Health Implications of Urinary Incontinence in Women
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).In the United States, an estimated 8 million women suffer from urinary incontinence. It affects 10%-70% of women living in a community setting and up to 50% of nursing home residents. Most women with incontinence do not seek medical help. The estimated annual direct cost of urinary incontinence in women in the United States is $12.43 billion. Numerous techniques have been developed to evaluate the types and extent of urinary incontinence. A number of treatment options exist, including behavioral, medical, and surgical approaches. The relative likelihood of each condition causing incontinence varies with the age and health of the individual. Onset of stress urinary incontinence during first pregnancy or postpartum period carries an increased risk of long-lasting symptoms (1). Urinary incontinence is a complex phenomenon with multiple causative factors, including psychogenic causes.
The purpose of this document is to understand the best available evidence for evaluating and treating urinary incontinence in women with a focus on overactive bladder (OAB). Prevalence of incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in the elderly. After the basic evaluation of urinary incontinence, simple cystometry is appropriate for detecting abnormalities of detrusor compliance and contractibility, measuring postvoid residual volume, and determining capacity. The differential diagnosis including genito-urinary and non-genito-urinary conditions and their various managements are also discussed. Although pharmacologic and non-pharmacologic therapies are effective in reducing urge incontinence, neither is curative in some patients.
Diagnosis, History and Voiding Diary
General gynecologic and neurologic examinations are needed on every woman with incontinence. A preliminary diagnosis can be made with simple office and laboratory tests, with initial therapy based on these findings. If complex conditions are present, the patient does not improve after initial therapy, or surgery is being considered, definitive, specialized studies may be necessary. A complete list of the patient's medications (including non-prescription medications) should be obtained. This is important to determine whether individual drugs may be influencing the function of the bladder or urethra, leading to urinary incontinence or voiding difficulties. After urologic history, thorough medical, surgical, gynecologic, neurologic and obstetric histories should be obtained. Assessment of mobility and living environment is especially important in certain patients. Questions should be asked about access to toilets or toilet substitutes and about social factors such as living arrangements, social contacts, and caregiver involvement. Strong coughing associated with smoking or chronic pulmonary disease can markedly worsen symptoms of stress incontinence. A bowel history is important because anal incontinence and constipation are relatively more common in women with urinary incontinence and pelvic organ prolapse. A history of hysterectomy, vaginal repair, pelvic radiotherapy, or retropubic surgery should alert the physician to possible effects of prior surgery on the lower urinary tract.
Daily urinary diaries are considered a practical and reliable method of obtaining information on voiding behavior because patient recall by history taking may be unreliable. Urinary diaries of diurnal voiding frequency, nocturnal voiding frequency, and number of incontinence episodes have been shown to be highly reproducible and correlated well with urodynamic diagnosis (2). Most authors recommend documentation of symptoms for a 3- to 7-day period. Consistent results have been shown between the first 3-day period and the last 4-day period, suggesting that a 3-day chart may be adequate to document symptoms, thus improving compliance. If excessive frequency and volume of fluid intake are noted, restriction of excessive oral fluid intake (combined with scheduled voiding) may improve symptoms of stress and urge incontinence by keeping the bladder volume below the threshold at which urinary leaking results. The physician should review the frequency/volume charts with the patient and corroborate or modify the initial diagnostic impression.
Risk Factors for Incontinence
A number of risk factors have been identified for incontinence. These include female gender; Caucasian race; obesity; depression and panic disorder; constipation and fecal incontinence; concomitant medical illnesses or conditions, including stroke; dementia; congestive heart failure; chronic obstructive pulmonary disease; diabetes; sleep disorders; impaired ability to perform activities of daily living; and impaired mobility (3). Several conditions have been identified that can lead to urge incontinence. Urinary tract infections and hormonal conditions, including estrogen deficiency, may contribute to overactive bladder (OAB)/urge incontinence. Excess intake of caffeine and alcohol has also been implicated in the development of OAB. Family and genetic factors can play a role in the pathogenesis of overactive bladder (OAB). Children who experience bladder problems (enuresis) are 10 to 20 times more likely to develop incontinence as adults than are their counterparts who do not have bladder problems. Nearly 100% of women with childhood enuresis develop urge incontinence as adults. Two genes potentially associated with inheritance of day and night incontinence have been identified: 4pa6.1 (dopamine receptors) or 12q24.2 (protein kinase C) (4). Concomitant medications can cause or contribute to OAB; these include antihypertensives, sedative hypnotics, diuretics, anticholinergics, antihistamines, psychotropic agents, and drugs that cause peripheral edema (non-steroidal anti-inflammatory drugs, gabapentin, rosiglitazone, and nifedipine). When elderly patients who most likely are already taking one or several medications, present with symptoms of OAB, it is vital to determine which of them may be causing the urinary symptoms or may interact with drugs generally prescribed for OAB.
Epidemiology of Overactive Bladder (OAB)
Overactive bladder (OAB) is a condition in which uninhibited vesical contractions, often combined with urethral relaxation mimicking the voiding reflex, occur at inappropriate times. The International Continence Society (ICS) defines OAB as a syndrome of lower urinary tract dysfunction and involuntary detrusor over-activity characterized primarily by symptoms of urgency with or without urge incontinence (involuntary leakage accompanied by or immediately preceded by urgency), urinary frequency (>8 micturitions every 24 hours), and nocturia (>1 micturation each night) in the absence of proven infection or other obvious pathology (5). Current classification by the ICS recognizes the symptom-based nature of this disorder, with urgency and frequency as the predominant symptoms, since many patients with OAB do not have urge incontinence. Urge incontinence is distinct from stress urinary incontinence, which is defined as involuntary leakage of urine on effort or exertion (eg, sneezing or coughing). Some individuals with OAB have mixed urinary incontinence -- that is, both urge incontinence and stress incontinence.
The prevalence of overactive bladder (OAB) has shown to increase with age. A large epidemiologic study in the Untied States using clinically validated, symptom-based criteria of OAB found an overall prevalence of 16.5% with a similar prevalence among men and women. This percentage indicates that OAB affects more people than other common conditions, such as hypertension, allergic rhinitis, and heart disease. Overall, the prevalence of OAB with urge incontinence ("wet" OAB) is reported to be 6.1%, whereas 10.4% of responders had OAB without urge incontinence ("dry" OAB). In this large study women had similar prevalence of wet and dry OAB, but in men, the prevalence of dry OAB was more than 5 times higher than was that of wet OAB: 13.4% and 2.6%, respectively (6). The epidemiologic survey revealed some age-specific patterns. OAB with urge incontinence is reported in these studies, more strongly associated with increasing age in women than in men, whereas OAB without urge incontinence was associated with a greater increase in men with advancing age than in women. OAB without incontinence seems to plateau in women after age 44 and in men after age 53. By contrast, OAB with incontinence continues to increase with older age.
Evaluation of Urinary Incontinence
Differential Diagnosis of Urinary Incontinence in Women (7)
I. Genito-urinary etiology:
- Filling and storage disorders -- Urodynamic stress incontinence; Detrusor over-activity (idiopathic and neurogenic); Mixed types.
- Fistula -- Vesical; Ureteral; Urethral
- Congenital -- Ectopic ureter; Epispadias
II. Non-genitourinary etiology:
- Functional -- Neurologic; Cognitive; Psychologic; Physical impairment
- Environmental
- Pharmacologic
- Metabolic
Effects on Physical, Social, Psychological, Occupational, and Sexual Functioning
Individuals with overactive bladder (OAB) and other urinary incontinence exhibit decrease in their quality of life (QOL). People are usually embarrassed about the possibility of leakage or an "accident" and may isolate themselves from social activity and/or arrange their day so that they can be close to toilet facilities. OAB has a greater negative effect on individuals' QOL than has diabetes, according to a study comparing their limitations to physical, emotional, and social functioning, vitality, and mental health. Persons with urinary incontinence are shown to have poorer physical, emotional, and social functioning, more bodily pain, and poorer overall health and vitality than does the general populations. Urinary incontinence places people at greater risk for urinary tract infections, skin infections, falls, and fractures. Although data are limited on sexual functioning in persons with urinary incontinence, a recent study of premenopausal women with urinary incontinence indicates that they have compromised sexual functioning, as reflected by lower scores of desire, arousal, lubrication, orgasm, and satisfaction, compared with healthy continent women. The excluded in the study were women with genital prolapse, major gynecologic abnormalities, and post-menopausal status (estrogen deficiency) -- factors that can lead to sexual dysfunction (8).
In addition to its social and psychological costs, urinary incontinence is associated with a substantial economic burden, partly related to work loss. Compared with employed who did not have urinary incontinence, those with urinary incontinence have a greater number of workdays lost per year, an excess of workdays lost because of health-related absenteeism, and an excess of days lost related to disability. Female employees with urinary incontinence have a higher risk of disability than does their male counterparts (9). In the year 2005, total costs (direct and indirect) of OAB in the United States were 13.1 billion; total costs were even higher for those persons with urinary incontinence -- 20.3 billion. The major cost difference between the 2 conditions was related to greater utilization of healthcare resources for persons with urinary incontinence, including physician visits and hospital services, as well as a greater risk of nursing home admission.
Medical Management of Voiding Dysfunction
Limitations of Existing Therapies
Significant different results exists in sensitivity to anticholinergic drugs; in some patients higher doses of anticholinergic drugs have been associated with improved outcomes, whereas others may achieve efficacy at a low dose. The variability in patient responses, along with an observed dose-response phenomenon, suggests that drawing on a response range of doses of an antimuscarinic agent may be the best approach to balancing effectiveness with tolerability. Although most studies of antimuscarinic therapy in patients with OAB have used a fixed-dose approach, individualized treatment according to response using a flexible-dose approach can improve outcome, as has been shown in several recent studies (10). Flexible-dosing options are available for 3 antimuscarinic agents: oxybutynin extended release 5, 10, 15, 20, 25, 30 mg daily, solifenacin 5 or 10 mg daily, and darifenacin 7.5 or 15 mg daily. The evidence in support of flexible dosing is strongest for oxybutynin extended release and suggestive for solifenacin and darifenacin. Pharmacologic therapy with antimuscarinic agents, although effective, has bothersome side effects that can compromise treatment adherence and lead to treatment discontinuation. The available agents are considered equivalent in efficacy at fixed doses, and each is associated with dose-related adverse events.
Summary
When patients with urinary incontinence adhere to behavioral therapy, it is effective in reducing the incidence of incontinence episodes; however, according to clinical studies, only about 20% to 30% of patients treated with behavioral therapy achieve total dryness. Successful behavioral therapy depends on patients' motivation and compliance, suggesting that outside of a clinical trial setting, its overall success rate may be lower. OAB is a common condition that becomes even more prevalent as people age. OAB is associated with significant psychosocial and physical morbidity as well as increased healthcare costs. The presence of urge urinary incontinence has an even greater impact on quality of life and healthcare costs than does OAB with no incontinence. Effective treatments are available for OAB, including behavioral and pharmacologic therapies. Although conservative therapy can be of great benefit, a positive outcome depends on the patient's capability, motivation, and adherence to treatment. Because the available antimuscarinic drugs, the first-line pharmacologic treatment of OAB, are of similar efficacy and their use is commonly associated with side effects, including dry mouth and constipation, their comparative tolerability may dominate the choice of agent. Flexible dosing, an option designed to capitalize on the wide range of sensitivity to antimuscarinic agents exhibited by patients with OAB, can provide effective treatment while balancing safety and tolerability. Further progress in the pharmacologic management of OAB will occur as advancements in understanding the neurophysiology of the lower urinary tract continue to take place.
References:
- Viktrup L, Rortveit G, Lose G. Risks of Stress Urinary Incontinence Twelve Years After the First Pregnancy and Delivery. Obstet Gynecol. 2006;108:248-254
- Assessment and treatment of urinary incontinence. Scientific Committee of the First International Consultation on Incontinence. Lancet 2000;355:2153-2158 (Level III)
- Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. 2nd ed. Plymouth, UK: Health Publication Ltd; 2002 (Level III)
- Eiberg H, Shaumburg HL, Von Gotard A, Rittig S. Linkage study of a large Danish 4-generation family with urge incontinence and nocturnal enuresis. J Urol. 2001;166:2401-02403
- Abrams P, Cardozo L, Fall M et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology. 2002;61:37-49
- Stewart WF, Van Rooyen JB, Cundiff JW et al. Prevalence and burden of overactive bladder in the Untied States. World J Urol. 2003;20:327-336
- ACOG Practice Bulletin. Urinary Incontinence in Women. Number 63, June 2005
- Aslan G, Koseoglu H, Sadik O et al. Sexual function in women with urinary incontinence. Int J Impot Res. 2005;17:248-251
- Wu EQ, Birnbaum H, Marynchenko M et al. Employees with overactive bladder: work loss burden. J Occup Environ Med. 2005;47:439-446
- MacDiarmid SA, Anderson RU, Armstrong RB et al. Efficacy and safety of extended release oxybutynin for the treatment of urge incontinence: an analysis of data from 3 flexible dosing studies. J Urol. 2005;174:1301-1305
Published: 9 February 2009
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