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Urinary incontinence in women

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Updated 2024 EAU and 2024 CUA guidelines for the diagnosis and management of urinary incontinence in women.

Background

Overview

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 (α-adrenergic agonists, α-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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Guidelines

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 Canadian Urological Association (CUA 2024), the European Association of Urology (EAU/EAUN 2024), 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 ...
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Diagnostic investigations

History and physical examination: as per EAU/EAUN 2024 guidelines, elicit a complete medical history, including symptoms and comorbidities, and perform a focused physical examination in female patients with LUTS, including UI. Perform a standardized cough stress test in all female patients presenting with stress UI.
A
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  • Laboratory tests

  • Post-void residual volume

  • Urodynamic studies

  • Urinary tract imaging

  • Urinary biomarkers

Diagnostic procedures

Cystoscopy: as per CUA 2024 guidelines, do not perform cystoscopy routinely in the index patient with stress UI.
D
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Medical management

General principles: as per EAU/EAUN 2024 guidelines, use a shared decision-making approach when deciding on appropriate treatment for stress UI.
A
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  • Duloxetine

  • Anticholinergics and beta-3 agonists

  • Vaginal estrogen

  • Systemic estrogen

  • Management of asymptomatic bacteriuria

  • Management of constipation

  • Management of fall risk

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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  • Smoking cessation

  • Weight loss

  • Bladder training

  • Pelvic floor muscle training

  • Mechanical devices

Therapeutic procedures

Urethral bulking agent injections: as per CUA 2024 guidelines, consider offering periurethral bulking agents as a less invasive treatment option in selected patients with mild-to-moderate-volume stress UI.
C

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  • Vaginal electrical stimulation

  • Vaginal laser therapy

  • Ttibial nerve electrical stimulation

Perioperative care

Preoperative counseling: as per CUA 2024 guidelines, engage in shared decision-making and offer appropriate conservative and surgical options in patients of childbearing age.
E
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Surgical interventions

Indications for surgery
As per EAU/EAUN 2024 guidelines:
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

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  • Mid-urethral slings

  • Autologous fascial slings

  • Retropubic colposuspension

  • Artificial urinary sphincter

  • Adjustable compression device

  • Excision of urethral diverticulum

Follow-up and surveillance

Management of postoperative voiding difficulties
As per CUA 2024 guidelines:
Perform catheterization for 1-2 days and conduct a repeat trial of void for the management of postoperative urinary retention following female stress UI surgery. Perform early sling loosening (within 1 week) or sling incision (at 4-6 weeks) when possible in patients with continued postoperative urinary retention.
E
Consider offering a sling incision in selected patients with overactive bladder following sling surgery, including patients with bladder outlet obstruction or refractory overactive bladder symptoms.
C

More topics in this section

  • Management of postoperative recurrent UTIs

  • Management of recurrent UI