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Evaluationofwomenwithurinaryincontinence
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.
Graphic62790Version2.0
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Effectofselectedmedicinesandotheragentsonbladderfunction
Medicinesandotheragents Effectonbladderfunction
Allergy
Analgesicandsedative
Anticholinergic*
Cardiology
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bladdermucosaoranticholinergiceffect
Psychotropic
Tricyclicantidepressants(amitriptyline,clomipramine, Decreasedcontractilityviaanticholinergiceffect
desipramine,doxepin,imipramine,nortriptyline,others)
Other
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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