Urinary incontinence, defined by the International Continence Society as “the complaint of any involuntary urinary leakage” is a common and under-reported symptom.¹

The prevalence of urinary incontinence is rising with the growth of an ageing population, thus making it imperative for clinicians to be well versed in its management in both primary and secondary care. In the UK it has been found to be second only to dementia as a trigger for residential care for the elderly. The psychosocial impact of urinary incontinence can shroud various aspects of the patient’s life, leading to lack of confidence, feeling of shame, depression, social withdrawal and strained marital relationships.²

Despite a range of management options, it appears to be undertreated. In practice it can be a challenge to identify, with patients believing that the condition is an inevitable consequence of childbirth or ageing or feeling reluctant to talk about embarrassing symptoms.

The bladder is designed as a compliant organ with small pressure changes occurring with large changes in volume. It spends 99% of its time in a storage function and 1% in voiding. Normal storage pressures run between 0-10mmHg with voiding pressures of up to 25mmHg.

The bladder cycle is a complicated process that allows the bladder to store urine until an appropriate, convenient time and place to empty is available. To achieve this, the bladder muscle (detrusor) must function normally, relaxing to store urine and then contracting at the correct time to empty the bladder. The urethra leading out from the bladder must also work correctly in conjunction with normal nerve control. 

For correct functioning of the urethra, it should be supported by muscles of the pelvic floor to help it remain closed while urine is stored in the bladder. The muscles should relax and open only when instructed by the brain to do so, ie. when it is socially convenient. 

“Normal bladder function is passing urine every three to four hours but should be less than eight times a day and not more than once during the night. You should, when your bladder is nearly full, be able to hold on until a toilet is reached.” This is a concise and useful explanation for discussing bladder problems with patients from bladdermatters.co.uk, a useful resource developed by clinicians.³

Overactive bladder describes a group of lower urinary tract symptoms, where there is no infection or pathology. These bothersome symptoms include urgency, frequency, nocturia and urgency incontinence. OAB symptoms can have major quality of life implications, can lead to social isolation and for the elderly, may lead to increased risk of falls as patients get up more frequently in the night.⁴ Symptoms can cause a great deal of distress and embarrassment, as well as significant costs, to both individuals and societies.⁵

The incidence of urinary incontinence varies at between 20% and 40% depending on the research populations and definitions used. It is more common in women and the incidence increases with age. However, over one-third of men aged 50 or more are living with moderate to severe symptoms.⁶ There is a discrepancy between the availability of adequate treatment options and the low percentage of older people with urinary incontinence that present and take advantage of them.⁷

Role of the primary care team

Patients may present with urinary incontinence problems to any of a number of healthcare professionals within the primary care setting. Reporting of the problem may be not just from the patient, but also from relatives, friends and home care attendants. 

Given the potential complexity of this issue, a detailed assessment needs to be performed prior to drawing up an individualised management plan. Both women and men suffer from difficulties with urinary incontinence. 

Various recommendations for specific pathways of care for women and men have emerged in more recent publications. These recognise the physiological and anatomical differences that exist between the sexes, coupled with specific changes that occur throughout the life cycle. 

Useful guidelines have been published by the European Association of Urology 2013⁵ and NICE 2015.⁸ The results of many years of research in this area, these guidelines form a good basis for supporting and promoting a consistent care pathway which has a robust scientific basis for individualised care in various settings.

Urinary incontinence symptoms

Urinary incontinence can be classified into three main types: 

• Stress urinary incontinence during sudden increase in abdominal pressure
• Urge urinary incontinence: a compelling urge to urinate
• Mixed urinary incontinence is a combination of both.

Lower urinary tract symptoms (LUTS) refer to symptoms that result from conditions and diseases affecting the bladder and urethra. These include:

• Urinary incontinence symptoms 
• Stress urinary incontinence 
• Urgency urinary incontinence
• Mixed urinary incontinence
• Nocturnal urinary incontinence
• Continuous, insensible and coital incontinence.

Bladder storage symptoms include overactive bladder urgency and frequency and nocturia with or without urgency incontinence.

Voiding symptoms include urinary retention, hesitancy, straining to void, slow and or interrupted stream, splitting or spraying, terminal dribble, position dependent micturition and incomplete emptying. Post-micturition symptoms include post-micturition leakage. Suspicious symptoms and signs include haematuria and dysuria that may indicate other pathology such as bladder tumour, stone disease, or urinary tract infection.⁴

Considerations in the older population

Multimorbidity needs to be considered when one encounters urinary difficulties in the older population. A British Journal of Geriatrics article draws attention to the issue of frailty, where a relatively minor event can lead to a significant deterioration in health.⁹

OAB is not an inevitable part of ageing and can be treated with a combination of behaviour modification and therapy. 

Research on the effects of medications in the elderly has been lacking but there have been some small-scale studies on antimuscarinics and cognition.

Another issue in the elderly is that the presence of pelvic organ prolapse is estimated at 37% in women over the age of 80 years.¹⁰ This contributes significantly to the occurrence of stress and mixed urinary incontinence. A broad range of issues needs to be considered when assessing elderly patients with urinary incontinence and overactive bladder including:

• Transfer ability – mobility/balance/arm strength and manual dexterity
• Eyesight
• Toileting ability
• Cognitive ability
• Environment suitability and support
• Social support.

Elderly patients are recognised to have two important features that potentially make them more prone to nocturesis. Firstly the physiological changes with age are often associated with development of a degree of lymphoedema in the lower limbs. This results in return of this fluid into the vascular system when they lie down at night and a resultant diuresis. 

Secondly, timing of medications such as diuretics to coincide with an individual patient’s care plan and mobility limitations can help to facilitate toileting and reduce the tendency to difficulties with overactive bladder and urinary incontinence.

Urinary incontinence and OAB in women

At the initial clinical assessment, UI in women should be categorised as:

• Stress UI (SUI)
• Mixed UI or 
• Urgency UI/overactive bladder (OAB).

History

A detailed history is useful to ascertain the aetiology and severity of the incontinence. A focused history should include precise details of:

• Obstetrical and gynaecological experience to date including parity, history of vaginal delivery or Caesarean section, instrumentation in labour, vaginal hysterectomy, pelvic surgery or radiotherapy
• Identification of existing medical problems including recurrent urinary tract infections, diabetes, neurological disorders including spinal injury and multiple sclerosis, bowel habit issues, mobility issues, cognitive function decline, social support, current coping mechanisms (eg. use of continence pads, reduced fluid intake) and a review of all medication as potential contributors to symptoms.

Examination

Physical examination and subsequent investigations are guided by the history and presence/absence of symptomatic pelvic organ prolapse.²

Abdominal examination

This may reveal potential contributing factors, eg. a palpable abdominal mass due to fibroids or a palpable bladder post-voiding, or malignancy. Abdominal examination also provides an opportunity to assess core muscle tone, particularly in women who have had one or more pregnancies.

Pelvic examination and digital rectal examination

This examination, where appropriate, requires a very sensitive approach including explanation and appropriate consent of the patient. 

Pelvic floor muscle tone, prolapse of the genito-urinary organs and ano-rectal tone (innervation) can be assessed. Such an assessment is particularly useful in patients presenting with SUI and mixed UI. 

Urine testing

Urine dipstick along with mid-stream urine (MSU) testing is advisable in all patients with symptomatic UI. Undertake a urine test in all women presenting with UI to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine.⁹

Signs for urgent referral in women

• Microscopic haematuria in women aged 50 years and older
• Visible haematuria
• Recurrent or persistent urinary tract infection associated with haematuria in women aged 40 years and older
• Suspected malignant mass from the urinary tract.²

A useful resource is the questionnaire for female urinary incontinence diagnosis (QUID) which provides six validated questions for use in consultation when females present with urinary incontinence.¹¹

Bladder diaries 

Bladder diaries help to record filling and voiding cycles, and provide valuable information regarding the patient’s fluid intake, urinary frequency, urgency, diurnal variations, nocturnal cycles, functional bladder capacity, UI episodes and total urinary output. 

The National Institute for Health and Care Excellence (NICE) recommends use of bladder diaries for a minimum of three days to include a combination of work and leisure days.⁸

Take home message

The key take-home message from the perspective of the GP is that a significant amount of individualised care of women with problems of urinary incontinence and overactive bladder can be initiated and managed within the primary care setting.

Waiting times for assessment and review in secondary care can be greater than 12 months. The vast majority of these patients have no renal impairment. However, it is when it when it interferes with a patient’s lifestyle and care dependency that it becomes a very real problem for the patient.

Practitioners should explore and outline with the patient a clearly understood proposed pathway of care including limitations and expectations. Expectations vary but may include dryness, decrease in symptoms or a lessening of the burden of care.

This approach may also include early initiation of the referral process to secondary care to help ensure a seamless transition, should this be required.

There is a range of options which can be potentially beneficial when discussing and organising an acceptable and realistic care pathway. It is important for practitioners to appreciate that pelvic floor exercises are not just for patients with symptoms of prolapse and stress incontinence, but need to be considered for patients with urgency and urge incontinence also. Likewise, the focus on fluid management is not the exclusive realm of the urgency/urge incontinence group.

Urinary incontinence and OAB in men 

Lower urinary tract symptoms are common in men and increase in frequency and severity with age. Most men with LUTS can be managed effectively in primary care, with either conservative measures or medical treatment. 

Voiding symptoms are the most common symptoms in men with LUTS but generally are less bothersome than storage symptoms. Voiding symptoms are usually caused by benign prostatic enlargement, but can be due to urethral stricture, meatal stenosis or a tight phimosis of the foreskin.

If patients fail to respond to initial management or in men with known or suspected neurological problems, consideration should be given to less common causes of voiding problems such as to impaired contractility of the detrusor muscle. Mixed voiding and storage symptoms are common in patients with bladder outflow obstruction due to benign prostatic hypertrophy.

Management plan for UI and OAB

Regardless of age, each patient should be assessed individually and care plan be devised taking a holistic approach.

• Lifestyle interventions
• Check BMI and explore if weight-loss may potentially be beneficial to care. This may also include an encouragement to participate in an increase in daily exercise
• Management of chronic constipation to reduce the recurring excess ‘straining at stool’ which places a significant pressure on the pelvic floor region
• Attention to reducing or stopping smoking. Nicotine is known to be an irritant to the bladder as well as potentially increasing an individual’s tendency to episodic cough episodes
• Fluid management. A bladder diary provides a very useful record of the volume and type of fluids taken. Reviewing the diary with the patient can help to identify substances which may be an irritant to the bladder wall such as excess caffeine intake (tea and coffee), high sugar content fluids, alcohol as well as green tea. A reduction or avoidance of these agents may prove very beneficial to the management of the presenting problem
• Volume of fluid intake and voiding times. Once again the bladder diary can potentially provide a useful insight into optimising care. In a determined effort to avoid urinary tract infections, the patient may in fact be consuming excessive amounts of fluid throughout the day and into the late evening. Ideally, a total maximum intake of 1.5-2 litres a day is to be recommended. 

Bladder training and pelvic floor exercises

Patient techniques should be taught aimed at coping with the urge to void, thus increasing the voiding interval. This includes distraction techniques, deep breathing and relaxation. Concentrate on suppressing the urge by squeezing the pelvic floor a number of times quickly.

Pelvic floor muscle training aims to improve the strength of the pelvic floor muscle contractions and is recommended as first-line management for SUI and mixed UI.

Referral to a physiotherapist, particularly one who has an expertise in this area, can be particularly beneficial. This helps to ensure that a patient is performing pelvic floor muscle exercises correctly. Effective pelvic floor exercises will require that the patient can in fact identify the correct muscles and has clear instructions on how to attain and maintain optimum muscle capacity. NICE guidelines for SUI recommend exercising these muscles three times per day with at least eight contractions.⁸

Attention to core muscle strength also plays an important role in reducing the intra-abdominal pressure and thus the potential force on the pelvic floor when a patient coughs, sneezes, strains at stool, etc. Again, care and direction from a physiotherapist to help ensure that one performs the core muscle exercises in a manner that does not inadvertently place excess pressure on the pelvic floor is most important.

Use of vaginal support pessaries is a conservative measure designed to support a prolapsing organ and limit its descent into the vagina. This may be of benefit for some women presenting with SUI or MUI by helping to restore the normal anatomy of the pelvic floor. Pessaries are more ideally used in women who are waiting for/unfit for/do not wish to have surgery.

Pharmacological therapy

A combined approach including behavioural changes and exercises and pharmacological treatment is the most effective approach. For women, local oestrogen use is associated with overall subjective improvement in women with incontinence, fewer voids in 24 hours, fewer nocturnal voids and less frequency and urgency.¹²

Antimuscarinics 

There are several anticholinergic agents available. These are first-line in treatment of urgency urinary incontinence and overactive bladder. They should not be offered to women with isolated stress urge incontinence. 

Ideally, a trial of three months to assess tolerability and efficacy is recommended prior to discontinuing an agent. A trial of at least two of these agents should be considered prior to moving on to another pharmacological option. These agents are used in men with identified storage difficulties in urinary control. 

The available drugs include fesoterodine, flavoxate, oxybutynin, solifenacin, tolterodine and trospium. Common side-effects include blurred vision, dry mouth, nausea and constipation.

Selective sympathetic adrenaline agonists

Mirabegron has been approved recently for the management of refractory overactive bladder. It works by activation of detrusor muscle receptors to relax the muscle and increase storage capacity. When using this, blood pressure should be regularly monitored and it is contraindicated where there is severe uncontrolled hypertension. Trials of combining antimuscarinic agents and mirabegron are underway.

Antidepressants

Duloxetine may be offered as second-line treatment to women with stress urinary Incontinence.

Various studies have shown high rates of discontinuation of drug therapy, including rates of 70-90% within one year.¹³ It is likely that one of the factors affecting this may be unrealistic expectations by the patient, so good communication and education about what is likely to be achieved is required.

Botulinum toxin injection

This is a hospital-based procedure involving bladder wall injection with botulinum toxin for detrusor overactivity in women who have not responded to conservative measures or drug therapy. It is used when medication is not tolerated or is ineffective.

Hospital-based interventions

Urodynamic assessment is recommended in appropriate patients. Electrical neuromodulation is a hospital-based treatment involving stimulation of the posterior tibial nerve (S2-S4) that shares a common root innervating the bladder. There are also a number of surgical options for both men and women. 

References

1. Abrams,P et al. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics, 2002; 21: 167-178 doi:10.1002/nau.10052
2. Chawathey, K. Urinary incontinence in women. InnovAit, 2015; 8(9): 517-523
3. www.bladdermatters.co.uk.
4. International Continence Society Fact Sheets 2015. www.ics.org
5. Lucas MG (chair) et al. Guidelines on Urinary Incontinence 2014. European Association of Urology. 
6. Rees J, Bultitude M, Challacombe B. The management of lower urinary tract symptoms in men. BMJ 2014;348; g3861 doi: 10.1136/bmj.g3861,1-8
7. Teunissen D, van Weel C, Lagro-Janssen, T. Urinary incontinence in older people living in the community: examining help-seeking behaviour. British Journal of General Practice, 2005; 55(519): 776-782
8. Urinary incontinence in women: management. National Institute for Health and Care Excellence. Issued September 2013. Last modified: November 2015 www.nice.org.uk/guidance/cg171
9. Fit for frailty. Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. A report from the British Geriatrics Society 2014. www.bgs.org.uk/campaigns/fff/fff –full.pdf
10. Thiagamoorthy G, et al. Management of prolapse in older women. Post Reproductive Health. The Journal of the British Menopause Society. 2014; 20(1): 30-35
11. Bradley CS, Rahn DD, Nygard IE, et al. The questionnaire for urinary incontinence diagnosis (QUID): validity and responsiveness to change in women undergoing non-surgical therapies of stress predominant urinary incontinence. Neurourology and Urodynamics 2010; 29: 727
12. Cody JD, Richardson K, Moehrer B. Oestrogen therapy for urinary incontinence in postmenopausal women. Cochrane Database Systemic Review 2009. Issue 10 Art No: CD 001405 doi:10 1002/14651858 .CD001405.pub3
13. D’Souza AO, et al. Persistence, adherence, and switch rates among extended-release and immediate-release overactive bladder medications in a regional managed care plan.J Manag Care Pharm. 2008; 14: 309-311