Management of urinary incontinence in womenBMJ 2000; 321 doi: http://dx.doi.org/10.1136/bmj.321.7272.1326 (Published 25 November 2000) Cite this as: BMJ 2000;321:1326
- Ranee Thakar, trainee in urogynaecology (, )
- Stuart Stanton, professor
- Correspondence to: R Thakar
- Accepted 30 August 2000
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
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.
Urinary incontinence affects 20% of women over the age of 40
It affects the quality of life and causes a financial burden to the NHS
Emphasis must be placed on primary health care as many patients can be managed at this level, thus ensuring appropriate referral to hospital
The main causes of urinary incontinence are urethral sphincter incompetence and an overactive bladder
Urodynamic studies are reserved for when conservative treatment has failed, surgery is intended, or voiding difficulties or neuropathy is present
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.
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
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 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
Vaginal cones (fig 2) are useful adjuncts to pelvic floor exercises. These graduated cone shaped appliances weigh between 20 and 100 g, and are retained by passive and active contraction of the pelvic floor when individually introduced into the vagina. The cones are useful for making women aware of their pelvic floor muscles, and graduation to the next weight lets them know that they are making progress. A 70% cure or improvement rate was reported after one month's training in cone use, with a highly significant correlation between urine loss and increase in weight of retained cones.12 No important side effects have been found.
In a single blind, randomised study, however, pelvic floor exercises alone were superior to both vaginal cones and electrical stimulation.13 In the only trial that has compared pelvic floor exercises with vaginal cones with pelvic floor exercises alone, the improvement rates in both groups were virtually identical.14
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
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 prosthesis—a 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
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.
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 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 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.
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.
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)
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.
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 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
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.
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.
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 βadrenergic 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.
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
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.
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.
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.
Conflict of interest None declared.