Urinary incontinence creates a high level of suffering. Yet many sufferers are reluctant to seek help. Less than half of the affected women want to talk about it, even though they have suffered from it for years. Since primary care providers can successfully treat urinary incontinence in 60-70% of cases, it is obvious what opportunities the diagnosis offers.
In clinical practice, it is particularly important to distinguish those forms of urinary incontinence that can be treated simply and effectively from those that require specific treatment, i.e. the complex forms that belong in the hands of specialists or specialized centers.
Forms of urinary incontinence
Complex forms are incontinence with anamnestic evidence of recurrent incontinence, incontinence with hematuria or with recurrent urinary tract infections. Incontinence is moreover complex with signs of micturition disturbance, in condition after radiatio in the small pelvis or in status after radical pelvic interventions. Retropubic pain or treatment failure also falls into this group.
The situation is different with neurogenic incontinence, for example in the context of multiple sclerosis. It is often difficult to treat and progressive in course.
Due to the demographic development with people getting older and older, the concept of functional incontinence is becoming more and more important. This occurs when the patient is no longer able to use the toilet independently due to physical or cognitive limitations, but there is no urogenital disease (i.e., the patient is unable to get to the toilet for excretion due to lack of mobility or can no longer find it due to dementia). In part, this term also overlaps with that of passive incontinence caused by various factors, the acronym of which is DIAPPERS (“Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excess urine output, Reduced mobility, Stool impaction and other factors”).
A rarity in clinical practice is extraurethral incontinence, in which urine output occurs via the vagina due to fistulae.
The diagnosis of incontinence in chronic urinary retention is complicated by the lack of definition of the threshold above which it is defined. Mostly values between 150 and 200 ml are used. The mere presence of residual urine in the absence of accompanying symptoms without evidence of impaired function, including of the upper urinary tract, does not per se imply pathological significance. The cause is an infravesical outflow obstruction or a chronically overstretched bladder wall in which the detrusor muscle no longer provides the contractile force necessary for bladder emptying. Therapy lies in eliminating the outflow obstruction or improving contractility. Drug therapy of outflow obstruction by alpha-blockers or improvement of detrusor contractility by cholinergics is possible. Surgical repair of a cystocele or resolution of colposuspension sutures can be frustrating, especially if a chronically overstretched bladder wall is already present.
Urinary incontinence in women
The main forms of urinary incontinence in women are stress incontinence and hyperactive bladder with and without incontinence (formerly urge incontinence). It is also called overactive bladder or “overactive bladder dry or wet” (OAB), popularly irritable bladder.
A stress incontinence (formerly stress incontinence) is characterized by urine leakage under physical stress such as coughing, sneezing, lifting weights or walking downhill, due to a functional weakness of the urinary sphincter apparatus that prevents adequate adaptation of the urethral pressure to the increased intra-abdominal pressure. Various mechanisms, such as local traumatic damage with loss of muscle fibers at the urethra, as well as age, where there is a loss of muscle fibers and thus muscle strength due to an estrogen deficit, or nonspecific connective tissue weakness, may be responsible for the development. In clinical practice, the graduation according to Ingelmann-Sundberg has become common.
Hyperactive bladder is a syndrome characterized by symptoms of imperative urination, pollakiuria (more than 7 micturitions/day), and nocturia (more than once per night); the presence of incontinence is optional.
Mixed forms are also frequently present. It is difficult to give information on the prevalence of the different forms of urinary incontinence, as this depends on various factors, such as the form of recording or the time of diagnosis. The most common form of urinary incontinence in women up to the age of 60 is stress incontinence, after which it is replaced by mixed incontinence. Urge incontinence increases from the age of 60 and peaks at the age of 90.
Reduced diagnosis is often useful
In the context of first-line therapy, baseline diagnostics can be greatly reduced. Although numerous guidelines recommend quite elaborate clarifications and examinations, the diagnostics can be greatly limited. Ultimately, there is surprisingly little evidence for absolutely necessary research. Certainly, at least a brief incontinence history should be obtained, an infection should be ruled out, a residual urine determination should be performed, and a micturition calendar should be established. A cough test with a full bladder with cough-synchronous urine output suggests the presence of stress incontinence.
Inflammation of the urinary tract can show the same symptoms as a hyperactive bladder. In addition, an infection can cause incontinence or exacerbate existing incontinence. An examination by means of a urine stick is sufficient. If recurrent urinary tract infections are suspected, it may be useful to perform a urine culture to enable a resistance-oriented therapy or prophylaxis, which is then part of the incontinence treatment. If urethritis is suspected, which can also show the symptoms of an overactive bladder and whose antibiotic therapy differs from that of cystis, a urethral swab makes sense. However, this is often unpleasant to painful for the patient. Germ determination can also be performed in urine, although the sensitivity and specificity are somewhat lower than with the smear. “Blind” antibiotic administration of azithromycin is considered critical in the current data.
Reduction in functional bladder capacity with increased residual urine can lead to pollakiuria, imperative urination, nocturia, and incontinence, so this simple examination is useful. In about one third of older patients, a weak detrusor muscle is found, which promotes residual urine formation. The mode of action of anticholinergics in the treatment of hyperactive bladder may make residual urine control useful before and during anticholinergic therapy, especially in the elderly.
Since the diagnosis of hyperactive bladder is symptom-based, it can be easily corroborated by keeping a micturition calendar. In addition, the success of the therapy can be made visible and verifiable in this way. For diagnosis, keeping the calendar for three days is enough. As a follow-up under anticholinergic therapy, one day a week is usually sufficient.
Further investigations such as imaging, cystoscopy or urodynamic evaluation are indicated in cases of clinical suspicion or complex incontinence with alguria and hematuria. A referral to the specialist, resp. to an appropriate center, then makes sense.
Ways of therapy
Effective therapeutic measures are available for the two main forms of urinary incontinence, as well as for their mixed forms, which primarily involve conservative management.
Since the ideas about the form and extent of continence depend very much on the point of view, it is advisable to assess the level of suffering, to address possible therapies as well as side effects and to define a realistic therapy goal together with the patient before starting treatment. Very different measures, such as medications, surgery or behavioral training, can lead to continence. The form of continence that can be achieved depends on the initial situation. Thus, social continence through continence aids or assisted continence with support from partners, relatives or caregivers should also be considered as realistic goals.
A sustainable therapeutic success can already be achieved by conservative measures, such as behavioral changes, i.e. weight reduction, smoking cessation, stool regulation, nutritional counseling, physiotherapy, adjustment of micturition and drinking behavior and, if indicated, local estrogenization.
Therapy of stress incontinence: Three quarters of women suffering from stress incontinence show an improvement of the symptoms during pelvic floor exercises with physiotherapeutic guidance, respectively. a disappearance of incontinence. Only just under half of the women who receive brief introductions or training materials are actually able to use the pelvic floor consciously. Physiotherapeutic guidance is therefore useful. Pelvic floor exercises can improve awareness, strength and reflexive ability. It is therefore clearly the first choice. This includes training with a vaginal probe with electrostimulation and biofeedback.
Drug therapy is possible with duloxetine. This serotonin-norepinephrine reuptake inhibitor is thought to improve bladder closure tone and contractility via increased neurotransmitter concentrations. In Switzerland, duloxetine is not approved with this indication; it is an off-label use. Therapy discontinuations are very common in long-term studies.
Foam vaginal tampons or urethral pessaries can usually provide good flanking or bridging services for women who only leak urine under special circumstances. Older, inoperable patients can also benefit from such therapy, as it can be carried out over a longer period of time.
The gold standard after failure of conservative measures is now considered to be the insertion of a suburethral sling (“tensionfree vaginal tape”, TVT). This procedure, which has few complications, is easy to perform and causes little stress, is also very effective in older or obese patients. Various substances (“bulking agents”) can be injected periurethrally and thus lead at least passively to continence. However, the subjective and objective success rates here are significantly lower than those of the gold standard, and the current data situation does not permit a general recommendation.
Therapy of hyperactive bladder: Behavioral interventions, such as education on proper drinking behavior (right amount at the right time), avoidance of irritants (including caffeine), bladder training (emptying the bladder every 1-3 h, increasing interval slowly in 15-30 min increments), and urge suppression techniques (“panic feeling” suppression, tightening the pelvic floor, calm breathing, going to the toilet slowly), have been shown to be effective in the treatment of hyperactive bladder, showing success rates between 60 and 80%. Moreover, they have the advantage of leading to sustainable success.
Anticholinergics can support and enhance this success, but their effect is limited to the duration of intake. Numerous anticholinergics are available: Trospium chloride, tolterodine, fesoterodine, solifenacin and darifenacin, additionally with local anesthetic effect oxybutinin. Despite their different properties or mechanisms of action, these preparations are similar in their efficacy and side effect profiles. There is no algorithm for their use, so that in everyday clinical practice it makes sense to use different preparations, some of which also differ in their application or galenic form.
Until now, the most common side effects of anticholinergics, such as dry mouth and constipation, which subside after three months, were mainly held responsible for therapy discontinuations (table 1) .
Now, a recently published study has revealed that there are a variety of different reasons for treatment discontinuation. For example, discontinuation took place when there was no effect. Unfortunately, this study does not answer the additional question for the causes, but some can be inferred and give us the opportunity to make therapy effective after all, if necessary ( Table 2).
Apart from this, there are some measures that, when applied in general, can optimize therapy (Tab. 3) .
Clear information on the mechanisms of continence and its failure can improve drinking and micturition behavior change. As mentioned above, the understanding of what continence means varies widely. This should lead to setting realistic, achievable goals when setting the therapy goal. The ability to independently vary the dose according to need – by prescribing a preparation with two dosages – can make it easier to deal with side effects that then occur passagerily at the higher dosage. It is also important to be open about the side effects, as there are few effective measures to address the troublesome dry mouth and constipation that is pre-existing in many older women.
Local estrogens are not effective in treating incontinence but are effective in treating urge symptoms in postmenopausal women. As a rule, there is no systemic effect.
If the options of conservative therapy are exhausted or the side effects are intolerable, Botox injections, neurostimulation, or surgical procedures such as bladder augmentation may be discussed.
Conclusion for practice
- Female urinary incontinence is common and significantly affects the quality of life of affected women. There are simple, effective treatment options.
- A basic work-up consists of a targeted anamnesis, exclusion of an infection, determination of residual urine and keeping a micturition calendar.
- Pelvic floor exercises under physiotherapeutic guidance, if necessary with electrical stimulation, are first-line therapy for stress incontinence. If the symptoms persist, surgical treatment is possible. Today, the insertion of a suburethral sling (“tensionfree vaginal tape”, TVT) is considered the gold standard.
- Therapy for hyperactive bladder focuses on lifestyle adjustments and behavioral changes, often supported by anticholinergics.
Jörg Humburg, MD
Bibliography with the author
