Approach to Urinary

Incontinence
Prof Dr Dilip Kumar Roy
Approach to Urinary Incontinence
Introduction
Physiology of micturition
Classification of urinary incontinence
Risk factors of urinary incontinence
Evaluation of urinary incontinence
Management of urinary incontinence
Conclusion
Introduction
Urinary incontinence is an involuntary and unintentional discharge of urine.

It is estimated that nearly 50 percent of adult women experience urinary

incontinence

But only 25 to 61 percent of symptomatic community dwelling women seek

care

Patients may be reluctant to initiate discussions about their incontinence

and urinary symptoms due to
- Embarrassment, Lack of knowledge about treatment options, Fear of surgery.
Introduction

Although women report incontinence more often than men

After 80 years of age, both sexes are affected equally.

Women commonly experience

• Stress or urge incontinence (i.e., overactive bladder)
• Or a combination of the two
• With approximately equal frequency.

In men
• Prostate problems, which lead to overflow incontinence
• Treatments of prostate problems , which may also lead to stress incontinence
Physiology of Micturition
What happens normally?
The brain and the bladder control urinary function.

The bladder stores urine until the person is ready to empty it.

Normally, the smooth muscle of the bladder is relaxed. The neck of the bladder is closed.
This holds the urine in the bladder.

The sphincter muscles are closed around the urethra, urine doesn't leak.

Once the person is ready to urinate, the brain sends a signal to the bladder.

Then the Detrusor muscles contract. The sphincters open up when the bladder contracts. Urination
starts
Bladder function represents an interplay between the
urinary tract and the nervous system.

There are two main phases, filling and emptying.

Filling : The normal bladder stores urine at a low

pressure that remains lower than urethral resistance.
Emptying: a decrease in urethral resistance and
contractions of the detrusor muscle with resultant
emptying
Detrusor contraction occurs as a result of increased para
sympathetic outflow

Detrusor remain Relaxed as a result of sympathetic inhibition.

There are 5 known muscarinic receptor subtypes (M1 to M5)

M3 receptors are responsible for detrusor smooth muscle

contraction

The muscarinic receptor antagonists used to treat OAB may affect

these receptors to varying levels.
 Autonomic control of micturation
Type of Name of nerve Spinal Action
nerve innervantion
Somatic • Pudendal Nerve S 2-4 • Sensory and voluntary
• Nerve to the motor to external
lavetor Ani spinchter
Sympathetic • Hypogastric T 11-12 • Detrusior relaxation
(Filling) nerve • Internal spinchter
contraction
Para • Pelvic nerve S 2-4 • Detrusor contraction
sympathetic • Internal sphincter
(Emptying) relaxation
Micturition Cycle
• Sympathetic system plays no role in micturition.
• They mediate the contraction of the urethral sphincter that
prevents semen from entering the bladder during ejaculation
 Refex control Voluntary control

Bladder fills Cerebral Cortex

+ +
Stretch receptor
+ Motor Neuron to external spinchter
Para Sympathetic
Nerves+
External urethral spinchter opens
Bladder when motor neuron is inhibited

Detrusor contracts
External urethral spinchter remains
closed when motor neuron is stimulated
Internal urethral sphincter
mechanically open when detrusor
contracts

Urination No Urination
Classification
Classification
Incontinence can be • Transient
classified as • Chronic

• Arises suddenly
• Lasts less than six months
Transient incontinence
• Can be reversed if the underlying cause is
addressed.

Chronic urinary • Stress incontinence

incontinence • Urge incontinence
does not typically resolve • Mixed incontinence
spontaneously, • Overflow incontinence
is classified into five types: • Functional incontinence
Stress Incontinence
Stress incontinence is characterized
Everyday physical exertion such as
coughing, sneezing, laughing and
lifting heavy loads
Stress incontinence is
Stress incontinence is caused by
Pelvic floor weakness may be
caused by
• By the loss of urine due to increased pressure in the abdomen.
• Can lead to an involuntary and uncontrolled discharge of urine.
• The most common cause of urinary incontinence in younger
women
• The second most common cause in older women.
• Impaired sphincter function due to pelvic floor weakness and
nerve malfunction.
• Increasing Age
• Multiple pregnancy and especially vaginal delivery
• Surgeries (e.g. on the prostate or uterus)
• As well as weakness of the connective tissue.
Urge Incontinence (Overactive Bladder
Syndrome)
The urge symptoms cannot be delayed and there is an involuntary leakage of urine before a
toilet can be reached.

It also involves a frequent urge to urinate with frequent visits to the toilet at very short intervals
(<30 minutes) to drain only small amounts of urine.

With UI , brain tells the bladder to empty - even when it isn't full.
Most often caused by loss of cerebral inhibition of detrusor contractions.
Or the bladder muscles are too active. They contract (squeeze) to pass urine before the bladder
is full,
a result of local irritation, inflammation, or infection within the bladder
Sensory : a result of local irritation, inflammation, or infection within the bladder
Neurologic : most often caused by loss of cerebral inhibition of detrusor contractions.
Overflow Incontinence
If the pressure in the urinary bladder exceeds the pressure of the bladder sphincter,
a continuous trickle of urine is discharged.

This is known as overflow incontinence.

The bladder is constantly overfilled and continuously releases small amounts of

urine in the absence of any urge to urinate.

Men are more affected by this type of incontinence than women.

Reasons for overflow incontinence can be Drainage disorders or detrusor

underactivity due to nerve damage
Mixed Incontinence

Stress and urge incontinence can also occur in combination.

If the patient suffer from an overactive bladder combined
with a disorder of the closure system, this is called mixed
incontinence.
The stress incontinence and the urge incontinence are
treated separately.
 Type of incontinence
Overflow Stress Urge
Functional incontinence

This type of incontinence is also referred to

as toileting difficulty
• Urine leakage occurs in despite having normal bladder
function and sensory cues
• Patient cannot reach a restroom in time because of
physical or medical conditions that limit their ability to
get to the bathroom.
 Risk Factors
Well-established risk factors for UI include • Medical comorbidities
• Increasing age, • Diabetes,
• Parity :Multiparity is a risk factor for urinary • Stroke,
incontinence • Depression,
• Mode of birth :Vaginal deliveries are • Fecal incontinence,
associated with an increased risk of UI • Genitourinary syndrome of menopause/
• Obesity vaginal atrophy,
• History of hysterectomy, Prostate surgery in • Hormone replacement therapy,
male • Genitourinary surgery (e.g., hysterectomy),
• Family history: UUI may be higher in • Pelvic radiation
patients with a family history. • Impaired functional status,
• Recurrent urinary tract infections (UTIs)
• Poor overall health
• Other risk factors include
• Diuretic use, SGLT2i
Effect of Urinary incontinance

If left untreated, UI can lead to

Sleep loss, depression, anxiety and loss of interest in sex

May experience feelings of rejection, social isolation,

dependency, loss of control and may also develop problems with
their body image
Evaluation of a patient of
Urinary Incontinence
Evaluation for UI

Patients can be evaluated for urinary incontinence in a family

physician’s office

The patient history is often the most important factor in identifying

- the type, severity, and burden of incontinence for patients.

Generally, more than one office visit is required to perform the

physical examination and necessary tests.

The first step in the evaluation is to identify transient or reversible

causes of urinary incontinence.
 Differential Diagnosis of Transient Causes of
Urinary Incontinence (DIAPPERS Mnemonic)
• Delirium
• Infection (acute urinary tract infection)
• Atrophic vaginitis
• Pharmaceuticals : Reversible (e.g., drug-induced) urinary retention
• Psychological disorder, especially depression
• Excessive urine output (e.g., hyperglycemia, Diuretics, SGLT2i)
• Reduced mobility (i.e., functional incontinence)
• Stool impaction

Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med.
1985;313(13):801.
History

A thorough medical history should be obtained from every

incontinent patient.

Physicians treating the incontinent patient should empathically ask

them how the incontinence specially affects their life and to what
degree the incontinence bothers them.

Taking history of diabetes mellitus is of special importance in urge

urinary incontinence due to glycosuria, detrusor overactivity, recurrent
urinary tract infections, and diabetic cystopathy.
Type of Symptoms History Etiology
incontinence
Stress Loss of small amount of urine during Patient usually can Childbirth and obesity in
Incontinence • Physical activity with increased intra- predict which women;
abdominal pressure (coughing, sneezing activities will cause May occur after
jumping, lifting, exercise); leakage prostatectomy in men
• Can occur with minimal
activity, such as walking or rising from a
chair
Urge Loss of urine preceded by a sudden and Volume of urine loss Bladder irritation caused
Incontinance severe desire to pass urine; is variable, ranging by cystitis,
(Sensory) patient typically loses urine on the way to from minimal to prostatitis, atrophic
the toilet flooding vaginitis, bladder
(if entire bladder diverticuli, prior pelvic
volume is emptied) radiation
therapy
Urge • Bladder contractions may also be Frequency and Loss of neurologic control
Incontinance stimulated by nocturia are common caused by
(Neurological) a change in body position (i.e., from Symptoms of stroke, dementia, spinal
supine to upright) urgency may also cord injury,
or with sensory stimulation (e.g., running occur without urinary Parkinson disease
water, hand washing, cold weather, loss, which is known
arriving at the front door) as overactive bladder
 Symptoms History Etiology
Mixed Involuntary leakage associated Patient should determine Combination of the
incontinence with symptoms of urgency; which symptom is etiologies for
loss of urine with exertion, effort, predominant and most stress and urge
sneezing, or coughing bothersome incontinence

Overflow • Dribbling of urine Does not usually occur • Anticholinergic

incontinence • Inability to empty bladder
• Urinary hesitancy
• Urine loss without a
recognizable urge or sensation
of fullness/pressure in lower
abdomen
unless bladder emptying medications
is poor (postvoid residual • Diabetes mellitus
volumes > 200 to 300 mL) • Multiple sclerosis
• Spinal cord injuries
• Prostatic enlargement
• Pelvic organ prolapse

Functional Caused by non genitourinary Impaired physical Severe dementia,

incontinence factors, such as cognitive function (immobility) physical frailty or
or physical impairments that and/or impaired inability to ambulate,
result in the patient’s inability to cognition mental health disorder (e.
void independently Possible lower urinary g., depression)
tract deficits
History
Type and Duration of complaint and whether the problem has been worsening

Triggering factors
• Cough,
• Sneezing,
• Lifting, bending,
• Sexual activity, or orgasm

Constant or intermittent urine loss

Associated frequency, urgency, dysuria, pain with a full bladder, and a history of urinary tract infections

Concomitant symptoms of fecal incontinence or pelvic organ prolapse

Coexisting complicating or exacerbating medical problems such as diabetes, Heart faiure, COPD,
neurologic disrorder
History
Obstetrical history, including
• Multiparty , difficult deliveries, episiotomy, forceps use, obstetrical lacerations,
and large babies.

The labor history should be elaborated..

• In prolonged second stage of labor when the fetal head hinges behind the
symphysis pubis, there can be denervation of the smooth and striated urethral
sphincter.
History of the previous pelvic surgeries,
• Especially the incontinence procedures, hysterectomy, or pelvic floor
reconstructive procedures

History of spinal and central nervous system surgeries

History
Lifestyle issues such as
• Smoking, alcohol or caffeine abuse
• Occupational and recreational factors causing severe or repetitive increase in
intra abdominal pressure

Patients with coexisting pelvic organ prolapse

• May report dyspareunia, vaginal pain on ambulation, and a bulging sensation in
vagina

Cancer of pelvic organs

• Needs to be excluded from the study
 Medications That Can Cause or Exacerbate Urinary Incontinence
Classification Medication Activity
Alpha-adrenergic Nasal decongestants Urinary retention in men with overflow
agonists incontinence related to BPH
Alpha-adrenergic Prazosin, terazosin, doxazosin, Urethral relaxation; may cause or exacerbate
antagonists silodosin, alfuzosin stress incontinence in women
Anticholinergic drugs Antihistamines, Anticholinergic actions; urinary retention in
tricyclic antidepressants, overflow incontinence or impaction
some antipsychotics
Antineoplastic drugs Vincristine Urinary retention
Calcium-channel Dihydropyridines (e.g., nifedipine) Urinary retention; nocturnal diuresis resulting
blockers from fluid retention
Diuretics /SGLT2i Furosemide, bumetanide Polyuria; frequency; urgency
Narcotic analgesics Opiates Urinary retention; sedation
Sedatives/hypnotics Long-acting benzodiazepines (e. Sedation; delirium; immobility
g., diazepam, flurazepam)
Voiding diary
Many patients provide an unclear voiding history, a voiding diary can be helpful

The simplest voiding diaries ask patients to

• Record the frequency of incontinence episodes,
• The situations in which incontinence occurs, which can help clarify the type of incontinence.

For example, the diary may reveal

• Leakage during times of increased abdominal pressure, suggestive of stress incontinence,
• Continious dribbling that is indicative of overflow incontinence.

Patients with stress incontinence usually wake once or not at all at night to void;

Patients with urge incontinence usually wake more than twice and as often as every hour.

A voiding diary can also serve as a baseline for comparing the severity of incontinence after treatment,

Thereby assessing the effectiveness of management associated with conditions causing polyuria (e.g., excess fluid
intake, diabetes mellitus).
Physical examination

The physical examination of the

patient with incontinence should
focus on both
• The general medical conditions that may
affect the lower urinary tract
• As well as the problems related to urinary
incontinence.
 Physical Examination Findings Associated with Urinary Incontinence
Organ Finding or Mechanism of effect Type of
system comorbidity incontinence

Abdominal Masses Chronic outflow obstruction or detrusor underactivity Overflow

Palpable bladder Detrusor underactivity from a neurologic or
obstructive cause

Cardiac Arteriovascular disease Detrusor underactivity or areflexia from ischemic Urge

myopathy or neuropathy
Volume overload
(congestive Fluid excretion shift toward increased volume of Urge
heart failure) urine

Musculo Mobility restriction, pain, Postponement of voiding and/or detrusor Urge, functional,
skeletal arthritis overactivity or both

Pulmonary Chronic cough from Increase in intra-abdominal pressure overcomes Stress

chronic obstructive sphincter closure mechanisms in the absence of a
pulmonary disease or bladder contraction
bronchitis
 Physical Examination Findings Associated with Urinary Incontinence
Organ Finding or comorbidity Mechanism of effect Type of
system incontinence
Neurologic Cerebral vascular accident, Detrusor overactivity from loss of central inhibition Urge, functional,
normal pressure hydrocephalus or both

Impaired mental status Failure to recognize need to void or to use toilet; environmental barriers Urge, functional,
(delirium), dementia or both

Spinal stenosis Detrusor underactivity; damage to detrusor upper motor neurons Overflow
(cervical stenosis) or areflexia (lumbar stenosis)
Pelvic Enlarged prostate, pelvic mass Chronic outflow obstruction from detrusor overactivity Overflow

Following prostatectomy Sphincter and/or nerve damage Stress

Vulvar or vaginal atrophy Diminished estrogen effects on periurethral tissues can Stress, urge, or
contribute to inflammation induced detrusor overactivity mixed

Weak pelvic floor muscles Denervation of pelvic floor and/or striated sphincter trauma Stress
Rectal Fissures may indicate chronic Intravesical pressure exceeds maximum urethral pressure, Overflow
constipation from fecal impaction detrusor underactivity

Reduced or absent anal sphincter Detrusor underactivity Overflow

tone; peripheral neuropathy
caused by diabetes mellitus,
alcoholism
COUGH STRESS TEST

If stress incontinence is suspected, the cough stress test is the

most reliable clinical assessment for confirming the diagnosis.

When compared with more sophisticated multichannel

urodynamic studies, the cough stress test demonstrates good
sensitivity and specificity for stress incontinence

Although it requires further confirmatory urodynamic evaluation

if the results are inconclusive.
Cough stress test
With a full bladder (although not to the point of abrupt urination), the patient should be in
the lithotomy position.

Women should separate the labia.

The patient should relax the pelvic muscles and forcibly cough once.

If the test is initially performed supine and no leakage is observed, the test should be
repeated in the standing position.

The patient stands with his or her legs shoulder-width apart over a cloth or paper sheet on
the floor to see the leakage.

If urine leaks with the onset of the cough and terminates with its cessation, the test is
positive for stress incontinence.
Cough stress test
A negative test shows no leak or a delayed leak by five to 15 seconds, and
rules out most cases of stress incontinence

False-negative results may occur

• if a patient’s bladder is empty,
• if the cough is not forceful enough,
• if the pelvic floor muscles contract to override urethral sphincter incompetence
• if severe prolapse masks the leakage.
Furthermore, a delayed leak may suggest a bladder spasm triggered by the
cough, and not a weakness of the sphincter. This indicates possible urge
incontinence.
Urodynamic Studies
•A means of evaluating pressure flow relationship between bladder and urethra.
•These may be indispensable if we want to reach a correct diagnosis of urge and mixed incontinence
•Components of urodynamic studies:
• 1.Uroflowmetry

2.Cystometry:
•a. Single channel cystometrography
•b. Multichannel cystometrography

3. Postvoid residual (PVR) urine volume

4. Urethral pressure profiles for urethral closure pressures

5. Leak Point Pressure (LPP) measurement

6. Neurophysiologic studies.
Uroflowmetry
Uroflowmetry is a measurement of rate of flow of urine.

Volume of urine voided over time is plotted a graph.

Normal flow rate is 15–25 ml/s. Flow rates <10 ml/s indicate atonic
bladder or bladder outlet obstruction.

During a uroflowmetry test, the person voids privately into a special funnel
that has a container and a measuring scale.

The equipment creates a graph that shows changes in flow rate with time
Normal findings in cystometry

1. First sensation of urination: 150–200 ml

2. Maximum capacity: 400–600 ml

3. Pves on filling 0–15 cm of H2O

4. Peak urinary flow rate of 15 ml/s

5. Absence of systolic detrusor contractions. The International incontinence society

has identified a minimal contraction of 15 cm of H2O over the baseline to be considered
significant
Postvoid Residual Urine Determination

High‑postvoid residual urine volume indicates

• Outlet obstruction
• or
• Impaired detrusor (bladder) contractility

PVR volumes can be measured directly by post void catheterization or ultrasonography.

It is important to perform this test within 10 min of voiding to avoid any false positive
results.
A PVR urine measurement
• Less than 50 mL is negative for overflow
• 100 to 200 mL is considered indeterminate (and the measurement should be repeated on another occasion)
• Greater than 200 mL is suggestive of overflow as a main contributing factor of incontinence.
Laboratory tests
Renal Function test:
• Serum creatinine level - which may be elevated if there is urinary
retention (overflow bladder) caused by bladder outlet obstruction or
denervation of the detrusor.

Urinalysis :
If not already performed to exclude acute urinary tract
infection as a cause of reversible incontinence, a
urinalysis should be obtained to rule out hematuria,
proteinuria, and glycosuria, any of which require a
diagnostic workup.
Management of urinary
incontinance
Treatment for urinary incontinence depends on
• the type of incontinence,
• its severity
• the underlying cause.

Less invasive treatments to start with and

then move on to other options if these techniques fails
When dealing with symptoms of OAB, it is imperative to identify
causes that are easily reversed and appropriately manage these
patients.
General Approach to Management

Intervention should be considered in patients with

- bothersome UI symptoms
- who desire treatment.

A step-wise approach to treatment is directed at the UI subtype,

• Starting with conservative management,

• Escalating to physical devices and medications
• Ultimately referring for surgical intervention

Initiating treatment with surgical intervention can be considered after appropriate counseling if
the patient prefers a surgical approach or if medications are contraindicated.
Initial treatment
Before starting any treatment for urinary incontinence, contributory factors
should be addressed such as
• Medical conditions
• Medications

Conservative therapies : Treat with these for six weeks before considering
subsequent therapies
• Lifestyle modifications
• Pelvic floor muscle exercise
• Bladder training in women with urgency incontinence and in some women with stress
incontinence
Assuming evidence of some progress, it is also reasonable to continue
conservative therapies for up to six months,
Medical conditions that need attention

Neurologic conditions may affect cortical inhibitory function, which can cause or
contribute to OAB such as
• Alzheimer’s or Parkinson’s disease (Stevens et al 2007).

Conditions that affect the spinal cord may also disrupt normal micturition reflexes,
resulting in OAB
• Multiple sclerosis,
• Disc herniation

Factors that affect the genitalia or the lower urinary tract, may lead to symptoms
similar to OAB eg,
• Bladder cancer
• Bladder stone
• Atrophic vaginitis
• Yeast infections
• Cystitis,.
All medications should be reviewed for
those that may affect urinary tract
function
 Medications That Can Cause or Exacerbate Urinary Incontinence
Classification Medication Activity
Alpha-adrenergic Nasal decongestants Urinary retention in men with overflow
agonists incontinence related to BPH
Alpha-adrenergic Prazosin, terazosin, doxazosin, Urethral relaxation; may cause or exacerbate
antagonists silodosin, alfuzosin stress incontinence in women
Anticholinergic drugs Antihistamines, Anticholinergic actions; urinary retention in
Tricyclic antidepressants, overflow incontinence or impaction
Some antipsychotics
Antineoplastic drugs Vincristine Urinary retention
Calcium-channel Dihydropyridines (e.g., Urinary retention; nocturnal diuresis resulting
blockers nifedipine) from fluid retention

Diuretics Furosemide, bumetanide, Polyuria; frequency; urgency

SGLT2i
Narcotic analgesics Opiates Urinary retention; sedation
Sedatives/hypnotics Long-acting benzodiazepines (e. Sedation; delirium; immobility
g., diazepam, flurazepam)
Lifestyle modification
These approaches can improve urinary and bowel incontinence
symptoms
• Weight loss in obese women
• Dietary changes
• Reduce consumption of alcoholic, caffeinated, and carbonated beverages
• Who are drinking excess amounts of liquids should normalize their fluid intake
• To decrease or eliminate liquid consumed after dinner for women who complain of
nocturia
• Constipation
• Constipation can exacerbate urinary incontinence and increase the risks of urinary
retention
• Constipation should be treated as indicated.
• Smoking cessation
• Beyond the general health benefits of smoking cessation, no studies have evaluated
whether smoking cessation decreases urinary incontinence
Management option for UI
Behavioral techniques
• Bladder training
• Double voiding,
• Scheduled toilet trips
• Fluid and diet management,

Pelvic floor muscle exercises

Medications

Electrical stimulation

Medical devices : Urethral insert, Pessary

Interventional therapies :Bulking material injections. OnabotulinumtoxinA (Botox). Nerve stimulators

Surgery : Sling procedures. Bladder neck suspension. Prolapse surgery, Artificial urinary sphincter.

Absorbent pads and catheters : Pads and protective garments. Catheter.

Start with Less invasive treatments and move on to other options if these techniques fail to help you.
Behavioral techniques
Bladder training
• to delay urination after you get the urge to go.
• Ask the patient to start by trying to hold off for 10 minutes every time he feel an urge to urinate.
• The goal is to lengthen the time between trips to the toilet until he were urinating only every 2.5 to 3.5
hours.
Double voiding
• to help you learn to empty your bladder more completely to avoid overflow incontinence.
• Double voiding means urinating, then waiting a few minutes and trying again even in the absence of urge.
Scheduled toilet trips
• to urinate every two to four hours rather than waiting for the need to go.

Fluid and diet management

• to regain control of your bladder.
• The patient may need to cut back on or avoid alcohol, caffeine or acidic foods.
• Reducing liquid consumption, losing weight or increasing physical activity also can ease the problem
Pelvic floor muscle exercises
Kegel exercises
• Ask the patient to Imagine that he is trying to stop his urine flow.
• Tighten (contract) the muscles he should use to stop urinating and hold for five seconds
• then relax for five seconds.
If this is too difficult, start by holding for two seconds and relaxing for three
seconds
Work up to holding the contractions for 10 seconds at a time.

Aim for at least three sets of 10 repetitions each time three times a day.

To help you identify and contract the right muscles,

• Workup with a pelvic floor physical therapist
• Biofeedback techniques may be tried
 Medications for Treatment of Urinary Incontinence
Agent Dosage Agent Dosage
Oral agents Intravesicular injection
Antimuscarinic (selective) Neuromuscular blocker
Darifenacin ER : low dosage 7.5 mg daily 100 units/
Darifenacin ER: maximum dosage 15 mg daily OnabotulinumtoxinA (Botox) 1 mL every
Solifenacin : low dosage 5 mg daily 6 months
Solifenacin: maximum dosage 10 mg daily
Trospium 20 mg twice daily
Fesoterodine ER 4-8 mg once daily
Antimuscarinic (nonselective) Transdermal agents
Oxybutynin: low dosage 5 mg daily Antimuscarinic (nonselective) One patch twice weekly
Oxybutynin: intermediate dosage 10 mg daily Oxybutynin†
Oxybutynin: maximum dosage 30 mg daily
Tolterodine (Detrol): low dosage 2 mg daily
Tolterodine: maximum dosage 4 mg daily
Beta-adrenergic Estrogen derivative
Mirabegron†: low dosage 25 mg daily Vaginal estrogen (estradiol 0.5 to 2 g twice weekly
Mirabegron†: maximum dosage 50 mg daily [Estrace] estrogen [Premarin])‡
Selective serotonin reuptake inhibitor
Duloxetine 40 mg twice daily
First-line pharmacologic treatment for UUI, according to the American Urological
Association, includes

Anticholinergic/antimuscarinic agents such as

• oxybutynin, Tolterodine, Trospium, Solifenacin, Darifenacin, Fesoterodine.

An alternative agent, mirabegron (a beta-3 adrenergic agonist), was introduced in 2012.

Selection is patient-specific and depends on a variety of factors, such as

• Cost
• Dosing
• Adverse effects
• Potential drug/disease state interactions.

Generally, extended-release formulations are preferred over immediate-release

formulations because their side effects are less bothersome.
Electrical stimulation
Electrodes are temporarily inserted into rectum or
vagina to stimulate and strengthen pelvic floor
muscles.
Gentle electrical stimulation can be effective for
stress incontinence and urge incontinence

But multiple treatments may be needed over several

months.
Medical devices
Urethral insert
• A small, tampon-like disposable device inserted into the urethra
before a specific activity, such as tennis, that can trigger
incontinence.
• The insert acts as a plug to prevent leakage and is removed before
urination.
Pessary
• A flexible silicone ring that you insert into your vagina and wear all
day.
• The device is also used in women with vaginal prolapse.
• The pessary helps support the urethra, to prevent urine leakage.
Interventional therapies
• A synthetic material is injected into tissue surrounding the urethra.
Bulking material • The bulking material helps keep the urethra closed and reduce
urine leakage.
injections. • This procedure is for the treatment of stress incontinence .
• It may need to be repeated more than once.

• Injections of Botox into the bladder muscle may benefit people who
OnabotulinumtoxinA have an overactive bladder and urge incontinence.
(Botox). • Botox is generally prescribed to people only if other treatments
haven't been successful.

• There are two types of devices that use painless electrical pulses
to stimulate the nerves involved in bladder control (sacral nerves).
• One type is implanted under your skin in your buttock and
Nerve stimulators. connected to wires on the lower back.
• The other type is a removable plug that is inserted into the vagina.
• Stimulating the sacral nerves can control overactive bladder and
urge incontinence if other therapies haven't worked.
Indications for Urologic Referral
• Incontinence associated with relapse or recurrent symptomatic urinary
tract infections
• Incontinence with new-onset neurologic symptoms, muscle weakness, or
both
• Marked prostate enlargement
• Pelvic organ prolapsed past the introitus
• Pelvic pain associated with incontinence
• Persistent hematuria
• Persistent proteinuria
• Postvoid residual volume > 200 mL
• Previous pelvic surgery or radiation
• Uncertain diagnosis
Cefalu CA. Urinary incontinence. In: Ham RJ, ed. Primary Care Geriatrics: A Case-Based Approach. 5th
ed. Philadelphia, Pa.: Mosby Elsevier; 2007:306-323
Weidner AC, Myers ER, Visco AG, et al.Am J Obstet Gynecol. 2001;184(2):20-27.
Surgery
If other treatments aren't working,

Sling procedures.
• Synthetic material (mesh) or strips of your body's tissue are used to
create a pelvic sling underneath the urethra where the bladder
connects to the urethra (bladder neck).
• The sling helps keep the urethra closed, especially when you cough or
sneeze.
• This procedure is used to treat stress incontinence.
Bladder neck suspension.
• This procedure is designed to provide support to the urethra and
bladder neck
Mid Urethral Sling surgery for SUI Bladder neck suspension
Prolapse surgery.
• In women who have pelvic organ prolapse and mixed incontinence,
surgery may include a combination of a sling procedure and
prolapse surgery.
• Repair of pelvic organ prolapse alone does not routinely improve
urinary incontinence symptoms.

Artificial urinary sphincter.

• A small, fluid-filled ring is implanted around the bladder neck to
keep the urinary sphincter shut until there's a need to urinate.
• To urinate, you press a valve implanted under your skin that causes
the ring to deflate and allows urine from your bladder to flow.
Artificial Urinary Sphincter
If medical treatments can't eliminate your incontinence, you can try
products that help ease the discomfort and inconvenience of leaking
urine:

Pads and protective garments.

• Most products are no more bulky than normal underwear and can be easily worn under
everyday clothing.
• Men who have problems with dribbles of urine can use a drip collector — a small
pocket of absorbent padding that's worn over the penis and held in place by close-
fitting underwear.
Catheter.
• If a person is incontinent because his/her bladder doesn't empty properly, doctor may
recommend and teach the person to insert a soft tube (catheter) into his /her urethra
several times a day to drain the bladder.
• The person should also be instructed on how to clean these catheters for safe reuse.
Conclusion

Urinary incontinence is an involuntary and unintentional discharge of urine.

UI may be transient or chronic . Chronic incontinence can be classified into five types

If left untreated, UI can lead to sleep loss, depression, anxiety and loss of interest in sex, feelings of
rejection, social isolation, dependency, loss of control and may also develop problems with their body
image

Evaluation of UI includes detail history , physical examination , bladder diary and investigations

Management of UI Treatment for urinary incontinence depends on the type of incontinence, its
severity , the underlying cause.

Intervention should be considered in patients with bothersome UI symptoms who desire treatment.

A step-wise approach to treatment is directed at the UI subtype, Starting with conservative

management, escalating to physical devices and medications Ultimately referring for surgical
intervention