Urinary Incontinence

What is urinary incontinence (UI)?

Urinary incontinence refers to the un-intentional loss of urine. The amount of urine lost may range from a few drops to completely emptying one's bladder.

UI is most common in perimenopausal and postmenopausal women, however due to stigma and or embarrassment many women do not usually disclose symptoms or seek treatment for this condition until symptoms are severe, unbearable or are significantly impairing their quality of life. Furthermore, not may clinicians screen for this condition.

Urinary incontinence is known to negatively impact a woman's quality of life.

Is urinary incontinence permanent?

Urinary incontinence may be temporary or chronic. For instance, it is not uncommon for pregnant women or women with an undiagnosed urinary tract infection to experience incontinence. These will usually resolve after pregnancy or after treatment.

Most types of urinary incontinence will resolve or be managed with treatment.

What are the different types of UI?

Types of urinary incontinence:

• Stress incontinence – leaking of urine with increased abdominal pressure in the presence of weak pelvic floor muscles e.g., coughing, sneezing, exercising etc.
• Urge Incontinence - he loss of urine after experiencing a sudden and uncontrolled sensation to urinate.
• Mixed urinary incontinence a combination of both stress and urinary incontinence.
• Overactive bladder – caused by spontaneous bladder spasms that trigger the loss of urine.
• Overflow incontinence – refers to accumulation of urine in the bladder to the point that bladder capacity is exceeded with subsequent spontaneous loss of urine.
• Coital incontinence – loss of urine during sexual intercourse - either during penetration or orgasm.

What causes urinary incontinence?

• Changes in anatomy, such as weakened pelvic floor muscles.
• Medications.
• Medical conditions like COPD, obesity, and those that affect the nervous system like diabetes, multiple sclerosis etc.
• Prolapse – such as a dropped bladder.
• Situational – limited mobility, fistulas.
• Urinary incontinence that is associated with aging (geriatric syndrome.).

What are signs and symptoms of urinary incontinence?

Patients may experience:

• Urinary frequency prompting many frequent visits to the bathroom.
• Urinary urgency.
• Increased night time voiding (nocturia).
• Hesitation.
• Double voiding and or dribbling.
• Change in stream.
• Change in volume of urine.

How is UI evaluated?

Women experiencing urinary incontinence should seek evaluation by a physician or a women's health clinician

The initial evaluation will include detailed questions about:

• Medical history including current medication list.
• Surgical history.
• Obstetric and sexual history.
• Pelvic exam.
• Diet -eating habits and fluid intake.
• A urine assessment and other bladder tests to rule out infection, urinary retention etc.

What is a voiding diary?

A patient may also be asked to keep a voiding diary - a journal of when one voids and when one leaks urine, amount of urine lost, volume of fluids and frequency of intake, activity at the time of urinary loss etc. This diary is then reviewed by the clinician and discussed with the patient.

Treating Urinary Incontinence

Treatment will be determined by the type of urinary incontinence a patient has. Treatment may include one or a combination of the following:

• Pelvic floor exercises (Kegel's) and pelvic floor physical therapy.
• Behavior modification – bladder training exercises, diet modification including modifying fluid intake and decreasing caffeine intake.
• Lifestyle changes.
• Medical devices like pessaries and support devices.
• Medications.
• Surgery – urethral slings, urethral bulking, botox injection, nerve stimulation such as sacral neural modulation and tibial stimulation etc.

Urinary incontinence in perimenopausal, menopausal and in postmenopausal women

• As women get older, they have an increased risk of developing urinary incontinence.
• Women in the perimenopausal and menopausal age group experience decrease in estrogen levels that affect the urogenital system including:
  • Decreased blood flow to the bladder, urethra and vagina.
  • Decreased tissue elasticity.
  • Decreased muscle mass.
  • Decreased urethral length and weakened urethral muscles.

The use of vaginal estrogen in this age group has shown to decrease urinary incontinence by approximately 70%.

• Approximately 50% of women over the age of 70 will be diagnosed with UI. UI in this age group appears to be more severe and may not respond to standard treatments. This may be attributed to the cumulative effects of genetic, physical and physiological effects on the urogenital system that occur during the woman`s life including pregnancy, child birth, menopause.
• Treating and managing urinary incontinence in elderly women is further complicated by the fact that many women may have other medical conditions whose symptoms include urinary incontinence. For instance, women with diabetes, kidney disease, immobility, obesity, hypertension, MS may all experience incontinence as part of the disease process.
• Management and treatment of urinary incontinence in women over age 65 presents a challenge to clinicians.
• While UI increases with aging, it does not mean that UI is a normal part of aging.
• UI negatively impacts a woman`s quality of life, impacting independence, physical activity and function.

References:

1. Urinary Incontinence in Women. ACOG Practice Bulletin Number 155. November 2015. A.
2. AUGS.
3. Parker-Autry C, Kuchel GA. Urinary Incontinence in Older Women: A Syndrome-Based Approach to Addressing Late Life Heterogeneity. Obstet Gynecol Clin North Am. 2021 Sep;48(3):665-675.
4. Lau HH, Huang WC, Su TH. Urinary leakage during sexual intercourse among women with incontinence: Incidence and risk factors. PLoS One. 2017 May 24;12(5):e0177075.