Urinary Incontinence

Aka: Urinary Incontinence, Incontinence

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II. Definitions

  1. Urinary Incontinence
    1. Involuntary urine loss
  2. Transient Urinary Incontinence
    1. Incontinence lasting <6 months and resolves if underlying cause reversed

III. Epidemiology

  1. Increased prevelance with age
    1. Age 44 year women: 17%
    2. Age 75 year women: 27%
    3. Overall Prevalence in adult women >50% in some studies
  2. High Incidence in female athletes
    1. Female Varsity Athletes: 32%
    2. Female Basketball players: 68%

IV. Physiology

  1. Physiology of urination and Bladder control
    1. Detrussor Muscle (Bladder) control
      1. Parasympathetic innervation
      2. Beta adrenergic control
    2. Internal Urethral sphincter
      1. Alpha adrenergic control
    3. External Urethral sphincter
      1. Somatic or voluntary control
  2. Incontinence is not a normal part of aging
    1. Age predisposes to Incontinence
    2. Age does not cause Incontinence

V. Pathophysiology

  1. Disorders of Urinary Storage
    1. Detrussor Hyperactivity
      1. Urge Incontinence
    2. Sphincter incompetence
      1. Urge Incontinence
      2. Stress Incontinence
  2. Disorders of Urine Emptying
    1. Detrussor hypoactivity
      1. Overflow Incontinence
    2. Urethral Sphincter obstruction
      1. Overflow Incontinence

VI. Risk Factors

  1. Increasing age
  2. Multiple prior vaginal deliveries
  3. Obesity
  4. Hysterectomy
  5. Comorbid medical conditions (e.g. Diabetes Mellitus, Congestive Heart Failure, Dementia)
  6. Diuretics
  7. High impact Exercise

VII. Types: Common

  1. Urge Incontinence (Overly sensitive Bladder)
    1. Loss of large Bladder volumes (contrast with Stress Incontinence) typically in older patients (esp. post CVA)
    2. Associated with strong sense of urinary urgency; Urinary Frequency and Nocturia may be present
    3. Caused be detrussor overactivity and more commonly associated with CNS or spinal cord disorders
    4. Example Causes: CVA, Cystitis, Bladder Cancer, Bladder stones
  2. Stress Incontinence (Loss of pelvic support at Urethra)
    1. Loss of small Bladder volumes (contrast with urge) that occurs with coughing, sneezing, lifting
    2. Urethral Hypermobility and Urethral sphincter dysfunction
    3. Most common cause of Urinary Incontinence in younger women
  3. Mixed Urinary Incontinence
    1. Combined Stress Incontinence and Urge Incontinence
    2. Occurs in one third of adults with Urinary Incontinence (most common Urinary Incontinence cause)

VIII. Types: Less Common

  1. Overflow Incontinence (Urinary Retention)
    1. Bladder overdistention with Urinary Retention
    2. Presents with dribbling or continuous urine leakage
    3. Post-void residual >200 cc of urine
    4. Bladder outlet obstruction is less common in women (consider evaluation for tumor mass)
    5. Example Causes: Diabetic Neuropathy, BPH, or pelvic mass
  2. Functional Incontinence
    1. Normal Bladder with decreased access to toilet (physical or Cognitive Impairment)
    2. Typically occurs in debilitated patients (e.g. severe Arthritis) or Dementia
  3. Low Pressure Urethra (Type 3)
    1. Urethral tone loss (<60 cm H20)
    2. Causes: Trauma, surgery

IX. Differential Diagnosis: (Mnemonic: "DIAPPERS") - Causes transient acute Incontinence

  1. Delirium
  2. Infection or Inflammation
    1. Recurrent Urinary Tract Infection
    2. Infectious Vaginitis
    3. Interstitial Cystitis
    4. Carcinoma-in-situ of the Bladder
  3. Atrophic Urethritis or Atrophic Vaginitis
  4. Pharmaceuticals
    1. See Medication Causes of Urinary Incontinence
    2. Diuretics
    3. Sedative-Hypnotic Medications
    4. Antipsychotic Medications
    5. Antidepressants
    6. Analgesics including Narcotics
    7. Muscle relaxants
    8. Sympathetic blockers
  5. Psychological causes
  6. Excessive Urine Output (e.g. Diabetes Mellitus)
  7. Restricted Mobility (i.e. difficult ambulation)
  8. Stool Impaction

X. History

  1. Voiding Diary (3 day journal)
    1. https://www.niddk.nih.gov/health-information/health-topics/urologic-disease/daily-bladder-diary/Documents/diary_508.pdf
    2. Frequency of Incontinence episodes
    3. Measured volumes of voids
    4. Estimated volumes of Incontinence
  2. Volume overload (CHF, Chronic Kidney Disease, Cirrhosis)
    1. Urge Incontinence
  3. Decreased mobility (e.g. Arthritis)
    1. Urge Incontinence
    2. Functional Incontinence
  4. Cerebrovascular Accident, Dementia or other diminished mental status
    1. Urge Incontinence
    2. Functional Incontinence
  5. Spinal Stenosis
    1. Overflow Incontinence

XI. Symptoms: Triggers

  1. Provocation with cough, valsalva, or bearing down
    1. Suggests Stress Incontinence
  2. Spontaneous loss of urine
    1. Detrussor Instability
    2. Urge Incontinence

XII. Symptoms: Urine Volume

  1. Small volume leakage with activity (5-10 ml/episode)
    1. Stress Incontinence
  2. Spontaneous uncontrolled large volume Bladder emptying
    1. Urge Incontinence

XIII. Symptoms: Timing

  1. Predictable episodes (e.g.cough, sneezing, Exercise)
    1. Stress Incontinence
  2. Immediately follows urge to void
    1. Urge Incontinence
  3. Nocturia
    1. Urge Incontinence
  4. Urinary Frequency
    1. Urge Incontinence

XIV. Exam: General

  1. Cognitive and Functional Assessment
    1. See Mental State Exam
    2. See Activities of Daily Living
  2. Fecal Impaction
    1. Overflow Incontinence
  3. Decreased anal sphincter tone
    1. Overflow Incontinence

XV. Exam: Female Genitourinary Exam

  1. Vulvar or Vaginal Atrophy (Menopause)
    1. Stress Incontinence
    2. Urge Incontinence
  2. Pelvic Organ Prolapse
    1. Stress Incontinence
    2. Overflow Incontinence (if obstruction)
  3. Perform Pelvic exam, lifting anterior vaginal wall
    1. Changes Bladder neck position
    2. Retest with cough or valsalva

XVI. Exam: Male Genitourinary Exam

  1. Benign Prostatic Hyperplasia
    1. Overflow Incontinence

XVII. Labs

  1. Urinalysis
    1. Evaluate for Urinary Tract Infection, Hematuria, Proteinuria and urinary Glucose
  2. Renal Function tests
    1. Indicated in cases of suspected urinary obstruction

XVIII. Diagnosis

  1. See Provoked Full Bladder Stress Test
  2. See Cough Stress Test
  3. Urodynamic Testing (Cystometrography)
    1. Indicated for Incontinence not due to stress or urge
  4. Post-void residual (Bedside Ultrasound performed after patient attempts to completely void)
    1. Urine PVR <50 ml
      1. Stress Incontinence
      2. Urge Incontinence
      3. Mixed Incontinence
    2. Urine PVR >200 ml
      1. Overflow Incontinence
    3. Variable
      1. Functional Incontinence

XIX. Evaluation

  1. Rule-out reversible cause
    1. Medication adverse effects
    2. Atrophic Vaginitis
    3. Benign Prostatic Hyperplasia (BPH)
    4. Polyuria
      1. Medication
      2. Diabetes Mellitus
    5. Fecal Impaction
    6. Urinary Tract Infection
    7. Functional Incontinence
      1. Limited mobility
      2. Altered Level of Consciousness
  2. Rule-out Overflow Incontinence
    1. Check post-void residual if indicated by history
  3. Consider neurologic or post-surgical cause
    1. See Low Pressure Urethra
  4. Distinguish Urge Incontinence from Stress Incontinence
    1. If secondary cause is unlikely

XX. Management: General

  1. Management is per specific Incontinence cause
    1. Urge Incontinence
    2. Stress Incontinence
    3. Overflow Incontinence
    4. Functional Incontinence
    5. Low Pressure Urethra (Type 3)
  2. Make toilets more accessible
    1. Higher toilets
    2. Well lit floors
    3. Change bedroom to be close to bathroom
    4. Consider bedside commode
  3. Wear clothes that are removed easily
  4. Use moderation in fluid intake (but avoid aggressive fluid restriction)
  5. Lose weight (if obese)
  6. Smoking Cessation
  7. Avoid Diuretics
    1. Avoid Alcohol
    2. Avoid Caffeine
    3. Avoid carbonated beverages

XXI. Management: Urology Referral Indications

  1. Incontinence secondary to Recurrent Urinary Tract Infections (or other relapsing condition)
  2. Incontinence with Muscle Weakness or other new-onset neurologic symptoms
  3. Severe Benign Prostatic Hyperplasia
  4. Severe Pelvic Organ Prolapse (beyond introitus)
  5. Incontinence with associated Pelvic Pain
  6. Incontinence with persistently positive urinary sediment
    1. Hematuria
    2. Proteinuria
  7. Postvoid residual Urine Volume >200 ml
  8. Prior pelvic surgery or pelvic radiation
  9. Idiopathic Urinary Incontinence diagnosis

XXII. Complications

  1. Increased anxiety and depressed mood
  2. Increased Urinary Tract Infections
  3. Increased Skin Infections
  4. Increased Fall Risk
  5. Increased Caregiver Burden
  6. Increased overall mortality among older institutionalized adults
    1. Damian (2017) J Adv Nurs 73(3): 688-99 [PubMed]

XXIII. Resources

  1. Help for Incontinent People
    1. Phone: (864) 579-7900
  2. AUA Step By Step Incontinence Treatment
    1. http://www.drylife.org/drylife.html
  3. Bladder Control in Women
    1. http://www.niddk.nih.gov/health/urolog/uibcw/

XXIV. References

  1. Frank (2010) Can Fam Physician 56(11): 1115-20 [PubMed]
  2. Gibbs (2007) Am J Med 120(3): 211-20 [PubMed]
  3. Goode (2010) JAMA 303(21): 2172-81 [PubMed]
  4. Hersh (2013) Am Fam Physician 87(9): 634-40 [PubMed]
  5. Holroyd-Leduc (2008) JAMA 299(12): 1446-56 [PubMed]
  6. Hu (2019) Am Fam Physician 100(6): 339-48 [PubMed]
  7. Khadelwal (2013) Am Fam Physician 87(8): 543-50 [PubMed]

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Related Studies

Ontology: Urinary Incontinence (C0042024)

Definition (MEDLINEPLUS)

Urinary incontinence (UI) is loss of bladder control. Symptoms can range from mild leaking to uncontrollable wetting. It can happen to anyone, but it becomes more common with age. Women experience UI twice as often as men.

Most bladder control problems happen when muscles are too weak or too active. If the muscles that keep your bladder closed are weak, you may have accidents when you sneeze, laugh or lift a heavy object. This is stress incontinence. If bladder muscles become too active, you may feel a strong urge to go to the bathroom when you have little urine in your bladder. This is urge incontinence or overactive bladder. There are other causes of incontinence, such as prostate problems and nerve damage.

Treatment depends on the type of problem you have and what best fits your lifestyle. It may include simple exercises, medicines, special devices or procedures prescribed by your doctor, or surgery.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI_NCI-GLOSS) Inability to hold urine in the bladder.
Definition (NCI_CTCAE) A disorder characterized by inability to control the flow of urine from the bladder.
Definition (NCI) Inability to control the flow of urine from the bladder.
Definition (CSP) failure of voluntary control of the vesical and urethral sphincters, with constant or frequent involuntary passage of urine.
Definition (MSH) Involuntary loss of URINE, such as leaking of urine. It is a symptom of various underlying pathological processes. Major types of incontinence include URINARY URGE INCONTINENCE and URINARY STRESS INCONTINENCE.
Concepts Pathologic Function (T046)
MSH D014549
ICD9 788.30, 788.3
ICD10 R32
SnomedCT 207170000, 207174009, 41840003, 158469002, 139399005, 142633003, 158472009, 236661008, 165232002
LNC LA6436-5
English Incontinence, Urinary, BLADDER INCONTINENCE, MICTURITION INVOLUNTARY, URINARY INCONTINENCE, URINATION INVOLUNTARY, URINE INCONTINENCE, Unable prevent bladder emptyng, Incontinence of urine NOS, [D]Incontinence of urine (context-dependent category), [D]Incontinence of urine NOS (context-dependent category), Unspecified urinary incontinence, Urine Incontinence, [D]Incontinence of urine, [D]Incontinence of urine NOS, unable to restrain urination, loss of control of urination (symptom), incontinent of urine, urinary loss of control, unable to restrain urination (symptom), loss of control of urination, urinary incontinence, urinary incontinence (diagnosis), Incontinence urinary, Micturition involuntary, Urination involuntary, Urinary incontinence NOS, Urinary Incontinence [Disease/Finding], bladder incontinent, urine incontinent, leaking urine, Unable (to);hold urine, Incontinence;urine, Urination;involuntary, incontinent bladder, urinary incontinences, urine incontinence, bladder incontinence, loss of bladder control, bladder control loss, urine leak, urine leaking, weak bladder, [D]Incontinence of urine (situation), Bladder: incontinent (finding), [D]Incontinence of urine NOS (situation), Bladder incontinence, Incontinence of urine, Absence of bladder continence, Urinary incontinence, Involuntary urination, Lack of bladder control, Leaking of urine, Loss of bladder control, UI - Urinary incontinence, Unable to control bladder, Unable to hold fluids, Unable to hold urine, Unable to prevent bladder emptying, Weak bladder, Bladder: incontinent, Urine incontinence, Urinary incontinence (finding), Incontinence urine, bladder; weak, incontinence; urinary, urine; incontinence, weak; bladder, Incontinence (Urinary), Urinary Incontinence, Urinary incontinence, unspecified, involuntary urination, unable to hold urine
French INCONTINENCE URINAIRE, Incontinence vésicale, Miction involontaire, Incontinence d'urine, Incontinence d'urine non précisée, Urination involontaire, INCONTINENCE D'URINE, INCONTINENCE VESICALE, MICTION INVOLONTAIRE, Incontinence urinaire
Portuguese INCONTINENCIA URINARIA, Incontinência vesical, Incontinência urinária NE, Micção involuntátia, Micção involuntária, INCONTINENCIA VESICAL, MICCAO INVOLUNTARIA, Incontinência urinária, Incontinência Urinária
Spanish INCONTINENCIA URINARIA, Incontinencia de orina, Incontinencia urinaria no especificada, Incontinencia vesical, Emisión involuntaria de orina, Micción involuntaria, [D]incontinencia urinaria (categoría dependiente del contexto), [D]incontinencia urinaria, SAI (categoría dependiente del contexto), DIURESIS INVOLUNTARIA, INCONTINENCIA VEJIGA URINARIA, MICCION INVOLUNTARIA, ORINA, INCONTINENCIA, ausencia de continencia urinaria, incontinencia urinaria (hallazgo), [D]incontinencia urinaria, SAI (situación), incontinencia de orina, incontinencia urinaria, [D]incontinencia urinaria, SAI, [D]incontinencia urinaria, [D]incontinencia urinaria (situación), incontinencia vesical, vejiga: incontinente (hallazgo), vejiga: incontinente, Incontinencia urinaria, Incontinencia Urinaria
German HARNINKONTINENZ, Blaseninkontinenz, Miktion unfreiwillig, unspezifische Harninkontinenz, Urinieren unfreiwillig, Urininkontinenz, BLASENINKONTINENZ, HARNABGANG UNKONTROLLIERT, MIKTION UNKONTROLLIERT, Nicht naeher bezeichnete Harninkontinenz, URININKONTINENZ, Harninkontinenz, Inkontinenz, Harn-
Dutch incontinentie urine, niet-specifieke urine-incontinentie, onvrijwillige urinelozing, urine incontinentie, onvrijwillige mictie, blaasincontinentie, blaas; zwak, incontinentie; urine, urine; incontinentie, zwak; blaas, Niet gespecificeerde urine-incontinentie, urine-incontinentie, Incontinentia urinae, Urine-incontinentie
Italian Incontinenza vescicale, Minzione involontaria, Incontinenza di urina, Incontinenza non specificata di urina, Incontinenza urinaria
Japanese 詳細不明の尿失禁, 膀胱性尿失禁, 不随意排尿, 尿失禁, ｼｮｳｻｲﾌﾒｲﾉﾆｮｳｼｯｷﾝ, ﾌｽﾞｲｲﾊｲﾆｮｳ, ﾎﾞｳｺｳｾｲﾆｮｳｼｯｷﾝ, ﾆｮｳｼｯｷﾝ
Swedish Urininkontinens
Finnish Virtsankarkailu
Russian NEDERZHANIE MOCHI, НЕДЕРЖАНИЕ МОЧИ
Czech Blíže neurčená močová inkontinence, Inkontinence močového měchýře, Mimovolní močení, Močová inkontinence, moč - inkontinence, inkontinence moči
Korean 상세불명의 요실금
Croatian URINARNA INKONTINENCIJA
Polish Nietrzymanie moczu
Hungarian Vizelet incontinentia, húgyúti incontinentia, Húgyhólyag incontinentia, Húgyúti incontinentia, Akaratlan vizeletürítés, Nem meghatározott vizeletincontinentia, Vizelet-incontinentia, Akaratlan vizelés
Norwegian Urininkontinens, Urinlekkasje
Derived from the NIH UMLS (Unified Medical Language System)

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