Urinary Incontinence in Women: Evaluation and Management

 

Am Fam Physician. 2019 Sep 15;100(6):339-348.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/urinary-incontinence/.

Author disclosure: No relevant financial affiliations.

Urinary incontinence is a common problem among women worldwide, resulting in a substantial economic burden and decreased quality of life. The Women's Preventive Services Initiative is the only major organization that recommends annual screening for urinary incontinence in all women despite low to insufficient evidence regarding effectiveness and accuracy of methods. No other major organization endorses screening. Initial evaluation should include determining whether incontinence is transient or chronic; the subtype of incontinence; and identifying any red flag findings that warrant subspecialist referral such as significant pelvic organ prolapse or suspected fistula. Helpful tools during initial evaluation include incontinence screening questionnaires, a three-day voiding diary, the cough stress test, and measurement of postvoid residual. Urinalysis should be ordered for all patients. A step-wise approach to treatment is directed at the urinary incontinence subtype, starting with conservative management, escalating to physical devices and medications, and ultimately referring for surgical intervention. Pelvic floor strengthening and lifestyle modifications, including appropriate fluid intake, smoking cessation, and weight loss, are first-line recommendations for all urinary incontinence subtypes. No medications are approved by the U.S. Food and Drug Administration for treatment of stress incontinence. Pharmacologic therapy for urge incontinence includes antimuscarinic medications and mirabegron. Patients with refractory symptoms should be referred for more invasive management such as mechanical devices, injections of bulking agents, onabotulinumtoxin A injections, neuromodulation, sling procedures, or urethropexy.

Urinary incontinence (UI), defined as any complaint of involuntary loss of urine,1 is a common issue, with a prevalence of 51% among adult women in the United States.2 Over half of affected women report that their UI symptoms are bothersome.3 This results in a substantial economic burden, up to $65 billion annually.4 Comorbidities include decreased quality of life (QOL) and productivity; increased anxiety and depression; increased urinary tract and skin infections; increased risk for falls and nonspine, nontraumatic fractures in older women; and increased caregiver burden.59 A large meta-analysis of the relationship of UI to mortality found that UI is associated with a pooled, adjusted hazard ratio of 1.27 (95% CI, 1.13 to 1.42).10 Another study found that UI was associated with a 24% increased risk of all-cause mortality among older institutionalized adults.11

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

A validated incontinence screening questionnaire should be used to help categorize the type of UI.21

C

Expert opinion and consensus guidelines

The cough stress test has excellent intertest reliability, sensitivity, and specificity and should be used to confirm stress UI.24,28,29

C

Expert opinion and consensus guidelines

Pharmacologic interventions should be selectively used as an adjunct to behavior therapies for urge UI.38,48

C

Expert opinion and consensus guidelines

Conservative management should be the first-line treatment for stress and urge UI.32,42,45,47

C

Expert opinion and consensus guidelines

Surgical therapy should be considered for patients with refractory UI.39,45,48

C

Expert opinion and consensus guidelines


UI = urinary incontinence.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

A validated incontinence screening questionnaire should be used to help categorize the type of UI.21

C

Expert opinion and consensus guidelines

The cough stress test has excellent intertest reliability, sensitivity, and specificity and should be used to confirm stress UI.24,28,29

C

Expert opinion and consensus guidelines

Pharmacologic interventions should be selectively used as an adjunct to behavior therapies for urge UI.38,48

C

Expert opinion and consensus guidelines

Conservative management should be the first-line treatment for stress and urge UI.32,42,45,47

C

Expert opinion and consensus guidelines

Surgical therapy should be considered for patients with refractory UI.39,45,48

C

Expert opinion and consensus guidelines


UI = urinary incontinence.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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JOCELYN S. HU, MD, is a staff family medicine physician at Bayne-Jones Army Community Hospital, Fort Polk, La....

ELYSE FIORE PIERRE, MD, is a staff family medicine physician at Winn Army Community Hospital, Fort Stewart, Ga.

Address correspondence to Jocelyn S. Hu, MD, 1585 Third St., Fort Polk, LA 71459 (email: jocelyn.s.hu.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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