Diagnosis and office-based treatment of urinary incontinence in adults. Part one: diagnosis and testing

Abstract

Urinary incontinence is a common problem in both men and women. This review article addresses its prevalence, risk factors, cost, the various types of incontinence, as well as how to diagnose them. The US Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Incontinence is a common problem with a high societal cost. It is frequently underreported by patients so it is appropriate for primary-care providers to screen all women and older men during visits. A thorough history and physical examination combined with easy office-based tests can often yield a clear diagnosis and rule out other transient illnesses contributing to the incontinence. Specialist referral is occasionally needed in specific situations before embarking on a treatment plan.

Introduction

Urinary incontinence (UI) is a common problem. Reported prevalence estimates vary between 5% and 54% [Minassian et al. 2003], and more women than men are affected. Its prevalence increases with age [Nygaard et al. 2008]. UI can result in prolonged hospital admission, urinary tract infections, contact dermatitis, and falls. It is a leading cause of admission to a nursing home by families who find it too difficult to care for a member with the problem [Thom et al. 1997]. This review article addresses the various types of incontinence as well as how to diagnose them. Office-based treatments are covered in detail and a summary of the various surgical therapies are given in part two of this review.

Methods

The following data sources were reviewed: the US Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and PubMed. A MEDLINE search was conducted using the key words of incontinence plus: bladder irritants, clinical practice guidelines, cost, diagnosis office urinary, estrogen, mixed incontinence, pad test, postvoid residual, prevalence, quality of life, risk factors, stress, urge, urinalysis urinary, and voiding diary urinary. Strength of recommendation taxonomy (SORT) criteria were utilized to grade the quality of evidence [Ebell et al. 2004].

Prevalence and risk factors (level of evidence: SORT B–C)

Older age and female gender are the most significant risk factors for UI, with twice as many females as males reporting this problem [Malmsten et al. 1997]. UI affects 10–35% of adults and 50–84% of elderly persons in long-term care facilities [Erdem and Chu, 2006].

Race and ethnicity have shown variable effects on UI in women. Although some studies have shown greater prevalence among Whites [Fultz et al. 1999; Anger et al. 2006], others have shown higher prevalence in African Americans [Freeman et al. 2001] and Hispanics [Daneshgari et al. 2008]. Other risk factors include increased parity, higher body mass index, higher weight, and hysterectomy [Minassian et al. 2008]. Women who participate in more physical activity, even high-impact exercises, do not have an increased risk of incontinence, contrary to common misconceptions. Vaginal estrogen cream use and diabetic neuropathy are independent predictors of UI [Jackson et al. 2006]. In addition to a history of surgery, past radiation is also associated with UI. Around 17% of men aged over 60 years, or an estimated 600,000 men, experience UI, and its prevalence increases with age [Stothers et al. 2007].

Potentially reversible causes such as urinary tract infection, physical restraints, and environmental barriers were associated with greater prevalence of UI among frail elderly men and women living in the community [Landi et al. 2003].

Cost and quality of life

A recent US study estimated the direct cost of treating UI in 2000 to be US$19.5 billion, 75% of which is spent on the treatment of women. Of this, US$14.2 billion were attributed to community residents and US$5.3 billion to institutional residents [Hu et al. 2003] (SORT C). Women with severe UI pay about US$900 annually for incontinence routine care. UI is associated with a significant decrement in health-related quality of life, including irritative skin conditions, urinary tract infections, falls, fractures, and additional nursing home admissions [Subak et al. 2006]. In a free health examination of participants who complained of UI, 66% of women and 58% of men stated that their quality of life was affected, particularly due to the impact on sexual function, and the need for pads or other incontinence devices [Temml et al. 2000].

Diagnosis

UI is defined as ‘the complaint of involuntary loss of urine’ [Haylen et al. 2010]. This is a relatively simple diagnosis to make since it is based simply on patient history. However, many patients are reluctant to volunteer this symptom without prompting, given the sensitive nature of the complaint. Also, many patients do not discuss their symptoms since they fear that there is no effective treatment, and they ascribe to the common belief in the ‘aging myth’ that urine leakage is a normal part of growing older. Overall less than 50% of individuals with UI report it to their physician [Weiss, 1998]. Given the high prevalence of this condition and the known patient reluctance to mention it on their own, it is reasonable for primary-care providers to inquire periodically about the presence of incontinence in all women and older men (SORT C). A simple question would be: ‘ do you ever leak urine or have difficulty in getting to the toilet on time?’ [Keilman, 2005].

The goals of an office-based evaluation of UI are: to identify transient causes of incontinence; if possible, identify the specific type and presence of incontinence; offer initial treatment for the incontinence; identify those individuals who need specialist referral (SORT C) (Figure 1).

Figure 1.

Flowchart in the diagnosis of urinary incontinence in adults.

Before embarking on a more complicated path to diagnosis of the type of incontinence, reversible or transient causes of incontinence should be sought. These are typically new in onset and can often be due to factors outside the urinary tract. These are especially important in the elderly where up to a third of cases of UI in community-dwelling older adults are transient [Shah and Badlani, 2002].

The mnemonic DIAPPERS has long been used to remember this list. These conditions should all be sought and ruled out in the initial office visit [Keilman, 2005]:

• D – delirium, dementia or other confusional states

• I – infections: urinary tract infections (UTI), respiratory

• A – atrophic vaginitis, labial agglutination

• P – psychological causes: depression, hopelessness

• P – pharmacological: alpha blockers, estrogens, sedatives/hypnotics, narcotics, diuretics

• E – endocrine disorders (e.g. hyperglycemia or hypercalcemia), excessive urine output, excessive fluid intake

• R – restricted mobility: physical restraints, environmental barriers, lack of caregiver assistance to toilet

• S – stool impaction, chronic constipation

The most useful tool in determining the type of incontinence is a thorough history (SORT C). Onset of symptoms, duration, frequency, severity (number of pads or clothing changes), amount of urine lost per episode, aggravating and relieving factors, associated symptoms (e.g. straining, intermittent stream, feeling of incomplete emptying), and patient concern (including impact on hygiene), all need to be elicited. In addition, past surgical and medical history is often highly relevant.

Differentiating between types of incontinence can often be a challenge, but there are many medical factors identified on history that can greatly assist in making the diagnosis.

Mechanism and classification of incontinence

Stress UI (SUI) is the complaint of involuntary urine loss on effort or physical exertion, or on sneezing or coughing [Haylen et al. 2010]. Risk factors for SUI in women include higher parity, younger age (perimenopausal or premenopausal), White race, smoking, lung disease, and obesity [Minassian et al. 2008; Jackson et al. 2006; Landi et al. 2003]. In contrast to common misconceptions, being physically active, even high-impact activities, does not increase the risk of developing SUI. It can actually be protective, probably due to its positive effect on healthy weight [Jiang et al. 2004]. SUI is described as occurring with coughing, sneezing, lifting, laughing, and physical activity. Its onset is typically after childbearing and often preceded by incontinence during pregnancy [Haylen et al. 2010]. It is typically only a small volume at a time, and is predictable with certain activities (i.e. ‘I only leak when I jog/sneeze/lift heavy things…’). Both men and women with SUI often report urinary frequency since they have learned that frequent emptying of the bladder decreases the amount of leakage. Patients report improvement if the bladder is kept empty and they do not move (i.e. sitting quietly). It typically does not occur at night. In men the vast majority of SUI occurs after a radical prostatectomy or transurethral resection of the prostate [Stothers et al. 2007].

Urgency UI is the complaint of involuntary loss of urine associated with urgency [Haylen et al. 2010]. In both sexes it occurs more often in older individuals. Other risk factors include pelvic radiation (e.g. prostate, bladder, uterine, cervical, rectal), diabetes, neurological disease (Parkinson’s, stroke, etc.), increased caffeine intake, excessive fluid consumption, excessive fluid excretion (e.g. diuretics, congestive heart failure), and fecal impaction [Minassian et al. 2008; Jackson et al. 2006; Stothers et al. 2007]. The incontinence is described as occurring on the way to the bathroom or with a sensation of urge. It is very bothersome since it is unpredictable and can be of large volume (flooding). It can occur while supine and common triggers of include hearing or feeling running water, exposure to cold, and psychological triggers (e.g. driving into driveway, hand on doorknob). It is often associated with other lower urinary tract symptoms such as frequency, urgency, and nocturia [Haylen et al. 2010].

Mixed UI is the complaint of involuntary loss of urine associated with urgency, and also with effort or physical exertion, or on sneezing or coughing [Haylen et al 2010]. It is important to determine which of these is predominant, since that is the symptom typically treated first.

Overflow UI is the involuntary leakage of urine in small amounts that is frequent or constant and associated with incomplete bladder emptying [Keilman, 2005]. This is a much less common cause of incontinence and often presents insidiously without the patient being aware that they are in retention. Patients can also present with associated obstructive voiding symptoms (e.g. straining, intermittent stream, and feeling of incomplete emptying). Both urge and stress-like incontinence can be the presenting symptom, but a postvoid residual confirms a full bladder after emptying. One must suspect this type of incontinence in all men given the risk of bladder outlet obstruction caused by the prostate. It is much less common in women, but can occur after sling surgery, or in the presence of advanced prolapse extending beyond the hymen. Other causes of retention include pelvic surgery causing denervation (e.g. rectal, uterine, prostate surgery), neurological damage to the pelvic nerves or spinal cord (e.g. diabetes, multiple sclerosis, spinal cord trauma). Transient bladder dysfunction causing retention can frequently occur in the presence of pain, narcotic usage, or impaired mobility, making it very common in hospitalized patients.

Functional UI is a diagnosis of exclusion and is incontinence with the urge to urinate, but being unable physically to get to the toilet, ask for assistance, or having no motivation to go to the toilet, and it is related to cognitive and functional status [Keilman, 2005]. This diagnosis must be suspected in patients who are frail, or are mobility impaired or cognitively impaired. Many often have concomitant stress or urgency incontinence, but it is their inability or lack of awareness of the need to go to the toilet that is the major cause of the incontinence. This type of incontinence can only be treated with timed voiding or by being prompted by their caregiver.

Continuous UI is the complaint of continuous involuntary urine loss [Haylen et al. 2010]. This is probably the rarest form of incontinence and is most often very severe SUI with a completely nonfunctional urethra. Other rare causes include vesicovaginal fistulas, ectopic ureters to the vagina, or other communications with the urinary tract and the body that cause constant urine dripping.

Evaluation

The necessary elements to making a correct diagnosis and guiding treatment include a thorough physical examination, urinalysis, postvoid residual, a voiding diary, and pad testing.

A physical examination should be carried out to assist in making a diagnosis of incontinence [Abrams et al. 2010] (SORT C). The focus should be on the genitourinary tract and include bladder palpation for tenderness or retention. In men, the prostate should be examined for size and possible inflammation and the penis evaluated for meatal stenosis. In women, a complete pelvic examination should be performed to check for urethral mobility, vaginal atrophy, prolapse, pelvic floor muscle tone, and the presence of surgical scars to suggest a prior sling surgery. A cough or Valsalva stress test with a full bladder can also be carried out at this time to confirm the presence of SUI. Other relevant portions of the physical examination in both genders include mental status, mobility, a general neurological examination, and height and weight to evaluate for obesity [Abrams et al. 2010].

The urinalysis is a vital part of any urologic examination (SORT C). The dipstick is a good screening tool, but microscopy is needed to confirm any abnormalities. Isolated hematuria, whether microscopic (> 3–5 red blood cells per high power field) or gross, should prompt upper tract imaging and urology referral. A UTI can present as incontinence and should be treated if found [Abrams et al. 2010].

The postvoid residual can be performed with a sterile in and out catheterization during the examination of genitalia, or with an ultrasound bladder scanner. Ideally the patient should have voided within the previous 10 min. If the patient cannot void, hydration should be provided and the examination carried out when they can void since random residual urine is of little clinical significance unless it is very low. There is no absolute cutoff for an abnormal postvoid residual, but it is known that it increases with age. A good rule of thumb is a residual less than the patient’s age is almost always normal, while a residual significantly higher than this should prompt urology referral [Abrams et al. 2010] (SORT C).

A voiding diary is recommended to both diagnose and guide therapy in incontinence [Abrams et al. 2010] (SORT B). A 1–3 day diary is sufficient [Groutz et al. 2000], and is much more reliable than patient recall. The patient records the time, voided volume (measured in a measuring cup or toilet hat), amount of urgency, amount of leakage, and volume of fluids ingested, as well as the type of fluids. Many patients with incontinence vastly over consume fluids in the belief that it is healthy. In addition, caffeine excess can easily be identified with the diary. Many patients void infrequently and are unaware, since this is a lifelong habit. While a voiding diary combines both objective and subjective assessments of voiding habits, it is universally held to be a useful tool for patients with incontinence, as one moves toward bladder retraining [Abrams et al. 2010; Groutz et al. 2000].

Pyridium pad testing can be carried out in the rare case that a female patient is unsure if the wetness is urinary, vaginal secretions, or sweat (especially when it is of small volume). Phenazopyridine hydrochloride is an azo dye oral analgesic excreted in urine that turns the urine an orange color. It can be given in a single dose while the patient wears a pad for a day to collect any wetness. Vaginal secretions and sweat are not routes for excretion of the dye, hence a positive pyridium pad test with an orange stain is indicative of urine loss. One caveat of this test is that normally continent women who perform this test during a period of exercise do stain the pad with a 3-mm spot, but this is not considered incontinence [Nygaard and Zmolek, 1995] (SORT B).

Pad testing is performed with the patient collecting all wet pads from a 24-h period and sealing them in an airtight bag so they can be weighed. A dry identical pad’s weight is subtracted to yield the total incontinence volume. A pad weight serves to quantify objectively the amount of incontinence since the number and thickness of pads used is highly dependent on patient preference [Groutz et al. 2000] (SORT C).

Validated questionnaires are an adjunct to the urinary symptom history. They can help quantify the severity of symptoms and can assess the bother. An ideal survey that applies to all incontinent patients of both genders does not exist [Shy and Fletcher, 2013]. The American Urological Association Symptom Index is commonly utilized in men. It does not address incontinence, but does quantify lower urinary tract symptoms. The urogenital distress inventory, incontinence impact questionnaire, and the Bristol female lower urinary tract symptoms are all commonly utilized in women and have a more general scope allowing for use in the primary-care setting. Caregivers should familiarize themselves with these surveys in order to use the correct one for the appropriate patient.

When referral is needed to a urologist

Some patients require immediate referral to a urologist since their incontinence is considered ‘complicated’, and they require either cystoscopic or urodynamic evaluation. Any patient with gross or microscopic hematuria (in the absence of a UTI), multiple recurring infections, unexplained bladder pain, significant pelvic organ prolapse (below the hymen), suspected neurological abnormality, or a significant postvoid residual should be referred before treatment [Abrams et al. 2010]. In addition, if a fistula or other severe abnormality is suspected, immediate referral is warranted. If a patient has incontinence after pelvic radiation, radical pelvic surgery, or prior incontinence surgery they require more in-depth urologic evaluation with urodynamics [Abrams et al. 2010] (SORT B). Most men with incontinence fall into this complicated incontinence group and require urologic evaluation unless they have only postmicturition dribble, which can be remedied by teaching them to perform a strong Kegel exercise, or to manually compress their bulbous urethra after voiding [Abrams et al. 2010] (SORT B). If the cause of their incontinence is known, for example, postprostatectomy, then lifestyle advice, timed voids, and physical therapy can be instituted immediately. Alpha-blocker therapy can be started if bladder outlet obstruction is suspected, as in the case of benign prostatic hyperplasia, and then the patient should be referred to a urologist after 8–12 weeks if the therapy fails [Abrams et al. 2010].

Conclusion

Incontinence is a common problem with a high societal cost. It is frequently underreported by patients so it is appropriate for primary-care providers to screen all women and older men during visits. A thorough history and physical examination combined with easy office-based tests can often yield a clear diagnosis and rule out other transient illnesses contributing to the incontinence. Specialist referral is occasionally needed in specific situations before embarking on a treatment plan.