle modifications, toilet scheduling regimens, and pelvic floor muscle rehabilitation) is first-line treatment for UI.
• Surgery rarely plays a role in initial management of UI but can be required for secondary complications (e.g., skin breakdown or infection). The decision to surgically treat symptomatic UI requires that lifestyle compromise warrant an elective operation and that nonoperative therapy be proven undesirable or ineffective.

Pharmacologic Treatments

Oxybutynin IR (Ditropan) 2.5 mg twice daily OR

Oxybutynin gel 3% (Gelnique 3%) Three pumps (84 mg) topically daily OR

Solifenacin (VESIcare) 5 mg daily