Clinical review

Management of urinary incontinence in women

Ranee Thakar, trainee in urogynaecology, Stuart Stanton, professor. 

Urogynaecology and Pelvic Floor Reconstruction, St George's Hospital, London SW17 0QT

Correspondence to: R Thakar bthakar{at}sghms.ac.uk

Urinary incontinence is defined by the International Continence Society as an involuntary loss of urine that is objectively shown and a social and hygiene problem.¹ Urinary incontinence not only causes considerable personal discomfort but is also of economic importance to the NHS, costing around £424m per annum.² In a survey of 10 226 adults aged over 40, the prevalence of incontinence in women was reported as 20.2%.³

View larger version (27K): [in this window] [in a new window]   Fig 1.   Classification of incontinence

Table 1 summarises the prevalence of urinary incontinence from a variety of studies.⁴ It is likely that about 3 million people are regularly incontinent in the United Kingdom, a prevalence of around 40 per 1000 adults.⁵

Incontinence can be broadly divided into genuine stress incontinence and an overactive bladder (detrusor instability) (fig 1). Bladder symptoms often do not correlate with the underlying diagnosis. Thus urge incontinence often but not always results from an overactive bladder. Emphasis must be placed on the management of urinary incontinence in primary care, as this is effective in both the short term and the long term and benefits secondary care by ensuring that only patients who cannot be managed in primary care are referred. ^{6 7} Urodynamic studies can be reserved for when conservative treatment has failed, surgery is intended, there are voiding difficulties, or a neuropathy is present.

	Methods

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

Our data were obtained from an electronic search of Medline (1966-2000) and by handsearching the citations shown by the initial electronic search. Where relevant, we quote textbooks and personal experience.

	General measures

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

Incontinent women benefit from simple advice on incontinent pads and garments. Patients with high fluid intake should restrict fluid to a litre a day (particularly if frequency is a problem), those with chronic cough should be advised to stop smoking, and constipation should be treated. Pelvic floor exercises may be helpful in the puerperium. Oestrogen replacement therapy is often beneficial in postmenopausal women.⁸ Diuretics may have to be stopped or reduced. In patients with chronic urinary incontinence, especially elderly women, it may be easier to provide an indwelling urethral or suprapubic catheter. Urinary incontinence may not always be cured, but with an integrated care plan between the patient, continence adviser, and doctor it is possible to improve quality of life.

	Genuine stress incontinence

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

Genuine stress incontinence is the most common cause of urinary incontinence in women. The conservative and surgical treatments will depend on the patient's preference, condition, and urodynamic diagnosis.

Conservative treatment
Conservative treatment is indicated when patients refuse or are undecided about surgery, they are physically or mentally unfit for surgery, or childbearing is incomplete.

Pelvic floor exercises
Pelvic floor exercises have been successfully used since 1948. Pelvic floor exercises concern re-education of the pelvic floor muscles by encouraging women to voluntarily contract their pelvic floor muscles. Visual or tactile biofeedback methods may be used to increase the strength of the contractions.⁹ The overall rate for cure or much improvement at five years is about 60%. ^{10 11}

View larger version (45K): [in this window] [in a new window]   Fig 2.   Vaginal cones (Colgate Medical, Berkshire)

Devices

Electronic devices
Electrical stimulation for urinary incontinence has been applied with some success by using a variety of appliances at different frequencies. The technique involves stimulation of the pudendal nerve with electrodes placed in the vagina or anus. The patient can adjust the strength of the variable current, and various regimens are available. In a prospective, multicentre, randomised, double blind, placebo controlled trial lasting 15 weeks, significant improvements were found in urinary leakage of cases when compared with controls on the basis of visual analogue scales, voiding diary (48% versus 19%), pad testing (89% versus 32%), and vaginal muscle strength (15.2 versus 8.9 mm Hg).¹⁵

Elevating devices
For mild sphincter incompetence, a tampon, reusable foam pessary, or prosthesis that supports the bladder neck may temporarily cure incontinence by elevating the bladder neck (fig 3). Such prostheses are recommended for incontinence at known times, such as during sports. A recent study of a bladder neck prosthesisa vaginal device designed to support the bladder neck (Introl, Uromed, Needham, MA)showed a mean reduction in urinary leakage from 59.8 to 22.8 episodes per week, and this was confirmed on testing with incontinence pads (78.5 to 23.4 g). Quality of life scores also improved. Side effects include urinary tract infections and soreness of the vaginal mucosa.¹⁶

View larger version (35K): [in this window] [in a new window]   Fig 3.   Conveen continence guard

Occlusive devices
Devices for occluding the urethra include urethral plugs and, more recently, expandable urethral devices. An 80% cure rate has been shown with intraurethral devices, with urinary tract infection in about 25% of women.¹⁷ Published data on an external device for occluding the urethra (Fem Assist, Insight Medical, Bolton, MA) showed low effectiveness and acceptability of the device, with only 2 of 31 (4.9%) participants completing the study.¹⁸ Compliance seems to be a major problem with all the devices, and patients also need sufficient manual dexterity.

Surgical treatment
Continence surgery is indicated when conservative treatment fails or the patient wants definitive treatment. The aims of continence surgery are to elevate the bladder neck, support the mid urethra, or increase urethral resistance. In general, the first attempt at continence surgery produces better results than repeat procedures.¹⁹ Clinical features, urodynamic data, and operation characteristics influence the choice of surgery, and the success rates vary (table 2).²⁰ The patient should be counselled about avoiding unnecessary heavy lifting or abnormal straining after continence surgery.

Urethral bulking agents
Urethral bulking agents are indicated for mild stress incontinence and for when the patient wants to defer or is unfit for surgery. The bulking agent is injected periurethrally or transurethrally under the submucosa to bulk the tissues around the bladder neck. Various agents are available, for example, glutaraldehyde cross linked bovine collagen, Macroplastique (Uroplasty, Breda, Netherlands), fat, and Durasphere (Advanced Uroscience, MN). The procedure can be done under local or light general anaesthetic with the patient as a day case. Reinjection is often required and does not preclude future surgery of the bladder neck. The benefits from urethral bulking agents deteriorate with time.²¹

Colposuspension
Colposuspension was described by Burch in 1961.²² It is indicated for genuine stress incontinence associated with a cystourethrocele. Two or three sutures (Ethibond) are placed between the paravaginal fascia on either side of the bladder neck and the base of the bladder and attached to the ipsilateral iliopectineal ligament. The most distal suture is placed at the bladder neck and the most proximal suture is placed as far cephalad as possible to support the bladder base.

Laparoscopic colposuspension
Laparoscopic colposuspension is a less invasive technique than an open procedure, with minimal disruption to lifestyle. Randomised controlled trials have shown it to be about 20% less successful than an open procedure. ^{23 24} Disadvantages include insufficient data from long term follow up, complications, cost of disposable equipment, a long operating time, and a steep learning curve.

Sling operation
Various types of material have been used for sling operations, which can be autologous (for example, rectus sheath, vaginal wall graft) or synthetic (for example, made from silastic, nylon, mersilene). When synthetic material is used there is a high incidence of erosion.

Tension free vaginal tape
Tension free vaginal tape (Gynecare, Ethican, Somerville, NJ) has increased in popularity for the treatment of genuine stress incontinence (fig 4). So far it has proved to be a safe and effective treatment. It is inserted under a local anaesthetic, regional block, or general anaesthetic and involves a vaginal and two small suprapubic incisions. After minimal paraurethral dissection of the vaginal wall, the special prolene tape covered with a plastic sheath wedged on to a 5 ml needle is attached to an introducer (or handle) and inserted into the retropubic area. The tip of this needle first perforates the urogenital diaphragm and is then passed lateral to the mid-urethra, upward and behind the pubic bone to perforate the rectus sheath and then the abdominal wall. The procedure is repeated on the other side so as to place the tape in a U shape around the mid-urethra. After cystoscopy to exclude bladder damage, the tape is adjusted without tension under the urethra. A three year follow up study has shown a cure rate of 86% and an improvement rate of 11%.²⁵ A large randomised study is currently under way to compare the tape to colposuspension.

View larger version (83K): [in this window] [in a new window]   Fig 4.   Tension free vaginal tape in situ (Ethicon)

Artificial urinary sphincter
Artificial urinary sphincters are used only in patients with complex sphincter incompetence or total loss of urethral resistance, when conventional surgery has failed, or for reconstructive procedures. The patient should be mentally alert, manually dexterous, and have sterile urine. Currently the American Medical Systems 800 sphincter is used. Complications found by Elliott and Barrett included recurrent urinary tract infections, mechanical failure, and erosion. ^{26 27} A review of Elliott and Barrett's results showed that at five years 90.4% of patients (both women and men) had a properly functioning artificial urinary sphincter and that 18% required reoperation to evaluate the sphincter.²⁸

	Overactive bladder (detrusor instability, unstable bladder)

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

An overactive bladder, the second most common cause of urinary incontinence in women, affects 30% of incontinent women, the prevalence increasing with age.²⁹ The bladder objectively contracts (spontaneously or on provocation) during the filling phase while the patient attempts to inhibit micturition. It may be due to hyperexcitability of detrusor muscle cells or a neuropathy involving the parasympathetic innervation. The symptoms include urgency, urge incontinence, frequency, and stress incontinence. Overactive bladder can only be diagnosed by subtracted filling cystometry, although cystometry is not always necessary before treatment.

Conservative treatment

Bladder retraining (behavioural therapy)
Bladder retraining should be the initial treatment for most patients with an overactive bladder, with or without stress incontinence. It is based on the assumption that conscious efforts to suppress sensory stimuli re-establishes cortical control over the bladder and thus a normal voiding pattern.³⁰ The aim is to reduce the voiding frequency to 3-4 hourly. The initial success rate of a long term study was 88% but declined to 38% after six months.³¹ A recent study showed that a behavioural strategy assisted by biofeedback was more effective and acceptable than oxybutinin treatment in women with urge and mixed incontinence.³² Enthusiastic patient contact, reassurance, and long term support are important. The degree of patient compliance determines the success.

Biofeedback
Biofeedback is a form of learning or re-education in which the patient is retrained within a closed feedback loop by using visual, auditory, or tactile signals to consciously inhibit any bladder contraction. Objective responses are recorded on a polygraph trace. Cardozo et al reported subjective and objective improvements of 81% with biofeedback.³³

Electrical stimulation
When conservative treatment fails and the symptoms affect quality of life, surgery may be carried out. An initial improvement or cure rate of 88% has been reported, with 77% still successful at one year.³⁴ Recently, a cure rate of 49% at eight weeks has been reported in a prospective, double blind, randomised trial.³⁵ The main difficulty is patient acceptance of the intravaginal or transanal stimulation for psychological or aesthetic reasons.

Pharmacotherapy
Drug therapy is the most popular mode of treatment for an overactive bladder. In general, drugs help by inhibiting the contractile activity of the bladder. These can be broadly classified into antimuscarinic drugs, calcium channel blockers, tricyclic antidepressants, musculotrophic drugs, and a variety of less commonly used drugs (table 3) Most have antimuscarinic activity and produce unwanted effects, which must be balanced against the benefits. Patients become less alert and should be cautioned about driving or operating dangerous machinery. The optimal dose should produce beneficial effects with an acceptable level of adverse effects. Oxybutinin has been the best drug available for the overactive bladder for several years and is widely used as the first line of treatment. Tolterodine is a recently introduced antimuscarinic agent, which has a lower affinity for muscarinic receptors in the salivary glands. Data suggest that this drug is better tolerated and associated with a higher compliance than oxybutinin.³⁶ For all antimuscarinic drugs, the dosage must be titrated depending on the subjective response and side effects, and each should be given for at least six weeks. The patient should be warned that overactive bladder is a relapsing and remitting condition and that treatment should be adjusted accordingly.

Neuromodulation
During the 1990s, sacral neuromodulation began to develop as a new therapy. The exact mechanism of action is not known, but activation of the spinal interneurones or  adrenergic neurones, which inhibit bladder activity, has been postulated. All patients must tested by stimulation of the S3 sacral nerve before they can be offered chronic stimulation with an implanted system. Around half of the patients respond favourably to the test, although treatment fails in 20-33% within 1-1.5 years of receiving the implant.³⁷ Durable success has, however, been reported in 60% of patients at five years.³⁸ Chronic stimulation of the sacral nerve may be associated with surgical morbidity, such as pain at the site of the electrodes or the neurostimulator, electrode migration, and infections from the implant. Hardware problems include broken electrodes, isolation defects, and battery exhaustion.

Surgery
The management of detrusor instability is mainly non-surgical. It is, however, a difficult condition to treat, and there are women who respond poorly to bladder retraining and pharmacological therapies. Surgery has a role in these women and should be done only as a last resort.

Ileocystoplasty (clam cystoplasty)
Ileocytoplasty (clam cystoplasty) involves anastomosis of about 25 cm of ileum on its vascular pedicle on to the bladder after the bladder has been cut along the coronal plane, thus increasing capacity with reduced activity during filling. A success rate of 53% has been reported.³⁹ Because of the problems encountered with the use of gastrointestinal segments, many investigators have tried alternative methods, materials, and tissue for bladder repair or replacement. Among these are autoaugmentation, ureterocystoplasty, methods for tissue expansion, seromuscular grafts, matrices for tissue regeneration, and tissue engineering by cell transplantation.⁴⁰

	Overflow incontinence

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

Chronic urinary retention with resultant overflow incontinence is uncommon in women. The causes include antispasmodic drugs, continence surgery, obstruction, psychosis, and neurological or inflammatory conditions. If there is outflow obstruction, urethral dilation or urethrotomy may be required. Treatment includes clean intermittent self catheterisation or a suprapubic catheter and management of the underlying cause.

	Other causes

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

Women with urinary fistulae (ureterovaginal, vesicovaginal, urethrovaginal) often complain of uncontrollable, continuous urinary leakage, which usually occurs after pelvic surgery, advanced pelvic malignancy, or radiotherapy. A small recent fistula may heal spontaneously if urine is diverted from the fistulous tract. If a fistula is diagnosed within 48 hours of surgery, and if there is no major inflammatory reaction or necrosis about the fistula, immediate reoperation and repair should be considered. If inflammation is present then treatment should be interim continuous bladder drainage.

	Conclusion

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

Incontinence causes distress, embarrassment, and inconvenience. It remains one of the last social taboos. Women should be encouraged to seek help early and to discuss their problems openly. Recently, the NHS has issued guidance on the provision of continence services.⁴¹ The guidance emphasises both the need for primary care to have a larger role (at practice and primary care group levels), with increased emphasis on more efficient services delivering improved health care.

	Footnotes

   Competing interests: None declared.

	References

Top Methods General measures Genuine stress incontinence Overactive bladder (detrusor... Overflow incontinence Other causes Conclusion References

1.	Abrams PH, Blaivis JG, Stanton SL, Anderson JT. Standardization of terminology of the lower urinary tract function. Neurourol Urodyn 1988; 7: 403-427.
2.	Continence Foundation. Making the case for investment in an integral continence service: a source book for continence services London: CF, 2000.
3.	Perry S, Assassa RP, Dallosso H, Shaw C, Williams K, Uzman U, et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: the Leicestershire MRC incontinence study. J Public Health Med 2000; 22: 3[Free Full Text].
4.	Royal College of Physicians. Incontinence: causes, management and provision of services. Report of working party. London: RCP, 1995.
5.	Norton C. Commissioning comprehensive continence services, guidance for purchasers. London: Continence Foundation, 1996.
6.	Seim A, Silvertsen B, Eriksen BC, Hunkskaar S. Treatment of urinary incontinence in women in general practice: observational study. BMJ 1996; 312: 1459-1462[Abstract/Free Full Text].
7.	O'Brien J, Long H. Urinary incontinence: long term effectiveness nursing intervention in primary care. BMJ 1995; 311: 1208[Free Full Text].
8.	Fantl JA, Cardozo L, McClish DK. Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis. First report of the hormones and urogenital therapy committee. Obstet Gynecol 1994; 83: 12-18[Abstract/Free Full Text].
9.	Cammu H, Van Nylen M. Pelvic floor exercises in genuine urinary stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1997; 8: 297-300[Medline].
10.	Cammu H, Van Naylen M. Pelvic floor muscle exercises: 5 years later. Urology 1995; 38: 332-337[CrossRef].
11.	Bo K, Talseth T. 5 year follow-up of pelvic floor exercises for treatment of stress incontinence. Clinical and urodynamic assessment. Neurourol Urodyn 1994; 13: 374-375.
12.	Peattie AB, Plevnik S, Stanton SL. Vaginal cones: a conservative method of treating genuine stress incontinence. Br J Obstet Gynaecol 1988; 95: 1049-1053[Medline].
13.	Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999; 318: 487-493[Abstract/Free Full Text].
14.	Pieber D, Zivkovic F, Tamussino K, Ralph G, Lippitt G, Fauland B. Pelvic floor exercise alone or with vaginal cones in the treatment of mild to moderate stress urinary incontinence in pre-menopausal women. Int Urogynecol J Pelvic Floor Dysfunct 1995; 6: 14-17.
15.	Sand PK, Richardson DA, Staskin DR, Swift SE, Appell RA, Whitmore KE, et al. Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial. Am J Obstet Gynecol 1995; 173: 72-79[Medline].
16.	Davilla DW, Neal D, Horbach N, Peacher J, Doughtie JD, Karram M. A bladder-neck support prosthesis for women with stress and mixed incontinence. Obstet Gynecol 1999; 93: 938-942[Abstract/Free Full Text].
17.	Staskin D, Bavemdam T, Miller J, Davilla GW, Diokno A, Knapp P, et al. Effectiveness of a urethral control insert in the management of stress urinary incontinence. Urol 1996; 47: 629-636.
18.	Tincello DG, Adams EJ, Bolderson J, Richmond DH. A urinary control device for management of female stress incontinence. Obstet Gynecol 2000; 95: 417-420[Abstract/Free Full Text].
19.	Jarvis GJ. Surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994; 101: 371-374[Medline].
20.	Jarvis GJ. Surgical treatment of incontinence in adult women. In: Abrams P, Saad K, Wein A, eds. Incontinence. St Helier, NJ: Health Publications, 1999:637-656.
21.	Gorton E, Stanton SL, Monga A, Wiskind A, Lentz G, Bland D. Periurethral collagen injections: long term follow-up. Br J Urol 1999; 84: 966-971.
22.	Burch JC. Urethro-vaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele and prolapse. Am J Obstet Gynecol 1961; 81: 281-290[Medline].
23.	Su TH, Wang KG, Hsu CY, Wei HJ, Hong BK. Prospective comparison of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence. Acta Obstet Gynecol Scand 1997; 76: 576-582[Medline].
24.	Burton G. A five year prospective randomised urodynamic study comparing open and laparoscopic colposuspension. Neurourol Urodyn 1999; 18: 295-296.
25.	Ulmsten U, Johnson P, Rezapour M. A three-year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence. Br J Obstet Gynaecol 1999; 106: 345-350[Medline].
26.	Elliott DS, Barrett DM. Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases. J Urol 1998; 159: 1206-1208[Medline].
27.	Elliott DS, Barrett DM. The artificial urinary sphincter in the female: indications for use, surgical approach and results. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9: 409-415[Medline].
28.	Carson CC. Infections in genitourinary prostheses. Urol Clin North Am 1989; 16: 139-147[Medline].
29.	Sifo Research and Consulting AB. A multinational tracking survey on overactive bladder problem. Stockholm: Sifo Research and Consulting, 1998.
30.	Karram MM. Detrusor instability and hyperreflexia. In: Walters MD, Karram MM, eds. Urogynecology and reconstructive pelvic surgery 2nd ed. London: Mosby, 1999.
31.	Ferrie BG, Smith JS, Logan D, Lyle R, Paterson PJ. Experience with bladder training in 65 patients. Br J Urol 1984; 56: 482-484[Medline].
32.	Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998; 280: 1995-2000[Abstract/Free Full Text].
33.	Cardozo LD, Abrams PD, Stanton SL, Feneley RC. Idiopathic bladder instability treated by biofeedback. Br J Urol 1978; 50: 521-523[Medline].
34.	Eriksen BC, Bergman S, Eiknes SH. Maximal electrical stimulation of the pelvic floor in female detrusor instability and urge incontinence. Neurourol Urodyn 1989; 8: 219-230.
35.	Brubaker L, Benson JT, Bent A, Clark A, Shott S. Transvaginal electrical stimulation for female urinary incontinence. Am J Obstet Gynecol 1997; 177: 536-540[CrossRef][Medline].
36.	Appell RA. Clinical efficacy and safety of tolterodine in the treatment of overactive bladder: a pooled analysis. Urology 1997; 50: 90-99[CrossRef][Medline].
37.	Bosch JLHR. Sacral neuromodulation in the treatment of the unstable bladder. Curr Opin Urol 1998; 8: 287-291[CrossRef][Medline].
38.	Bosch JLHR, Groen J. Seven years experience with sacral (S3) segmental nerve stimulation in patients with urge incontinence due to detrusor instability or hyperreflexia. Neurourol Urodyn 1997; 16: 426-427. (Abstract 56.)
39.	Awad SA, Al-Zahrani HM, Gajewski JB, Bourque-Kehoe AA. Long-term results and complications of augmentation ileocystoplasty for idiopathic urge incontinence in women. Br J Urol 1998; 81: 569-573[Medline].
40.	Atala A. New methods of bladder augmentation. Br J Urol 2000; 85(suppl 3): 24-34.
41.	Good practice in continence services. London: Department of Health, 2000.

(Accepted 30 August 2000)