This post is co-authored by Brooke Faught, DNP, WHNP-BC, NCMP, IF, and Brandy Hood, MD
Urinary incontinence impacts women’s lives and wellbeing in more ways than the obvious, including contributing to social isolation, falls, and hip fractures. It is also a tremendous financial burden on patients and on the nation, with an estimated annual cost of $66 billion in the United States.
Yet despite the personal and societal costs, even discussing incontinence with patients often means overcoming stigma. Patients often fail to divulge their experience with urinary incontinence unless specifically questioned. And when they do, they often couch it defensively and tentatively. Clinicians often hear, “Oh yeah, I leak a little when I run, but I’ve had two babies. That’s normal, right?” Or, “I always have to pee as soon as I put my key in the door and sometimes I don’t make it.”
While urinary incontinence is fairly common, it is not a normal symptom that patients should be afraid to discuss or tolerate. As providers, we need to ensure our patients understand that and know that we can help.
In this post, we’ll discuss tools for evaluation and treatment that providers should know.
Types of Urinary Incontinence
First, let’s understand the types and causes of urinary incontinence. The most common types are stress and urge.
- Stress incontinence occurs when a defect in the supportive tissue of the urethra and/or pelvic floor allows urine to pass through the urethral sphincters due to heightened abdominal pressures often caused from jumping, laughing, sneezing, coughing, and vomiting.
- Urge incontinence occurs due to overactivity of the detrusor muscle of the bladder that causes an increase in intravesical pressure. During a detrusor contraction, urine in a full bladder either expels out of the urethra or refluxes back up into the kidneys. While more noticeable, urinary incontinence is less concerning than reflux.
Other less common types of urinary incontinence include functional and overflow incontinence. Although outside the scope of this blog post, patients with urinary incontinence should also be screened for fecal incontinence.
Providers need to conduct thorough evaluations for urinary incontinence. That means asking questions about:
- frequency of symptoms
- exacerbating factors
- volume of leakage
- number of pads used each day
- urinary frequency
- symptom impact
- risk factors, including:
- past pregnancies
- number of vaginal deliveries
- vulvovaginal and pelvic surgeries
- menopausal status, neurologic conditions
- history of recurrent UTIs
Voiding Diaries: A 24-48 voiding diary is a great evaluation tool because it allows for the comparison of fluid input/output and also provides objective data when evaluating treatment efficacy.
Exam: A full pelvic floor examination aids the health care provider in understanding important urogenital factors that may be associated with a patient’s symptoms including pelvic floor tone and strength, prolapse, urethral hypermobility, and vulvovaginal tissue atrophy. The provider should perform a digital and speculum exam. Patients should also be examined in the supine and standing positions. Urodynamics provides additional details about patients’ symptoms of incontinence and should be considered in cases where patients report mixed urinary incontinence (more than one type of incontinence) or when they do not respond to conventional therapy such as behavioral modifications, pelvic floor physical therapy and/or oral medications.
Many patients report onset of stress incontinence during pregnancy and after vaginal deliveries, although nulliparous status and lack of previous vaginal deliveries does not preclude the patient from experiencing stress incontinence. Genetics also plays a big role in a woman’s potential for experiencing stress incontinence.
Weight loss may help patients reduce stress incontinence. In some cases, continence pessaries provide enough support at the urethral neck to prevent stress incontinence. I also often recommend pelvic floor physical therapy as a first line treatment approach for women reporting stress incontinence unless they have severe urethral hypermobility (identified on exam) and/or intrinsic sphincter deficiency (identified on urodynamics). In the latter cases, women often require surgical intervention.
If patients fail conservative interventions including at least two oral anticholinergic meds and/or a β3 -adrenergic agonist, they are candidates for third-line therapies including neuromodulation and intravesical Botulinum Type-A toxin. Tibial nerve stimulation offers patients a non-invasive treatment option for urgency and urge urinary incontinence, although patients must come into the medical clinic for twelve weekly 30-minute sessions. Sacroneuromodulation involves the surgical placement of a small implant that functions at the pudendal nerve complex. The length of the battery life depends upon multiple variables of each individual patient. Intravesical Botulinum Type-A toxin is injected directly into the bladder mucosa with the assistance of the cystoscope. The effects of this therapy may last up to 6 months although upwards of 5% of recipients experience transient urinary retention.
Final Thoughts for Providers
Urinary incontinence is not just a nuisance that should be ignored or tolerated, but rather a health condition with significant personal and economic impacts. Health care providers who care for women should screen for urinary incontinence and offer treatment and/or an appropriate referral(s) when identified. It is our responsibility to bring conversations about incontinence out of the shadows, and ensure our patients get the care they need and the quality of life they deserve.