Urinary incontinence: management in general practice

Urinary incontinence is broadly defined as the unintentional passing of urine.¹ The reported prevalence of urinary incontinence varies but studies suggest a figure of around 25-45%² hence representing a significant burden on general practice. Importantly, due to women finding symptoms embarrassing, it may be an underreported problem.²

There are two main types of urinary incontinence:

1. Overactive bladder: urge incontinence
2. Weakness of the pelvic floor and urethral sphincter: stress incontinence.

Diagnosis of urinary incontinence

Diagnosis of the type of incontinence in general practice should be clinical, based on the typical story.

1. Urge incontinence (detrusor muscle overactivity): urges to urinate followed by uncontrollable emptying of the bladder
2. Stress incontinence: leakage of small amounts of urine with increase in intra-abdominal pressure (e.g. laughing/coughing).³

If the type of incontinence is not clear from initial discussion, ask the patient to complete a bladder diary to clarify the urinary pattern. These should be used for a minimum of three days and covering variations in their usual activities i.e. on both working and leisure days. Input/output charts and more information can be printed from the BAUS website.⁴

Some other things to consider in forming a diagnosis:

• Digital assessment to confirm pelvic floor muscle contraction before pelvic floor muscle training is recommended by NICE
• Check for diuretic use
• Ask about chronic cough
• Perform a urine dipstick test in all women to rule out infection as a key differential for frequency and urgency
• Perform a bladder scan to assess post-void volume if patient describes symptoms of voiding dysfunction or is having recurrent UTI’s
• Use a validated urinary incontinence-specific symptom and quality-of-life questionnaire.⁵

Pad tests, cystoscopy or any imaging (including ultrasound) are not recommended by NICE in the first instant in a patient presenting with incontinence alone.

Red flags for continence issues in women

Red flags’ for an urgent referral include:

• Microscopic haematuria in women aged over 50 years
• Visible haematuria
• Recurrent or persisting UTI associated with haematuria in women aged 40 years or over
• Suspected malignant pelvic mass.⁵

Early secondary care referral should be sought care in any women with urinary incontinence plus:

• Persisting bladder or urethral pain
• Clinically benign pelvic masses
• Associated faecal incontinence
• Suspected neurological disease
• Voiding difficulty
• Suspected urogenital fistulae
• Previous continence or pelvic cancer surgery
• Previous pelvic radiation therapy.⁵

From the history, a woman’s urinary incontinence should be categorised as urge incontinence, stress incontinence or mixed incontinence (a combination of symptoms from each category) and that initial treatment should be commenced on this basis.

In mixed urinary incontinence, treatment should be directed first towards the predominant symptom, rather than aiming to target both.

Treatment of urinary incontinence

 

Step-wise management	Stress Incontinence	Urge Incontinence
Initial management	Lifestyle changes + Pelvic floor muscle training (8 contractions, three times a day for 3 months)*	Lifestyle changes + Bladder training (minimum of 6 weeks- resisting voiding when one gets the urge)*
If no improvement€¦	Secondary care review to be sought	Bladder training plus overactive bladder medication and review at 4 weeks
If still no improvement€¦	–	Adjust drug/dose and arrange re-review
If still no improvement	–	Refer to secondary care

*Pelvic floor exercises and bladder training advice leaflets are printable from the BAUS website.⁴

Lifestyle changes for both stress and urge incontinence

Note these are recommended alongside, not as, first-line treatments. Suggestions to patients should include:

• Caffeine reduction (coffee, fizzy drinks)
• Modify fluid intake (if low or high)
• Lose weight if appropriate.^1,5

Overactive bladder medication

These are anti-muscarinic medications (e.g. oxybutynin, tolterodine) to be offered on top of bladder training if not effective after six weeks.

Side effects of anti-muscarinic medications are well-documented and elderly patients have been found to be more susceptible. Patients must be counselled to look out for these adverse effects. Side effects include constipation, dizziness, dry mouth, dyspepsia, headache, nausea, vision disorders. Perhaps most importantly in the elderly, research has shown an association between these drugs and cognitive impairment, falls and mortality.⁶ Different anti-muscarinic medications are deemed to be similarly effective in terms of symptomatic improvement so choice of drug is likely to depend on likely to depend on €˜tolerability, patient preference, and cost’.⁷

Some considerations when choosing medicines for overactive bladder:

• • Do not offer oxybutynin (IR) to frail older women
  • Consider anticholinergic load of current drugs ( €˜anticholinergic burden’ toolkits are available to assign a comparative number to the anticholinergic burden of a drug)
  • NICE advises offering the medicine with the lowest cost first
  • Transdermal options should be considered for those unable to take oral tablets
  • Mirabegron is recommended when antimuscarinic drugs are contraindicated, ineffective or have unacceptable side effects (NB contraindicated in severe HTN).

Patients on long-term medicine for overactive bladder should be reviewed every 12 months, or every six months if they are aged over 75 to monitor for adverse effects.⁵

Duloxetine for stress incontinence

The guidance is that duloxetine should not be used routinely as first or second-line treatment for women with stress incontinence. It may be offered as second-line therapy for women who would prefer to avoid, or at not suitable for, surgical treatment. If prescribed, patients should be counselled about its adverse effects including nausea, dry mouth, fatigue and constipation.⁵

Systemic hormone replacement therapy

These are not recommended in the treatment of urinary incontinence but intravaginal oestrogens should be considered in postmenopausal women with urge incontinence in addition to vaginal atrophy.⁵

Prognosis for urinary incontinence

Despite not being a life-threatening condition, evidence demonstrates that urinary incontinence affects a patient’s quality of life by affecting multiple domains⁸. Treatments may not necessarily be curative and lead to full continence, but should instead aim to reduce symptom severity and hence reduce burden on a patient’s everyday functioning.

Further care for managing continence

In secondary care, for urge incontinence, management options that will be discussed with the patient include botox injections, sacral neuromodulation, augmentation cystoplasty and urinary diversion under a urological surgeon. For stress incontinence, surgical options can be explored including colposuspension and sling surgeries.⁵

Patient education is essential when managing incontinence especially around managing lifestyle factors and drug side effects. Patient support and information is provided by www.bladderandbowel.org. BAUS.org.uk also provides information for both clinicians and patient and has printable patient leaflets on a range of topics.

 

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Dr Catriona Boyd, Fy2, Manchester University NHS Foundation Trust

Dr Denise Stevens, Specialty Doctor, Stroke Unit, Manchester University NHS Foundation Trust

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References

1. Urinary Incontinence. Available from: https://www.nhs.uk/conditions/urinary-incontinence/ [Accessed 1^st December 2019]
2. Buckley BS, Lapitan MCM. Prevalence of Urinary Incontinence in Men, Women, and Children€”Current Evidence: Findings of the Fourth International Consultation on Incontinence. Urology. 2010; 76(2): 265-270. Available from: doi.org/10.1016/j.urology.2009.11.078.
3. Longmore M, Wilkinson I, Baldwin A, Wallin E. Oxford Handbook of Clinical Medicine. 9th ed. Oxford: Oxford University Press, 2010.
4. The British Association of Urological Surgeons. Incontinence of Urine. Available from: https://www.baus.org.uk/patients/conditions/5/incontinence_of_urine [Accessed 1st December 2019]
5. National Institute for Health and Care Excellence (NICE). Urinary incontinence and pelvic organ prolapse in women: management: NICE Guideline [NG123]. 2019. Available from: https://www.nice.org.uk/guidance/ng123 [Accessed 1st December 2019].
6. Derbyshire Medicines Management. Anticholinergic drugs. Available from: http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_4/Anticholinergics_drugs.pdf [Accessed 1st December 2019]
7. Eyes on evidence. Anticholinergic drugs for urinary incontinence in women. National Institute for Health and Care Excellence (NICE). 12 June 2012. Available from: https://www.evidence.nhs.uk/document?id=1668828&returnUrl=search%3Fq%3Dantimuscarinic&q=antimuscarinic [Accessed 1^st December 2019]
8. Ko Y, Lin SJ, Salmon JW, Bron MS. The impact of urinary incontinence on quality of life of the elderly. Am J Manag Care. 2005; 11(4 Suppl):S103-11. Available from: https://www.ajmc.com/journals/supplement/2005/2005-07-vol11-n4suppl/jul05-2091ps103-s111 [Accessed 10^th December 2019]