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Urinary incontinence in women

Definition
UI is defined as involuntary or abnormal leakage of urine.
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Pathophysiology
UI has multiple possible causes, including age-related functional changes (overactive detrusor, impaired bladder contractility, decreased pressure in urethra closure, atrophy of urethral areas, prostatic hypertrophy), lesions in the CNS, excess urine output, restricted mobility, stool impaction, UTI, delirium, and medications (alpha-adrenergic agonists, alpha-adrenergic antagonists, anticholinergics, cancer drugs, calcium-channel blockers, diuretics, opiates, sedatives).
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Epidemiology
The prevalence of any symptom UI is high in the adult population, with an estimated age-standardized prevalence of 51.1% in women and 13.9%, in men respectively.
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Disease course
Clinical manifestations include urine leakage and, depending on the etiology, associated LUTS of urgency, frequency, nocturia, weak urination, and incomplete emptying associated.
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Prognosis and risk of recurrence
UI is a predictor of death in the general population and geriatric population. UI is associated with psychological morbidity and may lead to substantial impairment of QoL.
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Key sources
The following summarized guidelines for the evaluation and management of urinary incontinence in women are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the American Physical Therapy Association (APTA 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021; 2020; 2017; 2014), the American Academy of Family Physicians (AAFP 2019), and the American College of Physicians (ACP 2014).
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Guidelines

1.Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, elicit a full clinical history and perform a thorough physical examination, including the standardized cough stress test, in all female patients presenting with stress UI. Elicit a thorough history and perform a physical examination as part of the assessment of mixed UI.
A
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  • Laboratory tests

  • Post-void residual volume

  • Urodynamic studies

  • Urinary tract imaging

2.Diagnostic procedures

Cystoscopy: consider performing cystoscopy in female patients with hematuria or refractory and/or complicated UI symptoms.
C

3.Medical management

General principles: as per APTA 2023 guidelines, counsel patients about the improved outcomes when medications are combined with pelvic health rehabilitation for urgency UI, urinary urgency, and/or urinary frequency.
B

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  • Duloxetine

  • Anticholinergics and beta-3 agonists

  • Vaginal estrogen

  • Systemic estrogen

  • Management of constipation

  • Management of fall risk

4.Nonpharmacologic interventions

Behavioral modifications
As per APTA 2023 guidelines:
Offer behavioral interventions, including dietary and fluid modification and urge suppression techniques, to improve symptoms of urgency UI, urinary urgency, and/or urinary frequency.
B
Consider offering mindfulness-based stress reduction to reduce symptoms of urgency UI, urinary urgency, and/or urinary frequency.
C

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  • Weight loss

  • Bladder training

  • Pelvic floor muscle training

  • Mechanical devices

5.Therapeutic procedures

Urethral bulking agent injections: offer urethral bulking agent injection in female patients seeking surgical treatment for stress UI following a thorough discussion of the risks and benefits relative to other surgical modalities.
A
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  • Vaginal electrical stimulation

  • Vaginal laser therapy

  • Ttibial nerve electrical stimulation

6.Surgical interventions

Indications for surgery, indications, EAU
Offer different surgical procedures, where appropriate, and discuss the advantages and disadvantages of each approach in patients who have explored/failed conservative management options.
A
Counsel female patients with UI regarding the following:
increased risks associated with surgery, together with the lower probability of benefit, in elderly patients and in patients with obesity
B
surgery for mixed UI is less likely to be successful than surgery for stress UI alone
A
one single treatment may not cure mixed UI and it may be necessary to treat other components of the incontinence problem as well as the most bothersome symptom.
B

More topics in this section

  • Indications for surgery (choice of technique)

7.Follow-up and surveillance

Management of recurrent urinary incontinence
As per EAU 2023 guidelines:
Decide on the choice of surgery for recurrent stress UI based on careful evaluation, including individual patient factors and further investigations, such as cystoscopy and multichannel urodynamics as appropriate.
A
Inform patients with recurrent stress UI that the outcome of a surgical procedure, when used as second-line therapy, is generally inferior to its use as first-line therapy, both in terms of reduced efficacy and increased risk of complications.
B