Urinary incontinence is the involuntary loss of urine. It is a prevalent and bothersome condition in females, with subtypes including stress, urge, mixed stress/urge, and overflow. Evaluation begins with a history to identify symptoms of the different subtypes and information about comorbid conditions, incontinence frequency and severity, and effect on quality of life. Based on patient history, other assessments could include urinalysis, a voiding diary, pelvic examination, urinary stress testing, and measurement of postvoid residual urine volume. Treatment varies by subtype, but begins with lifestyle modifications, including decreasing caffeine intake, engaging in physical activity to strengthen pelvic floor muscles, and avoiding excessive fluid consumption. Pelvic floor physical therapy can help with urge and stress incontinence, pessaries and vaginal inserts can help with stress incontinence, and timed or prompted voiding can be useful for both subtypes. Pharmacotherapy for urge incontinence has typically involved anticholinergic drugs, but because of adverse effects, beta-3 adrenergic agonists are being more widely used. If needed for urge incontinence, procedural treatments can be considered, including onabotulinumtoxinA injections, percutaneous tibial nerve stimulation, and sacral neuromodulation. Numerous procedural treatments are available for stress incontinence; placement of midurethral slings is the most common. For overflow incontinence, treatments include catheterization or targeting the source of obstruction or detrusor hypoactivity.
Case 3. UI is a 53-year-old patient with frequent, strong, sudden urges to urinate for the past few years. This has recently resulted in small amounts of leakage when she cannot get to a bathroom quickly. She has been wearing a sanitary pad daily but worries about her symptoms when she isn’t near a bathroom.
Background
The International Continence Society defines urinary incontinence as any involuntary loss of urine.1 This section will review the epidemiology and risk factors for each type of incontinence, their subtypes, and the recommended diagnostic evaluation and treatments.
Epidemiology
The prevalence of urinary incontinence increases with age, although rates vary based on case definitions used. Approximately 17% of women older than 20 years and 38% older than 60 years have urinary incontinence. Overall, it affects 10% to 20% of all women, including up to 77% of female nursing home residents. However, it is underdiagnosed and undertreated, with only 25% of affected women seeking care and only half of those receiving treatment.2
Incidence varies by race and ethnicity. Hispanic patients have the highest rate of any type of diagnosed urinary incontinence, Chinese patients have the highest rate of stress incontinence, and Black patients have the highest rate of urge incontinence.3 Possible reasons for these variations include cultural differences in the level of comfort when discussing symptoms with a clinician of a different race, gender, or culture, as well as communication and language barriers. Comfort in discussing urinary incontinence symptoms with peers or clinicians varies among patients from different ethnic groups, but all groups studied find urinary incontinence to be embarrassing, shameful, and taboo.4
Definitions
There are several subtypes of urinary incontinence. These include stress, urge, mixed, and overflow incontinence (Table 11,2). When considering data from all patients, mixed incontinence is reported to be the most bothersome and stress incontinence the least bothersome.3
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