Urinary incontinence is an underdiagnosed and underreported problem that increases with age—affecting 50-84% of the elderly in long-term care facilities ^[1] —and at any age is more than twice as common in females than in males.

Signs and symptoms

Types of urinary incontinence

• Stress: Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder ^{[2, 3, 4]}
• Urge: Involuntary leakage accompanied by or immediately preceded by urgency
• Mixed: A combination of stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing
• Functional: The inability to hold urine due to reasons other than neuro-urologic and lower urinary tract dysfunction (eg, delirium, psychiatric disorders, urinary infection, impaired mobility)

Diagnosis

Patients with urinary incontinence should undergo a basic evaluation that includes a history, physical examination, and urinalysis. In selected patients, the following may also be needed:

• Voiding diary
• Cotton swab test
• Cough stress test
• Measurement of postvoid residual (PVR) urine volume
• Cystoscopy
• Urodynamic studies

The following points regarding the clinical presentation should be sought when obtaining the history:

• Severity and quantity of urine lost and frequency of incontinence episodes
• Duration of the complaint and whether problems have been worsening
• Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm)
• Constant versus intermittent urine loss
• Associated frequency, urgency, dysuria, pain with a full bladder
• History of urinary tract infections (UTIs)
• Concomitant fecal incontinence or pelvic organ prolapse
• Coexistent complicating or exacerbating medical problems
• Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies
• History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures
• Other urologic procedures
• Spinal and central nervous system surgery
• Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure
• Medications

Relevant complicating or exacerbating medical problems may include the following:

• Chronic cough
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure
• Diabetes mellitus
• Obesity
• Connective tissue disorders
• Postmenopausal hypoestrogenism
• CNS or spinal cord disorders
• Chronic UTIs
• Urinary tract stones
• Benign prostatic hyperplasia
• Cancer of pelvic organs

Medications that may be associated with urinary incontinence include the following:

• Cholinergic or anticholinergic drugs
• Alpha-blockers
• Over-the-counter allergy medications
• Estrogen replacement
• Beta-mimetics
• Sedatives
• Muscle relaxants
• Diuretics
• Angiotensin-converting enzyme (ACE) inhibitors

Management

Successful treatment of urinary incontinence must be tailored to the specific type of incontinence and its cause. The usual approaches are as follows:

• Stress incontinence: Pelvic floor physiotherapy, anti-incontinence devices, and surgery
• Urge incontinence: Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention
• Mixed incontinence: Pelvic floor physical therapy, anticholinergic drugs, and surgery
• Overflow incontinence: Catheterization regimen or diversion
• Functional incontinence: Treatment of the underlying cause

• Persistent incontinence despite all appropriate treatments
• Inability to participate in behavioral programs, due to illness or disability
• Presence of an incontinence disorder that cannot be helped by medications
• Presence of an incontinence disorder that cannot be corrected by surgery

• Alpha-adrenergic agonists
• Anticholinergic agents
• Antispasmodic drugs
• Tricyclic antidepressants
• Estrogen
• Alpha-adrenergic blockers
• Botulinum toxin

Surgical care for stress incontinence involves procedures that increase urethral outlet resistance, including the following:

• Bladder neck suspension
• Periurethral bulking therapy
• Midurethral slings
• Artificial urinary sphincter

• Sacral nerve modulation
• Injection of neurotoxins such as botulinum toxin
• Bladder augmentation