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2/4/2016 Evaluationofwomenwithurinaryincontinence

OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Evaluationofwomenwithurinaryincontinence

Author SectionEditors DeputyEditors


EmilySLukacz,MD,MAS LindaBrubaker,MD,FACS,FACOG LeePark,MD,MPH
KennethESchmader,MD KristenEckler,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Feb2016.|Thistopiclastupdated:Mar14,2016.
INTRODUCTIONUrinaryincontinence,theinvoluntaryleakageofurine,oftenremainsundetectedandundertreated[13].Itisestimatedthatbetween26and61
percentofcommunitydwellingwomenseekcareforurinaryincontinence[46].Patientsmaybereluctanttoinitiatediscussionsabouttheirincontinenceandurinary
symptomsduetoembarrassment,lackofknowledgeabouttreatmentoptions,and/orfearofsurgery.

Thistopicwillreviewtheepidemiology,riskfactors,etiology,andinitialevaluationofthenonpregnantwomanwithurinaryincontinence.Thetreatmentofurinary
incontinenceinwomenandurinaryincontinenceinpregnantwomenandinmenarediscussedseparately.(See"Treatmentofurinaryincontinenceinwomen"and
"Urinaryincontinenceandpelvicorganprolapseassociatedwithpregnancyandchildbirth"and"Urinaryincontinenceinmen".)

IMPACTONHEALTHUrinaryincontinenceisnotassociatedwithincreasedmortality[7].However,incontinencecanimpactmanyotheraspectsofapatient's
health.

QualityoflifeUrinaryincontinenceisassociatedwithdepressionandanxiety,workimpairment,andsocialisolation[812].Urinaryincontinencehasbeen
demonstratedtoadverselyimpactqualityoflifeeveninnursinghomeresidents[13].

SexualdysfunctionIncontinenceduringsexualactivity(coitalincontinence),whichmayaffectuptoonethirdofallincontinentindividuals,andfearof
incontinenceduringsexualactivitybothcontributetoincontinencerelatedsexualdysfunction[14].Urgencyincontinencehadgreaternegativeimpacton
sexualfunctioncomparedwithurgencyorfrequencywithoutincontinence[15,16].

MorbidityThemedicalmorbidityassociatedwithurinaryincontinenceincludesperinealinfectionsfrommoistureandirritation(eg,candidaorcellulitis)and
fallsandfractures[17].

IncreasedcaregiverburdenIncontinenceinolderpersonsisassociatedwithincreasedcaregiverburden[18].Sixto10percentofnursinghome
admissionsintheUnitedStatesareattributabletourinaryincontinence[19].

EPIDEMIOLOGY

PrevalenceUrinaryincontinenceiscommoninwomen,particularlyinpregnancy.Urinaryincontinenceinpregnancyisdiscussedseparately.(See"Urinary
incontinenceandpelvicorganprolapseassociatedwithpregnancyandchildbirth".)

Estimatesofprevalencevarydependingonthepopulationstudiedandtheinstrumentsusedtoassessseverity.Weeklyurineleakagehasbeenreportedin10
percentofwomeninanethnicallydiverseUnitedStatesurbanpopulationand16percentofnonpregnantwomen20yearsinanationallyrepresentativesample
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[20,21].InalargeUnitedStateshealthmaintenanceorganization,amongwomenaged25to84years,bothersomestressurinaryincontinence(SUI)wasreportedin
15percentofwomenandurgencyincontinence/overactivebladderin13percent[22].Othersurveyshavereportedprevalencesofanyurinaryincontinencefrom13
percentinnulligravidwomenaged16to30yearsto17percentinnonpregnantwomenaged20years[23,24].

Theprevalenceofurinaryincontinenceincreaseswithageandisparticularlyhighforindividualslivinginnursinghomes,withratesrangingfrom43to77percent
[25,26].Urinaryincontinenceisalsocommoninpersonswithcognitiveimpairment/dementia,withtheprevalencerangingfrom10to38percent[27].

Notallwomenwhodevelopurinaryincontinencewillhavesymptomsindefinitely.Inalongitudinalcohortstudyof4127middleagedwomen,theannualincidence
rateofurinaryincontinencewas3.3percentandtheannualremissionratewas6.2percent[28].Factorsassociatedwithpersistentsymptoms(ie,noresolution)
wereweightgainandtransitiontomenopausalstatus.

RiskfactorsRiskfactorsforurinaryincontinenceinclude[26,2933]:

ObesityObesityisthestrongestriskfactorforincontinence.Obesewomenhaveanearlythreefoldincreasedoddsofurinaryincontinencecomparedwith
nonobesewomen[21,29,34,35].Weightreductionisassociatedwithimprovementandresolutionofurinaryincontinence,particularlySUI.Several
observationalstudieshavereporteda50percentorgreaterreductioninSUIafterbariatricsurgeryinducedweightloss[3638].

ParityIncreasingparityisariskfactorforurinaryincontinenceandpelvicorganprolapse[33,39].(See"Urinaryincontinenceandpelvicorganprolapse
associatedwithpregnancyandchildbirth",sectionon'Prevalenceinparouswomen'.)

ModeofdeliveryComparedwithwomenwhohavehadacesareansection,womenwhohavehadavaginaldeliveryareathigherriskforstress
incontinence.However,cesareandeliverydoesnotprotectwomenfromurinaryincontinence.Therelationshipbetweenurgencyincontinence/overactive
bladderandmodeofdeliveryislesscertain.(See"Urinaryincontinenceandpelvicorganprolapseassociatedwithpregnancyandchildbirth",sectionon'Mode
ofdelivery'.)

FamilyhistoryTheriskofurinaryincontinence,particularlyurgencyincontinence,maybehigherinpatientswithafamilyhistory.Onestudyfoundthatthe
riskofincontinencewasincreasedforbothdaughters(relativerisk[RR]1.3,95%CI1.21.4)andsisters(RR1.6,95%CI1.31.9)ofwomenwith
incontinence[32].Twinstudiesattributea35to55percentgeneticcontributiontourgencyincontinence/overactivebladderbutonly1.5percentforstress
incontinence[40,41].

AgeBoththeprevalenceandseverityofurinaryincontinenceincreasewithage[21,23,42].InalargerepresentativeUnitedStatessurveyofnonpregnant
women,urinaryincontinencewasreportedtoaffect3.5percentofwomenages20to29,increasingto38percentofwomenage80years[23].Onethirdof
womenintheNurse'sHealthStudy(aged54to79years)whoreportedurineleakageoncemonthlyatbaselineprogressedtoleakingatleastonceaweek
overtwoyearfollowup[43].However,studiescontrollingforothercomorbidconditionssuggestthatagealonemaynotbeanindependentriskfactorfor
incontinence[22].

Ethnicity/raceTheprevalenceofurinaryincontinencebyraceorethnicityinwomenhasbeenvariablyreported.Somestudiesreporthigherprevalencein
nonHispanicwhitewomencomparedwithAfricanAmericanwomen[20,23,4446].Otherstudiesdonotreportdifferencesbetweenracial/ethnicgroups
[21,47,48].

OthersSmokinghasalsobeenassociatedwithanincreasedriskofincontinence[49,50].Othersuggestedriskfactorsincludecaffeineintake,diabetes,

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stroke,depression,fecalincontinence,vaginalatrophy,hormonereplacementtherapy,genitourinarysurgery(eg,hysterectomy),andradiation[1,34,45,5158].

Stressincontinencehasbeenassociatedwithparticipationinhighimpactactivities,includingjumpingandrunning[59,60].Additionalriskfactorsforurgency
incontinenceincludeimpairedfunctionalstatus,recurrenturinarytractinfections,andbladdersymptomsinchildhood,includingchildhoodenuresis[61,62].

ETIOLOGYContinencedependsuponbothintactmicturitionphysiology(includinglowerurinarytract,pelvic,andneurologiccomponents(figure1))aswellasan
intactfunctionalabilitytotoiletoneself.(See"Anatomyandlocalizationofspinalcorddisorders",sectionon'Autonomicfibers'.)

ClassificationThemaintypesofurinaryincontinencearestress,urgency,andoverflowincontinence.Manywomenhavefeaturesofmorethanonetype[63,64].
Identifyingtheclassificationofincontinencehelpsguidetherapy.(See"Treatmentofurinaryincontinenceinwomen".)

StressincontinenceIndividualswithstressincontinencehaveinvoluntaryleakageofurinethatoccurswithincreasesinintraabdominalpressure(eg,with
exertion,sneezing,coughing,laughing)intheabsenceofabladdercontraction[39,65,66].Stressincontinenceisthemostcommontypeinyoungerwomen,with
thehighestincidenceinwomenages45to49years[42,61,67].

Mechanismsofstressincontinenceincludeurethralhypermobilityandintrinsicsphinctericdeficiency(ISD).

Urethralhypermobilityisthoughttostemfrominsufficientsupportofthepelvicfloormusculatureandvaginalconnectivetissuetotheurethraandbladder
neck[68].Thiscausestheurethraandbladdernecktolosetheabilitytocompletelycloseagainsttheanteriorvaginalwall.Withincreasesinintraabdominal
pressure(eg,fromcoughingorsneezing)themusculartubeoftheurethrafailstoclose,leadingtoincontinence(likesteppingonahoseinsand).

Insufficienturethralsupportmayberelatedtolossofconnectivetissueand/ormuscularstrengthduetochronicpressure(ie,highimpactactivity,chronic
cough,orobesity)ortraumaduetochildbirth,particularlyvaginaldeliveries.Childbirthcancausetraumadirectlytothepelvicmusclesandmayalsodamage
nervesleadingtopelvicmuscledysfunction.Treatmentsforhypermobilitystressincontinenceareaimedatprovidingabackboardofsupportfortheurethra.
(See"Urinaryincontinenceandpelvicorganprolapseassociatedwithpregnancyandchildbirth",sectionon'Mechanismsofpelvicfloorinjury'and"Treatment
ofurinaryincontinenceinwomen".)

Intrinsicsphinctericdeficiency(ISD)isanotherformofstressurinaryincontinence(SUI)thatresultsfromalossofurethraltonethatnormallykeepsthe
urethraclosed.Thiscanoccurinthepresenceorabsenceofurethralhypermobilityandtypicallyresultsinsevereurinaryleakageevenwithminimalincreases
inabdominalpressure.Ingeneral,ISDresultsfromneuromusculardamageandcanbeseeninwomenwhohavehadmultiplepelvicorincontinencesurgeries.
ItischallengingtotreatwomenwithISD,andtheyhaveworsesurgicaloutcomes[69,70].(See"Surgicalmanagementofstressurinaryincontinencein
women:Choosingaprimarysurgicalprocedure",sectionon'Lackofurethralhypermobilityandintrinsicsphincterdeficiency'.)

UrgencyincontinenceWomenwithurgencyincontinenceexperiencetheurgetovoidimmediatelyprecedingoraccompaniedbyinvoluntaryleakageofurine
[62,65].Theamountofleakagerangesfromafewdropstocompletelysoakedundergarments."Overactivebladder"isatermthatdescribesasyndromeofurinary
urgencywithorwithoutincontinence,whichisoftenaccompaniedbynocturiaandurinaryfrequency[62,65].Theterms"urgencyincontinence"and"overactive
bladderwithincontinence"areoftenusedinterchangeably.

Urgencyincontinenceismorecommoninolderwomenandmaybeassociatedwithcomorbidconditionsthatoccurwithage[71,72].Itisbelievedtoresultfrom
detrusoroveractivity,leadingtouninhibited(involuntary)detrusormusclecontractionsduringbladderfilling[62].Thismaybesecondarytoneurologicdisorders(eg,
spinalcordinjury),bladderabnormalities,ormaybeidiopathic[62].Theprevalenceofinvoluntarydetrusorcontractions,ordetrusoroveractivity,hasbeenfoundin

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21percentofhealthy,continent,communitydwellingelderly[73].(See"Chroniccomplicationsofspinalcordinjuryanddisease",sectionon'Urinarycomplications'.)

MixedincontinenceWomenwithsymptomsofbothstressandurgencyincontinencearedescribedashavingmixedincontinence[65,74].

OverflowincontinenceOverflowincontinencetypicallypresentswithcontinuousurinaryleakageordribblinginthesettingofincompletebladderemptying.
Associatedsymptomscanincludeweakorintermittenturinarystream,hesitancy,frequency,andnocturia.Whenthebladderisveryfull,stressleakagecanoccur
orlowamplitudebladdercontractionscanbetriggeredresultinginsymptomssimilartostressorurgencyincontinence.

Overflowincontinenceiscausedbydetrusorunderactivityorbladderoutletobstruction.

DetrusorunderactivityDetrusorunderactivitymaybecausedbyimpairedcontractilityofthedetrusormuscle[72].Impairedurothelialsensoryfunctionmay
alsocontribute.Studiessuggestthatdetrusorcontractilityandefficiencydecreasewithage[75].Severedetrusorunderactivityoccursinabout5to10percent
ofolderadults[72,76].Otheretiologiesofdetrusorunderactivityincludesmoothmuscledamage,fibrosis,lowestrogenstate,peripheralneuropathy(dueto
diabetesmellitus,vitaminB12deficiency,alcoholism),anddamagetothespinaldetrusorefferentnervesbypathologiesaffectingthespinalcord(eg,multiple
sclerosis,spinalstenosis)[77,78].(See"Disordersaffectingthespinalcord".)

Asubsetofwomenwiththisconditioncanhavedetrusorhyperactivitywithimpairedcontractility(DHIC).WithDHIC,thebladderdoesnoteffectivelycontract
toemptyandalsohaslowamplitudehyperactivity,resultinginurgencyaswellasoverflowincontinence.DHICisparticularlydifficulttotreatasanytherapy
foroveractivityresultsinincreasedurinaryretentionandoverflowincontinence.

BladderoutletobstructionBladderoutletobstructioninwomenisgenerallycausedbyexternalcompressionoftheurethra.Thisoccurswithfibroids,
advancedpelvicorganprolapse(ie,beyondthehymen),orovercorrectionoftheurethrafrompriorpelvicfloorsurgery.Lesscommoncausesincludeexternal
massesortumorsatthelevelofthebladderoutletoruterineincarcerationofaretroverteduterus(whichcanoccurinpregnancyorinthesettingoffibroids).
(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement"and"Incarceratedgravid
uterus".)

Othercontributingfactors/conditionsOtheretiologiesforurinaryincontinenceincludeotherurologicorgynecologicdisorders,systemicdiseases,and
potentiallyreversiblecauses(eg,medications).

VaginalatrophyInpostmenopausalwomen,lowestrogenlevelsresultinatrophyofthesuperficialandintermediatelayersoftheurethralmucosal
epithelium.Atrophyresultsinurethritis,diminishedurethralmucosalseal,lossofcompliance,andpossibleirritation,allofwhichcancontributeto
incontinence.(See"Clinicalmanifestationsanddiagnosisofvaginalatrophy",sectionon'Pathophysiology'.)

Otherurologic/gynecologicdisordersOtherlesscommonurologicorgynecologicdisordersthatcancauseurinaryincontinenceincludeurogenitalfistulas,
urethraldiverticula,andectopicureters.(See"Urogenitaltractfistulasinwomen".)

SystemiccausesPatientswhohaveunderlyingmedicalconditionsthatcontributetourinaryincontinencewillalsohaveothercharacteristicfeaturesor
relevanthistory.

NeurologicdisordersSpinalcorddisorderscanleadtooverflowincontinenceasdiscussedabove.Otherexamplesofneurologicdisordersthatcan
leadtourinaryincontinenceinclude:stroke,Parkinsondisease,andnormalpressurehydrocephalus.(See"Medicalcomplicationsofstroke"and"Clinical
manifestationsofParkinsondisease"and"Normalpressurehydrocephalus".)
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Overflowincontinenceandpoorurinarystreamcanbepresentinpatientswithdiabeticautonomicneuropathy.(See"Diabeticautonomicneuropathy".)

CancerLesscommonsystemiccausesofurinaryincontinenceincludebladdercancerorinvasivecervicalcancer.(See"Clinicalpresentation,
diagnosis,andstagingofbladdercancer"and"Invasivecervicalcancer:Epidemiology,riskfactors,clinicalmanifestations,anddiagnosis",sectionon
'Clinicalmanifestations'.)

PotentiallyreversiblecausesPotentiallyreversiblecausesoforcontributorstourinaryincontinenceincludemedications(table1),alcoholandcaffeine
intake,constipation/stoolimpaction,andurinarytractinfection(UTI).UTImaycauseorworsenurinaryincontinence.WomenwithUTImayhavemore
incontinencenotonlyduringtheepisodebutalsoimmediatelyfollowingtheUTI[79].(See"Acuteuncomplicatedcystitisandpyelonephritisinwomen",section
on'Clinicalsuspicion'.)

FunctionalincontinenceFunctionalincontinenceoccurswhenapatienthasintacturinarystorageandemptyingfunctionsbutisphysicallyunabletotoilet
herselfinatimelyfashion.Thisappearstobeacommoncontributortourinaryincontinenceforolderwomen.Asanexample,inonestudythatincluded177
womenaged57to85yearswithdailyurinaryincontinence,62percentreportedatleastonefunctionaldisabilityordependenceand24percentreported
specificdifficultyordependencewithusingthetoilet[80].Suchfunctionalincontinencemaybereversibleinthesettingofmodifiablefactors(eg,decreased
mobilitypostsurgery,decreasedmanualdexterity,andchangeincognitiveormentalstatusfromsedationfrommedications)[65,81,82].

CognitiveimpairmentTheassociationbetweencognitiveimpairmentandincontinenceisinpartmediatedbyfunctionalimpairmentanddisability[83].
Comorbidconditionsandmedicationsalsooftencontribute.

EVALUATIONTheinitialevaluationofurinaryincontinenceincludescharacterizingandclassifyingthetypeofincontinence,identifyingunderlyingconditions(eg,
neurologicdisorderormalignancy)thatmaymanifestasurinaryincontinence,andidentifyingpotentiallyreversiblecausesofincontinence(algorithm1)[8486].

Theevaluationshouldstartwithathoroughhistory,physicalexamination,andurinalysis[61,85].Additionalevaluationiswarrantedinthepresenceofcomplex
medicalconditionsorconcerningfindingsonhistoryand/orphysicalexamination.

HistoryManypatientsarereluctanttoinitiateadiscussionabouttheirincontinence.Womenwhohavecomorbidconditionsassociatedwithincreasedrisk(eg,
prolapse,bowelleakage,diabetes,obesity,neurologicdisease)andthosewhoareover65yearsofageshouldspecificallybeaskedabouturinaryincontinence[87].

Thehistoryfurtherclarifiesthepatient'surinarysymptomsandseverityandidentifiespotentialunderlyingcausesthatmaybetreatableorrequirefurtherevaluation
[65].Classifyingthetypeofincontinencehelpsdirecttreatment(algorithm1).(See"Treatmentofurinaryincontinenceinwomen".)

ClassifyingincontinenceSymptomsofincontinenceandclassificationcanbeelicitedusingshortstandardizedquestionnaires.Thethreeincontinence
questionnaire(3IQ)(form1)canhelpdistinguishbetweenstress,urgency,andmixedincontinence[88].Inamulticenterstudyof300middleagedwomenwith
moderateincontinence,the3IQhadasensitivityof0.75andspecificityof0.77foridentifyingurgencyincontinenceandasensitivityof0.86andspecificityof
0.60forstressincontinence[88].

Relevanturinarysymptomsincludefrequency,volume,severity,hesitancy,precipitatingtriggers,nocturia,intermittentorslowstream,incompleteemptying,
continuousurineleakage,andstrainingtovoid[62].Symptomclustersareassociatedwithspecificvoidingabnormalities.Asexamples:

Stressurinaryincontinence(SUI)isassociatedwithurinelosswithincreasesinintraabdominalpressure,suchasoccurswithlaughing,coughing,or
sneezing.Urinevolumelostmaybesmallorlarge.Thereisnourgetourinatepriortotheleakage.
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Urgencyincontinence/overactivebladderisassociatedwithfrequent,smallvolumevoidsthatmaykeepthepatientupatnightorworsenaftertakinga
diuretic.Thepatienthasastrongurgetovoidwithaninabilitytomakeittothebathroomintime.

Overflowincontinenceduetodetrusormuscleunderactivityischaracterizedbythepainlesslossofurinewithnowarningortriggers.Thevolumeleaked
maybesmallorlarge.Urinelossoftenoccurswithchangesinposition.Thismaybeassociatedwithurinaryhesitancy,slowflow,urinaryfrequencyand
nocturia.

Overflowincontinenceduetourinaryoutletobstruction,suchasfrompelvicorganprolapse,fibroids,orpelvicsurgery,isoftenassociatedwithan
intermittentorslowstream,hesitancy(difficultygettingurinestreamstarted),andasensationofincompleteemptying.Womenwithobstructionoften
needtostraintopasstheirurine.

SystemicsymptomsWeevaluateallwomenwithincontinenceforurinarytractinfection(UTI),askingaboutsymptomssuchasfever,dysuria,pelvicpain,
andhematuria.(See"Acuteuncomplicatedcystitisandpyelonephritisinwomen",sectionon'Clinicalsuspicion'.)

Symptomsthatareconcerningforotherunderlyingconditionsasthecauseofurinaryincontinenceinclude:suddenonsetofincontinence,associated
abdominal/pelvicpainorhematuriawithouturinarytractinfection,changesingaitornewlowerextremityweakness,cardiopulmonaryorneurologicsymptoms,
andmentalstatuschanges.Womenwiththesesymptomsshouldhaveappropriateworkupandevaluationforunderlyingconditionsand/orspecialistreferralif
necessary.(See'Specialistreferral'below.)

Wealsoaskaboutchangesinbowelfunction(eg,constipation).Inolderadults,wetypicallyaskaboutandassessfunctionalstatus,mobility,andcognitive
status[65,81].(See"Officebasedassessmentoftheolderadult".)

MedicationsSomemedications(table1)cancontributetourinaryincontinence[82].Alcoholandcaffeineintakeshouldbespecificallyelicited.

VoidingdiariesVoidingdiariesarehelpfulintheassessmentofurinaryincontinencesymptoms.Oneexample,ofavoidingdiarycanbefoundonthe
AmericanUrogynecologicSocietywebsite.Whilebasicdiaryrecordsoffrequencyandvolumeareneithersensitivenorspecificfordeterminingthecauseof
incontinence[63,89],theymaybehelpfultodetermineifurinaryincontinenceisassociatedwithhighfluidintake.Inaddition,theyprovideameasureofthe
severityoftheproblemthatcanbefollowedovertime.Voidingdiariesalsoidentifythemaximumtimeintervalthatthewomancanreasonablywaitbetween
voids,ameasureusedtoguidebladdertraining.(See"Treatmentofurinaryincontinenceinwomen",sectionon'Bladdertraining'.)

Whilemostclinicalstudiesuseathreedayvoidingdiarytoassessoutcomesoftreatment,wefindbettercompliancewitha24hourdiary.Normalvoiding
frequencyislessthaneighttimesadayandonceatnight,withtotalvolumesoflessthan1800mLper24hours[90,91].

ImpactonqualityoflifeCliniciansshouldidentifythosesymptomsthataremostbothersometothepatientasthiscanhelpguidetreatment.Theimpactof
thepatient'sincontinenceonherqualityoflifecanbeassessedinformallybyaskingafewtargetedquestionsorbyusingavalidatedinstrument(eg,
InternationalConsultationonIncontinenceQuestionnaire,KingsHealthQuestionnaireareavailableforevaluatingimpactofincontinenceonqualityoflife)[92].
WeusethePelvicFloorDistressInventoryandthePelvicFloorImpactQuestionnaire[93].ThePatientGlobalImpressionofImprovement(PGII)andPatient
GlobalImpressionofSeverity(PGIS)(table2)arealsoacceptablemeasurestoassessimprovementandsatisfaction,respectively[94].(See"Treatmentof
urinaryincontinenceinwomen".)

PhysicalexaminationAllwomenpresentingwithincontinenceneedapelvicexaminationwithspecialattentiontoevaluateforvaginalatrophy,pelvicmasses,

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andpelvicorganprolapse.Thecomponentsofadetailedpelvicexaminationarediscussedseparately.(See"Thegynecologichistoryandpelvicexamination",
sectionon'Componentsoftheexamination'and"Clinicalmanifestationsanddiagnosisofvaginalatrophy",sectionon'Pelvicexamination'and"Pelvicorgan
prolapseinwomen:Diagnosticevaluation".)

Adetailedneurologicexaminationisnotnecessaryintheinitialevaluationofallwomenwithincontinenceunlesspatientspresentwithsuddenonsetofincontinence
(especiallyurgencysymptoms)ornewonsetofneurologicsymptoms[84].Inpatientswherethereisconcernforneurologicdisease,weperformalimitedevaluation
oflowerextremitystrength,reflexes,andperinealsensation.Unilateralweaknessorhyperreflexiaofthelowerextremitymayidentifyauppermotorlesion.Absent
perinealsensationwithdecreasedrectaltoneisconcerningforcaudaequinasyndrome.(See"Thedetailedneurologicexaminationinadults".)

LaboratorytestsAurinalysisshouldbeperformedinallpatients,andurinecultureperformedifaurinarytractinfection(UTI)issuggestedonscreening.

UrinecytologyisindicatedinpatientswithoutUTIwhohavegrosshematuriaormicroscopichematuriawithriskfactorsformalignancy(eg,extensivesmoking
history).(See"Etiologyandevaluationofhematuriainadults",sectionon'Urinecytology'and"Etiologyandevaluationofhematuriainadults",sectionon'Risk
factorsformalignancy'and"Clinicalpresentation,diagnosis,andstagingofbladdercancer".)

Wedonotroutinelycheckrenalfunctionunlessthereisconcernforsevereurinaryretentionresultinginhydronephrosis[65].Otherlaboratorytestingisdetermined
bysignsorsymptomselicitedonhistoryandphysicalexam.

ClinicaltestsOnlyafewclinicaltestsarenecessaryfortheinitialevaluationofawomanwithurinaryincontinenceasconservativetreatmentcanbeinitiated
basedonsymptomsalone.Wedonotobtainradiographicimagingfortheinitialevaluationinpatientswithoutcomplexneurologicconditionsorabnormalfindingson
physicalexamination.

Wecheckabladderstresstestaspartoftheinitialworkupofstressincontinence.Althoughinoursubspecialtypracticeweroutinelyevaluatewomenwitha
postvoidresidual(PVR)byeithercatheterizationorbladderscan,thisisnotnecessaryintheinitialevaluationofurinaryincontinencebythegeneralpractitioner.
Urodynamictestingisalsonotroutinelyperformedinitiallybutmaybedonepriortoconsideringsurgicaltherapies.(See"Surgicalmanagementofstressurinary
incontinenceinwomen:Preoperativeevaluationforaprimaryprocedure",sectionon'Officetesting'and"Surgicalmanagementofstressurinaryincontinencein
women:Preoperativeevaluationforaprimaryprocedure",sectionon'Urodynamictesting'.)

BladderstresstestInpatientswithsuspectedstressincontinence,weperformthebladderstresstesttoconfirmthediagnosis.Thistestisperformedwith
thepatientinthestandingpositionwithacomfortablyfullbladder.Whiletheexaminervisualizestheurethrabyseparatingthelabia,thepatientisaskedto
valsalvaand/orcoughvigorously.Theclinicianobservesdirectlywhetherornotthereisleakagefromtheurethra.Thistestmaybedifficultinwomenwith
mobilityorcognitiveimpairmentsthesewomenmaybenefitfromperformingthetestinthedorsallithotomyposition.

Apooledanalysisofthreestudiesdemonstratedthatapositivebladderstresstesthelpstoconfirmstressleakageinwomenwithstressormixed
incontinence[63].Anegativetestislessusefulbecauseafalsenegativemayresultfromasmallurinevolumeinthebladderorfrompatientinhibition.

PostvoidresidualMeasuringthepostvoidresidual(PVR)isnotrequiredforinitialtherapyforstressorurgencyurinaryincontinence[65].However,
measuringthePVRcanbehelpfulwhendiagnosisisuncertain,initialtherapyisineffective,orinpatientswherethereisconcernforurinaryretentionand/or
overflowincontinence.Thesepatientsincludethosewithneurologicdisease,recurrenturinarytractinfections,historyconcerningfordetrusorunderactivityor
bladderoutletobstruction,historyofurinaryretention,severeconstipation,pelvicorganprolapsebeyondthehymen,newonsetorrecurrentincontinenceafter
surgeryforincontinence,diabetesmellituswithperipheralneuropathy,ormedicationsthatsuppressdetrusorcontractilityorincreasesphinctertone(table1)
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[85,9597].

ParametersforinterpretingtheresultsofPVRtestingareneitherstandardizednorwellevaluated.Ingeneral,aPVRoflessthanonethirdoftotalvoided
volumeisconsideredadequateemptying.AdditionalsuggestedparametersincludeaPVRoflessthan50mLasnormalandaPVRgreaterthan200mLas
abnormal[91,98].(See"Postoperativeurinaryretentioninwomen",sectionon'Spontaneousvoidingtrial'.)

UrodynamictestingWedonotroutinelyreferforurodynamictestingintheinitialevaluationofurinaryincontinenceinwomenwhosesymptomsare
consistentwithstress,urgencyormixed,incontinence[99,100].Urodynamictestingisinvasiveandisnotnecessarytoinitiatetherapy.A2013systematic
reviewof99studiesincludingover80,000womenfoundinsufficientevidencetosupporttheabilityofurodynamictestingtopredicttheoutcomesof
nonsurgicaltreatmentforstressincontinence[101].

However,inwomenwithsuspectedoverflowincontinence(eg,underlyingneurologicconditions,historyofdiabetes,orbysymptomhistory),urodynamic
testingmaybeindicatedforfurtherevaluation.Indicationsforurodynamictestingarediscussedseparately.(See"Urodynamicevaluationofwomenwith
incontinence".)

UrethralmobilityevaluationSomesubspecialistsmayevaluateforurethralhypermobility.Thisisdiscussedseparately.(See"Surgicalmanagementof
stressurinaryincontinenceinwomen:Preoperativeevaluationforaprimaryprocedure",sectionon'Assessingurethralmobility'.)

SpecialistreferralInasmallnumberofcases,referraltoaspecialistiswarrantedforpatientswithurinaryincontinence(algorithm1).Indicationsforreferral
includethepresenceof:

Associatedabdominalorpelvicpainintheabsenceofurinarytractinfection

Grossormicroscopichematuriawithriskfactorsformalignancyintheabsenceofaurinarytractinfection(see"Etiologyandevaluationofhematuriain
adults")

Suspectedvesicovaginalfistulaorurethraldiverticulaonvaginalexamination(see"Urogenitaltractfistulasinwomen"and"Urethraldiverticuluminwomen")

Otherabnormalphysicalexaminationfindings(eg,pelvicmass,pelvicorganprolapsebeyondthehymen)(see"Pelvicorganprolapseinwomen:Anoverview
oftheepidemiology,riskfactors,clinicalmanifestations,andmanagement")

Newneurologicsymptomsinadditiontoincontinence

Uncertaintyindiagnosis

Historyofpelvicreconstructivesurgeryorpelvicirradiation

Persistentlyelevatedpostvoidresidualvolume,aftertreatmentofpossiblecauses(eg,medications,stoolimpaction)

Suspectedoverflowincontinence,particularlyinthesettingofunderlyingconditions(eg,neurologicconditions,diabetes)

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"BeyondtheBasics."TheBasicspatient
educationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducation
th th
http://www.uptodate.com/contents/evaluationofwomenwithurinaryincontinence?topicKey=PC%2F6874&elapsedTimeMs=0&source=search_result&searchTerm=incontinencia+urinaria+en+mujeres&selectedTitle=1%7E150 8/27
2/4/2016 Evaluationofwomenwithurinaryincontinence

piecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantin
depthinformationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalsolocatepatient
educationarticlesonavarietyofsubjectsbysearchingon"patientinfo"andthekeyword(s)ofinterest.)

Basicstopics(see"Patientinformation:Urinaryincontinence(TheBasics)"and"Patientinformation:Neurogenicbladderinadults(TheBasics)"and"Patient
information:Treatmentsforurgencyincontinenceinwomen(TheBasics)")

BeyondtheBasicstopics(see"Patientinformation:Urinaryincontinenceinwomen(BeyondtheBasics)"and"Patientinformation:Urinaryincontinence
treatmentsforwomen(BeyondtheBasics)")

Patientscanbereferredtoincontinencepatientadvocacygroups.Thesegroupscansupplyadditionalinformationaboutincontinenceanditsmanagement,including
linkstoproductsuppliers.Someusefulresourcesare:

NationalAssociationforContinence:1800BLADDER(2523337)
SimonFoundationforContinence:180023SIMON(2374666)

SUMMARYANDRECOMMENDATIONS

Urinaryincontinenceiscommoninwomen.Riskfactorsforurinaryincontinenceincludeobesity,parity,modeofdelivery,olderage,andfamilyhistory.(See
'Epidemiology'above.)

Themajorclinicaltypesofurinaryincontinencearestressincontinence(leakagewithmaneuversthatincreaseintraabdominalpressure),urgencyincontinence
(suddenurgencyfollowedbyleakage),mixedincontinence(symptomsofbothstressandurgency),andoverflowincontinence."Overactivebladder"isaterm
thatdescribesasyndromeofurinaryurgency,withorwithoutincontinence.(See'Classification'above.)

Otheretiologiesforurinaryincontinenceinwomenincludeotherlesscommonurologicorgynecologicdisorders(eg,urogenitalfistulas,cancer),neurologic
diseases(eg,multiplesclerosis),andpotentiallyreversiblecauses(eg,medications(table1)).(See'Etiology'above.)

Theinitialevaluationofurinaryincontinenceincludescharacterizingandclassifyingthetypeofincontinence,identifyingunderlyingconditions(eg,neurologic
disorderormalignancy)thatmaymanifestasurinaryincontinence,andidentifyingpotentiallyreversiblecausesofincontinence(algorithm1).Thisevaluation
includesathoroughhistory,physicalexamination,andurinalysis.(See'Evaluation'above.)

Thehistoryclassifiesandprioritizesthepatient'surinarysymptoms,aswellasidentifiesothersymptomsthatindicatetheneedtoevaluatefurtherfor
underlyingcausesofincontinenceduetoseriousconditionsorpotentiallyreversiblemedicalorfunctionalconditions.(See'History'above.)

Womenpresentingwithurinaryincontinenceshouldhaveapelvicexamination.Apatient'shistorymaysuggestothercomponentsofthephysicalexam
thatareimportantindiagnosis.(See'Physicalexamination'above.)

Aurinalysisshouldbeperformedinallpatients.Ifaurinarytractinfectionissuspected,thenaurinecultureisobtained.(See'Laboratorytests'above.)

Abladderstresstestisusedtodiagnosestressurinaryincontinence(SUI).Postvoidresidualvolumeandurodynamictestingarenotroutinelyperformed.

http://www.uptodate.com/contents/evaluationofwomenwithurinaryincontinence?topicKey=PC%2F6874&elapsedTimeMs=0&source=search_result&searchTerm=incontinencia+urinaria+en+mujeres&selectedTitle=1%7E150 9/27
2/4/2016 Evaluationofwomenwithurinaryincontinence

(See'Clinicaltests'above.)

Referraltoaspecialistisindicatedinasmallnumberofcases:incontinencewithabdominal/pelvicpainorhematuriaintheabsenceofurinarytractinfection,
suspectedvesicovaginalfistula,abnormalphysicalexaminationfindings(eg,pelvicorganprolapse),newneurologicsymptomsinadditiontoincontinenceor
suspectedoverflowincontinence.(See'Specialistreferral'above.)

ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeCatherineEDuBeau,MD,whocontributedtoanearlierversionofthistopic
review.

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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Topic6874Version30.0

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GRAPHICS

Diagramshowingneuralcircuitscontrollingcontinence
andmicturition

(A)Urinestoragereflexes.Duringthestorageofurine,distentionofthe
bladderproduceslowlevelvesicalafferentfiring,whichinturnstimulates
(1)thesympatheticoutflowtothebladderoutlet(baseandurethra)and(2)
pudendaloutflowtotheexternalurethralsphincter.Theseresponsesoccur
byspinalreflexpathwaysandrepresent"guardingreflexes,"whichpromote
continence.Sympatheticfiringalsoinhibitsdetrusormuscleandmodulates
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transmissioninbladderganglia.Aregionintherostralpons(thepontine
storagecenter,or"L"region)increasesexternalurethralsphincteractivity.
(B)Voidingreflexes.Duringeliminationofurine,intensebladderafferent
firingactivatesspinobulbospinalreflexpathwayspassingthroughthe
pontinemicturitioncenter,whichstimulatetheparasympatheticoutflowto
thebladderandinternalsphinctersmoothmuscleandinhibitthe
sympatheticandpudendaloutflowtotheurethraloutlet.Ascendingafferent
inputfromthespinalcordmaypassthroughrelayneuronsinthe
periaqueductalgray(PAG)beforereachingthepontinemicturitioncenter.

Reproducedwithpermissionfrom:AbramsP,CardozoL,WeinA(Eds).Incontinence:
2ndedInternationalConsultationonIncontinence,HealthPublicationsLtd.2002.
p.88.CopyrightHealthPublications.

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Effectofselectedmedicinesandotheragentsonbladderfunction

Medicinesandotheragents Effectonbladderfunction

Allergy

Antihistamines FirstgenerationH 1 receptorantagonists(eg, Decreasedcontractilityviaanticholinergiceffect


brompheniramine,chlorpheniramine,clemastine,
cyproheptadine,dimenhydrinate,diphenhydramine,
hydroxyzine,others)

Decongestants Pseudoephedrine,phenylephrine Increasedurethralsphinctertone

Analgesicandsedative

Benzodiazepines Chlordiazepoxide,clonazepam,temazepam,triazolam, Impairedmicturitionviamusclerelaxanteffect


others

Opioids Codeine,meperidine,morphine,oxycodone,others Decreasedsensationoffullnessandincreasedurethral


sphinctertone

Anticholinergic*

Antimuscarinics Darifenacin,fesoterodine,oxybutynin,solifenacin, Decreasedcontractilityviaanticholinergiceffect


(overactivebladder tolterodine,trospium
medications)

Spasmolytic Dicyclomine,hyoscyamine,glycopyrrolate, Decreasedcontractilityviaanticholinergiceffect


methscopolamine,propantheline,scopolamine(hyoscine)

Anticholinergics Benztropine,trihexyphenidyl Decreasedcontractilityviaanticholinergiceffect


(antiparkinson
medications)

Cardiology

ACEinhibitors(ACEi) Enalapril,lisinopril,ramipril,others Decreasedcontractilitychroniccoughing

Alphaagonists Midodrine,phenylephrine,vasopressors(various) Increasedurethralsphinctertone

Alpha 1 blockers Alfuzosin,doxazosin,prazosin,silodosin,tamsulosin, Decreasedurethralsphinctertone


terazosin

Antiarrhythmic Disopyramide,flecainide Decreasedcontractilityvialocalanestheticeffecton

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bladdermucosaoranticholinergiceffect

Diuretics Various Increasedurineproduction,contractility,orrateof


emptying

Psychotropic

Antidepressants Serotoninnorepinephrinereuptakeinhibitors(SNRIs): Increasedurethralsphinctertone


duloxetine,reboxetine

Tricyclicantidepressants(amitriptyline,clomipramine, Decreasedcontractilityviaanticholinergiceffect
desipramine,doxepin,imipramine,nortriptyline,others)

Antipsychotics Firstgeneration(chlorpromazine,fluphenazine, Mixedeffectsdescribeddecreasedcontractilityvia


methotrimeprazine)secondgeneration(clozapine, anticholinergiceffectincreasedmicturitionandstress
olanzapine,risperidone)othershavelowereffect incontinenceviastimulationofalpha1receptors,and/or
centraldopaminergicreceptors

Other

Skeletalmuscle Orphenadrine,tizanidine(alsocyclobenzaprine,baclofen, Decreasedcontractilityviaanticholinergiceffect


relaxants andmethocarbamolbuteffectislower)

Estrogens Oralestrogens(hormonereplacementtherapy) Increasedurinaryincontinence

Beta 3 agonist Mirabegron Decreasedcontractilityviabeta 3 adrenergiceffect

Alcohol Decreasedcontractility

Caffeine Increasedcontractilityorrateofemptying

ACE:angiotensinconvertingenzyme.
*Inhaledantimuscarinicbronchodilators(eg,ipratropium,tiotropium)andophthalmicdrops(eg,atropine,cyclopentolate)canbeabsorbedsystemically
invaryingdegreesurinaryretentionhasbeenrarelyassociatedwiththeiruseparticularlyamongolderadults,menwithbenignprostatichyperplasia
(BPH),andadministrationofinhaledanticholinergicdrugbynebulizer.
Increasedmicturitionreportedby3%ofpatientsinclinicalstudiesofcalciumchannelblockersmixedeffectshavebeendescribed.
NotavailableinUnitedStates.

Preparedwithdatafrom:
1.VerhammeK,SturkenboomM,StrickerB,etal.Druginducedurinaryretention.DrugSaf200831:373.
2.ZyczynskiH,ParekhM,KahnM,etal.Urinaryincontinenceinwomen.AmericanUrogynecologicSociety(2012)availableat
http://eguideline.guidelinecentral.com/i/76622augsurinaryincontinence

Graphic101070Version1.0

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Evaluationandtreatmentofurinaryincontinenceinwomen

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UI:urinaryincontinenceUTI:urinarytractinfection.
*RefertoUpToDatetopiconevaluationofwomenwithurinaryincontinence.
Overflowincontinencemanagedseparately.

Preparedwithdatafrom:
1.GormleyEA,LightnerDJ,FaradayM,VasavadaSP.DiagnosisandTreatmentof
OveractiveBladder(NonNeurogenic)inAdults:AUA/SUFUGuidelineAmendment.JUrol
2015Epubaheadofprint.
2.GormleyEA,LightnerDJ,BurgioKL,etal.Diagnosisandtreatmentofoveractivebladder
(nonneurogenic)inadults:AUA/SUFUguideline.JUrol2012188:2455.
3.AmericanUrogynecologicSociety.UrinaryIncontinenceinWomenpocketguide.
http://eguideline.guidelinecentral.com/i/76622augsurinaryincontinence(Accessed
March3,2015).

Graphic100050Version2.0

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The3incontinencequestionnaire(3IQ)

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Reproducedwithpermissionfrom:BrownJS,BradleyCS,SubakLL,etal.Thesensitivityand
specificityofasimpletesttodistinguishbetweenurgeandstressurinaryincontinence.AnnIntern
Med2006144:715.Copyright2006AmericanCollegeofPhysicians.

Graphic72319Version11.0

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Patientglobalimpressionofimprovement

GPI:Globalperceptionofimprovement(BeDri)
Overall,doyoufeelthatyouare:
Muchbetter

Better
Aboutthesame
Worse
Muchworse

PGIS:Patientglobalimpressionofseverity
1.Checktheoneboxthatdescribeshowyoururinarytractconditionisnow:
Normal

Mild
Moderate

Severe

PGII:Patientglobalimpressionofimprovement
2.Checktheoneboxthatbestdescribeshowyoururinarytractconditionisnow,comparedwithhowitwasbeforeyoubegantakingmedicationin
thisstudy:
Verymuchbetter

Muchbetter
Alittlebetter
Nochange
Alittleworse
Muchworse
Verymuchworse

Source:YalcinI,BumpRC.Validationoftwoglobalimpressionquestionnairesforincontinence.AmJObstetGynecol2003189:98.

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ContributorDisclosures
EmilySLukacz,MD,MASGrant/ResearchSupport:BostonScientific[prolapsesurgery(nativetissuerepair)]Pfizer[urinaryinfections(vaginalestrogen
cream/ring)]Uroplasty[urinaryincontinence(urethralbulkinginjection)].Consultant/AdvisoryBoards:AmericanMedicalSystems,Inc[prolapseandfecal
incontinence(Elevatemesh,Topassling)]Axonics[urinaryandfecalincontinence(neuromodulation)]RenewMedical[fecalincontinence(analinsert)].Other
FinancialInterest:MedEdicus[urinaryincontinence(manuscriptauthorshiphonoraria)].LindaBrubaker,MD,FACS,FACOGNothingtodisclose.KennethE
Schmader,MDGrant/Research/ClinicalTrialSupport:Merck[Herpeszoster(Zostervaccine)].LeePark,MD,MPHNothingtodisclose.KristenEckler,MD,
FACOGNothingtodisclose.

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,
andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconformto
UpToDatestandardsofevidence.

Conflictofinterestpolicy

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