Female Urinary Incontinence: To Be Expected with Age?

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.

Evaluation

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
  • hematuria
  • dysuria
  • urinary frequency
  • nocturia
  • enuresis
  • 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.

Stress Incontinence

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.

Urge Incontinence

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.

Fall 2018 Healthy at Any Age and Older Women’s Health Coalition

As women’s health nurse practitioners, we work with women across their lifespans, from adolescence to advanced age. Our experience with such a wide range of ages has shown us that it’s the aging population that is often neglected.

The population of aging women is soaring and this generation of women approaches aging differently than their mothers and grandmothers did.

  • Between 2005 and 2015, the number of women aged 65 and older more than tripled to 26 million.
  • The number of older women will double by 2030 and continue to rise.
  • By 2030, about one in five Americans of both sexes will be older than 65, with women outnumbering men.
  • There are more women in the workforce after 65 and there are higher expectations for how to live well in retirement.

These older women are also facing more challenges, which include poverty, caregiving burdens, and stigmas around sexuality, mental health, addiction, and disability.

That’s why, for the last two years, NPWH has been convening leaders from a variety of organizations that touch the lives of women and aging populations to determine how to harness our work to make the whole larger than the sum of the parts. We recently gathered  at a “Healthy at Any Age” /Older Women’s Health Coalition planning meeting in early November to continue our efforts from a spring meeting where we began to lay the groundwork for an Older Women’s Health Coalition that will work with policymakers, clinicians, researchers and the general public on issues facing aging women.

Diverse leaders rolled up their sleeves to review the suggested goals, structure, and agenda for how a new coalition that will focus on advancing the health interests of older women.

We will focus on four efforts:

  • Advocating for federal legislative and regulatory policies – including federal funding for health research and services —  that benefit older women.
  • Promoting greater public education about the holistic needs of older women – particularly in physical and mental health care and breakdown stigmas and stereotypes
  • Strengthening the knowledge of the clinical community about how to treat and engage with older women patients and their families/caregivers
  • Promoting additional research into medical therapies that will improve older women’s health and wellness

As a next step, we are continuing to refine priorities for the coalition and are excited to dive into research on a report to be released next year. We also want to open up the conversation to others who care about aging women.

If you are interested in learning more about how you can get involved, please email info@NPWH.org.

Looking Back at the 21st Annual Premier Women’s Healthcare Conference

Thank you so much to everyone who attended the 21st Annual Premier Women’s Healthcare Conference last month! This was our biggest conference yet – between attendees, speakers, and exhibitors, we welcomed almost 1,000 champions of women’s health to San Antonio. For those who missed it – or those who want to relive it – I wanted to take the time to share some highlights:

  • Our educational sessions are always a highlight of the conference and we hope you enjoyed the plenaries, breakout sessions, and workshops. As always, all sessions will be uploaded to the NPWH website so you can watch any session you might have missed. Look for an email with more information in December.
  • Our Student Leadership Program returned this year, allowing 11 WHNP students from around the country the chance to attend the conference and gain invaluable experience. It was such fun to see these future leaders at work, and we look forward to them being a part of NPWH for years to come. We encourage everyone to share this opportunity with any students they know next year.
  • We also brought back our Inspirations in Women’s Health Awards! Congratulations to the following winners and leaders in the field:
    • Marcia Clevesy, DNP, WHNP-BC (Practice): In addition to her work as an associate professor at the University of Las Vegas, Dr. Clevesy volunteers weekly at the Nevada Obstetrical Charity Clinic, a nonprofit organization providing obstetrical and gynecologic care services at reduced fees for uninsured women. She recently implemented a QI project that improved postpartum depression screening detection and rates at the clinic.
    • Nalo Hamilton, PhD, MSN, APRN-BC (Research): Dr. Hamilton is both a biological researcher and a practicing WHNP. Her unique background in biochemistry and molecular biology, combined with her clinical expertise as a WHNP, enables her to investigate questions related to women’s health. Her current research focuses on the identification of biological markers for screening and therapeutic treatment of triple-negative breast cancer.
    • Allyssa Harris, PhD, RN, WHNP-BC (Policy): Dr. Harris is the WHNP program director at Boston College. She is also a mentor for Boston College’s Keys to Inclusive Leadership Program, which helps to prepare nurses from disadvantaged backgrounds to enter the nursing workforce.
    • Anne Moore, DNP, WHNP, ANP, FAANP (Education): Moore was instrumental in developing the WHNP program at Vanderbilt University, serving a total of 22 years as both an instructor and program director. She is currently the senior medical science liaison at AMAG Pharmaceuticals.
  • We consistently heard from exhibitors that they loved the engagement and excitement they receive from our attendees! We hope you enjoyed talking with them and learning about new products and treatments. This was our biggest exhibit hall to date, and we look forward to expanding even more next year!

Click here to view more highlights from the conference. Thank you all for your continued support, and we look forward to seeing you in Savannah, Georgia, October 16-19, 2019!

G Johnson

Gay Johnson, CEO