Introduction

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.

Classification

Classification
  • overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
  • stress incontinence: leaking small amounts when coughing or laughing
  • mixed incontinence: both urge and stress
  • overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Aetiology

Risk factors
  • advancing age
  • previous pregnancy and childbirth
  • high body mass index
  • hysterectomy
  • family history

Clinical features

Investigations

Initial investigation
  • bladder diaries should be completed for a minimum of 3 days
  • vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
  • urine dipstick and culture
  • urodynamic studies

Management

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
  • bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
  • bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'
  • mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

If stress incontinence is predominant:
  • pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
  • surgical procedures: e.g. retropubic mid-urethral tape procedures