Evaluation of Women With Urinary Incontinence

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Evaluation of wom en with urinary incontinence

Official reprint from UpT UpToDate® www.uptodate.com   ©2016 UpToDate® www.uptodate.com

Evaluation of women with urinary incontinence Author  Author  Emily S Lukacz, MD, MAS

Section Editors Linda Brubaker, MD, FACS, FACOG Kenneth E Schmader, MD

Deputy Editors Lee Park, MD, MPH Kristen Eckler, MD, FACOG

 All topics topics are upda updated ted as new eviden evidence ce becomes becomes available available and our our peer review process  process   is comple complete. te. Literature review current current through: Feb 2016. | This topic last updated: Mar 14, 2016. INTRODUCTION   — Urinary incontinence, the involuntary leakage of urine, often remains undetected and undertreated [ 1-3 1-3]. ]. It is estimated that between 26 and 61 percent of community-dwelling women seek care for urinary incontin ence [4-6 4-6]. ]. Patients may be reluctant to initiate discussions about their incontinence and urinary symptoms due to embarrassment, lack of knowledge about treatment options, and/or fear of surgery.

This topic will review the epidemiology, risk factors, etiology, and initial ev aluation aluation of the non-pregnant woman with urinary incontinence. The treatment of urinary incontinence in women and urinary incontinence in pregnant women and in men are discussed separately . (See (See "Treatment of urinary incontinence in women" and and "Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth"   and "Urinary incontinence in men".) men" .) IMPACT ON HEALTH  — Urinary incontinence is not associated with increased mortality [ 7]. However, incontinence can impact many other aspects of a patient's health.

● Quality of life – Urinary incontinence is associated with depression and anxiety, work impairment, and social isolation [ 8-12 8-12]. ]. Urinary incontinence has been demonstrated to adversely impact quality of life even in nursing home residents [ 13 13]. ]. ● Sexual dysfunction – Incontinence during sexual activity (coital incontinence), which may affect affect up to one-third of all incontinent individuals, and fear of  incontinence during sexual activity both contribute to incontinence-related sexual dysfunction [ 14 14]. ]. Urgency incontinence had greater negative impact on sexual function compared with urgency or frequency without incontinence incontinence [15,16 [ 15,16]. ]. ● Morbidity  – The medical medical morbidity associ associated ated with urinary incontinence includes incontinence  includes perineal perineal infections from from moisture and irritation (eg, candida or cellulitis) and falls and fractures [17 [ 17]. ]. ● Increased caregiver burden  – Incontinence in older persons is associated with increased caregiver burden [ 18 18]. ]. Six to 10 percent of nursing home admissions in the the United States Stat es are attributable to urinary incontinence [ 19 19]. ]. EPIDEMIOLOGY Prevalence — Urinary incontinence is common in women, particularly in pregnancy. Urinary incontinence in pregnancy is discussed separately. (See "Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth" .)

Estimates of prevalence vary depending on the population studied and the instruments used to assess severity. Weekly urine leakage has been reported in 10 percent of women in an ethnically-diverse United States urban population and 16 percent of non-pregnant women ≥20 years in a nationally representative sample

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Evaluation of wom en with urinary incontinence

[20,21 20,21]. ]. In a large United States health maintenance organization, among women aged 25 to 84 years, bothersome stress urinary incontinence (SUI) was reported in 15 percent of women and urgency incontinence/overactive bladder in 13 percent [ 22 22]. ]. Other surveys have reported prevalences of any urinary incontinence from 13 percent in nulligravid women aged 16 to 30 years to 17 percent in non-pregnant women aged ≥20 years [ 23,24 23,24]. ]. The prevalence of urinary incontinence increases with age and is particularly high for individuals living in nursing homes, with rates ranging from 43 to 77 percent [25,26 25,26]. ]. Urinary incontinence is also common in persons with cognitive impairment/dementia, with the prevalence ranging from 10 to 38 percent [ 27 27]. ]. Not all women who develop urinary incontinence will have symptoms indefinitely. In a longitudinal cohort study of 4127 middle-aged women, the annual incidence rate of urinary incontinence was 3.3 percent and the annual remission rate was 6.2 percent [ 28 28]. ]. Factors associated with persistent symptoms (ie, no resolution) were weight gain and transition to menopausal status. Risk factors — Risk factors for urinary incontinence include [26,29-33 [26,29-33]: ]:

● Obesity – Obesity is the strongest risk factor for incontinence. Obese women have a nearly threefold increased odds of urinary incontinence compared with non-obese women [ 21,29,34,35 21,29,34,35]. ]. Weight reduction is associated with improvement and resolution of urinary incontinence, particularly SUI. Several observational studies have reported a 50 percent or greater reduction in SUI after bariatric-surgery induced weight loss [ 36-38 36-38]. ]. ● Parity – Increasing parity is a risk factor for urinary incontinence and pelvic organ prolapse [ 33,39 33,39]. ]. (See "Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth", section on 'Prevalence in parous women' .) ● Mode of delivery  – Compared with women who have had a cesarean section, women who have had a vaginal delivery are at higher risk for stress incontinence. However, cesarean delivery does not protect women from urinary incontinence. The relationship between urgency incontinence/overactive bladder and mode of delivery is less certain. (See "Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth", section on 'Mode of delivery'.) delivery' .) ● Family history – The risk of urinary incontinence, particularly urgency incontinence, may be higher in patients with a family history. One study found that the risk of incontinence was increased for both daughters (relative risk [RR] 1.3, 95% CI 1.2-1.4) and sisters (RR 1.6, 95% CI 1.3-1.9) of women with incontinence [32 [ 32]. ]. Twin studies attribute a 35 to 55 percent genetic contribution to urgency incontinence/overactive bladder but only 1.5 percent for stress incontinence [40,41 [ 40,41]. ]. ● Age  – Both the prevalence and severity of urinary incontinence increase with age [ 21,23,42 21,23,42]. ]. In a large representative United States survey of non-pregnant women, urinary incontinence was reported to affect 3.5 percent of women ages 20 to 29, increasing to 38 percent of women age ≥80 years [ 23 23]. ]. One-third of  women in the Nurse's Health Study (aged 54 to 79 years) who reported urine leakage once monthly at baseline progressed to leaking at least once a week over two-year follow-up [43 [ 43]. ]. However, studies controlling for other comorbid conditions suggest that age alone may not be an independent risk factor for  incontinence [22 [ 22]. ]. ● Ethnicity/race  – The prevalence of urinary incontinence by race or ethnicity in women has been variably reported. Some studies report higher prevalence in non-Hispanic white women compared with African American women [ 20,23,44-46 20,23,44-46]. ]. Other studies do not report differences between racial/ethnic groups [21,47,48 21,47,48]. ]. ● Others – Smoking has also been associated with an increased risk of incontinence [ 49,50 49,50]. ]. Other suggested risk factors include caffeine intake, diabetes,

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Evaluation of women with urinary incontinence

stroke, depression, fecal incontinence, vaginal atrophy, hormone replacement therapy, genitourinary surgery (eg, hysterectomy), and radiation [ 1,34,45,51-58]. Stress incontinence has been associated with participation in high-impact activities, including jumping and running [ 59,60]. Additional risk factors for urgency incontinence include impaired functional status, recurrent urinary tract infections, and bladder symptoms in childhood, including childhood enuresis [ 61,62]. ETIOLOGY  — Continence depends upon both intact micturition physiology (including lower urinary tract, pelvic, and neurologic components ( figure 1)) as well as an intact functional ability to toilet oneself. (See "Anatomy and localization of spinal cord disorders", section on 'Autonomic fibers' .) Classification   — The main types of urinary incontinence are stress, urgency, and overflow incontinence. Many women have features of more than one type [ 63,64]. Identifying the classification of incontinence helps guide therapy. (See "Treatment of urinary incontinence in women" .) Stress incontinence — Individuals with stress incontinence have involuntary leakage of urine that occurs with increases in intra-abdominal pressure (eg, with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction [ 39,65,66]. Stress incontinence is the most common type in younger women, with the highest incidence in women ages 45 to 49 years [ 42,61,67].

Mechanisms of stress incontinence include urethral hypermobility and intrinsic sphincteric deficiency (ISD). ● Urethral hypermobility is thought to stem from insufficient support of the pelvic floor musculature and vaginal connective tissue to the urethra and bladder  neck [68]. This causes the urethra and bladder neck to lose the ability to completely close against the anterior vaginal wall. With increases in intra-abdominal pressure (eg, from coughing or sneezing) the muscular tube of the urethra fails to close, leading to incontinence (like stepping on a hose in sand). Insufficient urethral support may be related to loss of connective tissue and/or muscular strength due to chronic pressure (ie, high-impact activity, chronic cough, or obesity) or trauma due to childbirth, particularly vaginal deliveries. Childbirth can cause trauma directly to the pelvic muscles and may also damage nerves leading to pelvic muscle dysfunction. Treatments for hypermobility stress incontinence are aimed at providing a backboard of support for the urethra. (See "Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth", section on 'Mechanisms of pelvic floor injury'   and "Treatment of urinary incontinence in women" .) ● Intrinsic sphincteric deficiency (ISD) is another form of stress urinary incontinence (SUI) that results from a loss of urethral tone that normally keeps the urethra closed. This can occur in the presence or absence of urethral hypermobility and typically results in severe urinary leakage even with minimal increases in abdominal pressure. In general, ISD results from neuromuscular damage and can be seen in women who have had multiple pelvic or incontinence surgeries. It is challenging to treat women with ISD, and they have worse surgical outcomes [ 69,70]. (See "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure", section on 'Lack of urethral hypermobility and intrinsic sphincter deficiency' .) Urgency incontinence  — Women with urgency incontinence experience the urge to void immediately preceding or accompanied by involuntary leakage of urine [62,65]. The amount of leakage ranges from a few drops to completely soaked undergarments. "Overactive bladder" is a term that describes a syndrome of urinary urgency with or without incontinence, which is often accompanied by nocturia and urinary frequency [ 62,65]. The terms "urgency incontinence" and "overactive bladder with incontinence" are often used interchangeably.

Urgency incontinence is more common in older women and may be associated with comorbid conditions that occur with age [ 71,72]. It is believed to result from detrusor overactivity, leading to uninhibited (involuntary) detrusor muscle contractions during bladder filling [ 62]. This may be secondary to neurologic disorders (eg, spinal cord injury), bladder abnormalities, or may be idiopathic [ 62]. The prevalence of involuntary detrusor contractions, or detrusor overactivity, has been found in

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Evaluation of women with urinary incontinence

21 percent of healthy, continent, community-dwelling elderly [ 73]. (See "Chronic complications of spinal cord injury and disease", section on 'Urinary complications' .) Mixed incontinence  — Women with symptoms of both stress and urgency incontinence are described as having mixed incontinence [ 65,74]. Overflow incontinence — Overflow incontinence typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying.  Associated symptoms can include weak or intermittent urinary s tream, hesitancy, frequency, and nocturia. When the bladder is very full, stress leakage can occur  or low amplitude bladder contractions can be triggered resulting in symptoms similar to stress or urgency incontinence.

Overflow incontinence is caused by detrusor underactivity or bladder outlet obstruction. ● Detrusor underactivity – Detrusor underactivity may be caused by impaired contractility of the detrusor muscle [ 72]. Impaired urothelial sensory function may also contribute. Studies suggest that detrusor contractility and efficiency decrease with age [ 75]. Severe detrusor underactivity occurs in about 5 to 10 percent of older adults [72,76]. Other etiologies of detrusor underactivity include smooth muscle damage, fibrosis, low estrogen state, peripheral neuropathy (due to diabetes mellitus, vitamin B12 deficiency, alcoholism), and damage to the spinal detrusor efferent nerves by pathologies affecting the spinal cord (eg, multiple sclerosis, spinal stenosis) [77,78]. (See "Disorders affecting the spinal cord" .)  A subset of women with t his condition can have detrusor hyperactivity with impaired contractility (DHIC). With DH IC, the bladder does not effectively c ontract to empty and also has low amplitude hyperactivity, resulting in urgency as well as overflow incontinence. DHIC is particularly difficult to treat as any therapy for overactivity results in increased urinary retention and overflow incontinence. ● Bladder outlet obstruction – Bladder outlet obstruction in women is generally caused by external compression of the urethra. This occurs with fibroids, advanced pelvic organ prolapse (ie, beyond the hymen), or overcorrection of the urethra from prior pelvic floor surgery. Less common causes include external masses or tumors at the level of the bladder outlet or uterine incarceration of a retroverted uterus (which can occur in pregnancy or in the setting of fibroids). (See "Pelvic organ prolapse in women: An overview of the epidemiology, risk factors, clinical manifestations, and management"   and "Incarcerated gravid uterus".) Other contributing factors/conditions — Other etiologies for urinary incontinence include other urologic or gynecologic disorders, systemic diseases, and potentially reversible causes (eg, medications).

● Vaginal atrophy  – In postmenopausal women, low estrogen levels result in atrophy of the superficial and intermediate layers of the urethral mucosal epithelium. Atrophy results in urethritis, diminished urethral mucosal seal, loss of compliance, and possible irritation, all of which can contribute to incontinence. (See "Clinical manifestations and diagnosis of vaginal atrophy", section on 'Pathophysiology' .) ● Other urologic/gynecologic disorders  – Other less common urologic or gynecologic disorders that can cause urinary incontinence include urogenital fistulas, urethral diverticula, and ectopic ureters. (See "Urogenital tract fistulas in women".) ● Systemic causes – Patients who have underlying medical conditions that contribute to urinary incontinence will also have other characteristic features or  relevant history. • Neurologic disorders  – Spinal cord disorders can lead to overflow incontinence as discussed above. Other examples of neurologic disorders that can lead to urinary incontinence include: stroke, Parkinson disease, and normal pressure hydrocephalus. (See "Medical complications of stroke"   and "Clinical manifestations of Parkinson disease"   and "Normal pressure hydrocephalus".)

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Evaluation of women with urinary incontinence

Overflow incontinence and poor urinary stream can be present in patients with diabetic autonomic neuropathy. (See "Diabetic autonomic neuropathy" .) • Cancer   – Less common systemic causes of urinary incontinence include bladder cancer or invasive cervical cancer. (See "Clinical presentation, diagnosis, and staging of bladder cancer"   and "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.) ● Potentially reversible causes – Potentially reversible causes of or contributors to urinary incontinence include medications ( table 1), alcohol and caffeine intake, constipation/stool impaction, and urinary tract infection (UTI). UTI may cause or worsen urinary incontinence. Women with UTI may have more incontinence not only during the episode but also immediately following the UTI [ 79]. (See "Acute uncomplicated cystitis and pyelonephritis in women", section on 'Clinical suspicion'.) ● Functional incontinence – Functional incontinence occurs when a patient has intact urinary storage and emptying functions but is physically unable to toilet herself in a timely fashion. This appears to be a common contributor to urinary incontinence for older women. As an example, in one study that included 177 women aged 57 to 85 years with daily urinary incontinence, 62 percent reported at least one functional disability or dependence and 24 percent reported specific difficulty or dependence with using the toilet [ 80]. Such functional incontinence may be reversible in the setting of modifiable factors (eg, decreased mobility postsurgery, decreased manual dexterity, and change in cognitive or mental status from sedation from medications) [ 65,81,82]. ● Cognitive impairment  – The association between cognitive impairment and incontinence is in part mediated by functional impairment and disability [ 83]. Comorbid conditions and medications also often contribute. EVALUATION  — The initial evaluation of urinary incontinence includes characterizing and classifying the type of incontinence, identifying underlying conditions (eg, neurologic disorder or malignancy) that may manifest as urinary incontinence, and identifying potentially reversible causes of incontinence ( algorithm 1) [84-86].

The evaluation should start with a thorough history, physical examination, and urinalysis [ 61,85]. Additional evaluation is warranted in the presence of complex medical conditions or concerning findings on history and/or physical examination. History — Many patients are reluctant to initiate a discussion about their incontinence. Women who have comorbid conditions associated with increased risk (eg, prolapse, bowel leakage, diabetes, obesity, neurologic disease) and those who are over 65 years of age should specifically be asked about urinary incontinence [ 87].

The history further clarifies the patient's urinary symptoms and severity and identifies potential underlying causes that may be treatable or require further evaluation [65]. Classifying the type of incontinence helps direct treatment ( algorithm 1). (See "Treatment of urinary incontinence in women" .) ● Classifying incontinence – Symptoms of incontinence and classification can be elicited using short standardized questionnaires. The three incontinence questionnaire (3IQ) (form 1) can help distinguish between stress, urgency, and mixed incontinence [ 88]. In a multicenter study of 300 middle-aged women with moderate incontinence, the 3IQ had a sensitivity of 0.75 and specificity of 0.77 for identifying urgency incontinence and a sensitivity of 0.86 and specificity of  0.60 for stress incontinence [ 88]. Relevant urinary symptoms include frequency, volume, severity, hesitancy, precipitating triggers, nocturia, intermittent or slow stream, incomplete emptying, continuous urine leakage, and straining to void [ 62]. Symptom clusters are associated with specific voiding abnormalities. As examples: • Stress urinary incontinence (SUI) is associated with urine loss with increases in intra-abdominal pressure, such as occurs with laughing, coughing, or  sneezing. Urine volume lost may be small or large. There is no urge to urinate prior to the leakage.

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Evaluation of women with urinary incontinence

• Urgency incontinence/overactive bladder is associated with frequent, small volume voids that may keep the patient up at night or worsen after taking a diuretic. The patient has a strong urge to void with an inability to make it to the bathroom in time. • Overflow incontinence due to detrusor muscle underactivity is characterized by the painless loss of urine with no warning or triggers. The volume leaked may be small or large. Urine loss often occurs with changes in position. This may be associated with urinary hesitancy, slow flow, urinary frequency and nocturia. • Overflow incontinence due to urinary outlet obstruction, such as from pelvic organ prolapse, fibroids, or pelvic surgery, is often associated with an intermittent or slow stream, hesitancy (difficulty getting urine stream started), and a sensation of incomplete emptying. Women with obstruction often need to strain to pass their urine. ● Systemic symptoms – We evaluate all women with incontinence for urinary tract infection (UTI), asking about symptoms such as fever, dysuria, pelvic pain, and hematuria. (See "Acute uncomplicated cystitis and pyelonephritis in women", section on 'Clinical suspicion' .) Symptoms that are concerning for other underlying conditions as the cause of urinary incontinence include: sudden onset of incontinence, associated abdominal/pelvic pain or hematuria without urinary tract infection, changes in gait or new lower extremity weakness, cardiopulmonary or neurologic symptoms, and mental status changes. Women with these symptoms should have appropriate work-up and evaluation for underlying conditions and/or specialist referral if  necessary. (See 'Specialist referral'  below.) We also ask about changes in bowel function (eg, constipation). In older adults, we typically ask about and assess functional status, mobility, and cognitive status [65,81]. (See "Office-based assessment of the older adult" .) ● Medications  – Some medications (table 1) can contribute to urinary incontinence [ 82]. Alcohol and caffeine intake should be specifically elicited. ● Voiding diaries  – Voiding diaries are helpful in the assessment of urinary incontinence symptoms. One example, of a voiding diary can be found on the  American Urogynecologic Society website. While basic diary records of frequency and volume are neither sensitive nor specific for determining the cause of  incontinence [63,89], they may be helpful to determine if urinary incontinence is associated with high fluid intake. In addition, they provide a measure of the severity of the problem that can be followed over time. Voiding diaries also identify the maximum time interval that the woman can reasonably wait between voids, a measure used to guide bladder training. (See "Treatment of urinary incontinence in women", section on 'Bladder training' .) While most clinical studies use a three-day voiding diary to assess outcomes of treatment, we find better compliance with a 24-hour diary. Normal voiding frequency is less than eight times a day and once at night, with total volumes of less than 1800 mL per 24 hours [ 90,91]. ● Impact on quality of life – Clinicians should identify those symptoms that are most bothersome to the patient as this can help guide treatment. The impact of  the patient's incontinence on her quality of life can be assessed informally by asking a few targeted questions or by using a validated instrument (eg, International Consultation on Incontinence Questionnaire, Kings Health Questionnaire are available for evaluating impact of incontinence on quality of life) [ 92]. We use the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire [93]. The Patient Global Impression of Improvement (PGII) and Patient Global Impression of Severity (PGIS) (table 2) are also acceptable measures to assess improvement and satisfaction, respectively [ 94]. (See "Treatment of  urinary incontinence in women" .) Physical examination — All women presenting with incontinence need a pelvic examination with special attention to evaluate for vaginal atrophy, pelvic masses,

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Evaluation of women with urinary incontinence

and pelvic organ prolapse. The components of a detailed pelvic examination are discussed separately. (See "The gynecologic history and pelvic examination", section on 'Components of the examination'   and "Clinical manifestations and diagnosis of vaginal atrophy", section on 'Pelvic examination'   and "Pelvic organ prolapse in women: Diagnostic evaluation" .)  A detailed neurologic examination is not necessary in t he initial evaluation of all women with incontinence unless patients present with sudden onset of incontinence (especially urgency symptoms) or new onset of neurologic symptoms [ 84]. In patients where there is concern for neurologic disease, we perform a limited evaluation of lower extremity strength, reflexes, and perineal sensation. Unilateral weakness or hyperreflexia of the lower extremity may identify a upper motor lesion. Absent perineal sensation with decreased rectal tone is concerning for cauda equina syndrome. (See "The detailed neurologic examination in adults" .) Laboratory tests — A urinalysis should be performed in all patients, and urine culture performed if a urinary tract infection (UTI) is suggested on screening.

Urine cytology is indicated in patients without UTI who have gross hematuria or microscopic hematuria with risk factors for malignancy (eg, extensive smoking history). (See "Etiology and evaluation of hematuria in adults", section on 'Urine cytology'   and "Etiology and evaluation of hematuria in adults", section on 'Risk factors for malignancy'  and "Clinical presentation, diagnosis, and staging of bladder cancer" .) We do not routinely check renal function unless there is concern for severe urinary retention resulting in hydronephrosis [ 65]. Other laboratory testing is determined by signs or symptoms elicited on history and physical exam. Clinical tests — Only a few clinical tests are necessary for the initial evaluation of a woman with urinary incontinence as conservative treatment can be initiated based on symptoms alone. We do not obtain radiographic imaging for the initial evaluation in patients without complex neurologic conditions or abnormal findings on physical examination.

We check a bladder stress test as part of the initial workup of stress incontinence. Although in our subspecialty practice we routinely evaluate women with a postvoid residual (PVR) by either catheterization or bladder scan, this is not necessary in the initial evaluation of urinary incontinence by the general practitioner. Urodynamic testing is also not routinely performed initially but may be done prior to considering surgical therapies. (See "Surgical management of stress urinary incontinence in women: Preoperative evaluation for a primary procedure", section on 'Office testing'   and "Surgical management of stress urinary incontinence in women: Preoperative evaluation for a primary procedure", section on 'Urodynamic testing' .) ● Bladder stress test – In patients with suspected stress incontinence, we perform the bladder stress test to confirm the diagnosis. This test is performed with the patient in the standing position with a comfortably full bladder. While the examiner visualizes the urethra by separating the labia, the patient is asked to valsalva and/or cough vigorously. The clinician observes directly whether or not there is leakage from the urethra. This test may be difficult in women with mobility or cognitive impairments; these women may benefit from performing the test in the dorsal lithotomy position.  A pooled analysis of t hree studies demonstrated that a positive bladder stress test helps to confirm st ress leakage in women with stress or mixed incontinence [63]. A negative test is less useful because a false negative may result from a small urine volume in the bladder or from patient inhibition. ● Postvoid residual – Measuring the postvoid residual (PVR) is not required for initial therapy for stress or urgency urinary incontinence [ 65]. However, measuring the PVR can be helpful when diagnosis is uncertain, initial therapy is ineffective, or in patients where there is concern for urinary retention and/or  overflow incontinence. These patients include those with neurologic disease, recurrent urinary tract infections, history concerning for detrusor underactivity or  bladder outlet obstruction, history of urinary retention, severe constipation, pelvic organ prolapse beyond the hymen, new onset or recurrent incontinence after  surgery for incontinence, diabetes mellitus with peripheral neuropathy, or medications that suppress detrusor contractility or increase sphincter tone ( table 1)

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Evaluation of women with urinary incontinence

[85,95-97]. Parameters for interpreting the results of PVR testing are neither standardized nor well-evaluated. In general, a PVR of less than one-third of total voided volume is considered adequate emptying. Additional suggested parameters include a PVR of less than 50 mL as normal and a PVR greater than 200 mL as abnormal [91,98]. (See "Postoperative urinary retention in women", section on 'Spontaneous voiding trial' .) ● Urodynamic testing  – We do not routinely refer for urodynamic testing in the initial evaluation of urinary incontinence in women whose symptoms are consistent with stress, urgency or mixed, incontinence [ 99,100]. Urodynamic testing is invasive and is not necessary to initiate therapy. A 2013 systematic review of 99 studies including over 80,000 women found insufficient evidence to support the ability of urodynamic testing to predict the outcomes of  nonsurgical treatment for stress incontinence [ 101]. However, in women with suspected overflow incontinence (eg, underlying neurologic conditions, history of diabetes, or by symptom history), urodynamic testing may be indicated for further evaluation. Indications for urodynamic testing are discussed separately. (See "Urodynamic evaluation of women with incontinence".) ● Urethral mobility evaluation – Some subspecialists may evaluate for urethral hypermobility. This is discussed separately. (See "Surgical management of  stress urinary incontinence in women: Preoperative evaluation for a primary procedure", section on 'Assessing urethral mobility' .) Specialist referral — In a small number of cases, referral to a specialist is warranted for patients with urinary incontinence ( algorithm 1). Indications for referral include the presence of:

●  Associated abdominal or pelvic pain in the absence of urinary t ract infection ● Gross or microscopic hematuria with risk factors for malignancy in the absence of a urinary tract infection (see "Etiology and evaluation of hematuria in adults") ● Suspected vesicovaginal fistula or urethral diverticula on vaginal examination (see "Urogenital tract fistulas in women"   and "Urethral diverticulum in women") ● Other abnormal physical examination findings (eg, pelvic mass, pelvic organ prolapse beyond the hymen) (see "Pelvic organ prolapse in women: An overview of the epidemiology, risk factors, clinical manifestations, and management" ) ● New neurologic symptoms in addition to incontinence ● Uncertainty in diagnosis ● History of pelvic reconstructive surgery or pelvic irradiation ● Persistently elevated postvoid residual volume, after treatment of possible causes (eg, medications, stool impaction) ● Suspected overflow incontinence, particularly in the setting of underlying conditions (eg, neurologic conditions, diabetes) INFORMATION FOR PATIENTS  — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5 th to 6 th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education

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Evaluation of women with urinary incontinence

pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want indepth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) ● Basics topics (see "Patient information: Urinary incontinence (The Basics)"   and "Patient information: Neurogenic bladder in adults (The Basics)"   and "Patient information: Treatments for urgency incontinence in women (The Basics)" ) ● Beyond the Basics topics (see "Patient information: Urinary incontinence in women (Beyond the Basics)"   and "Patient information: Urinary incontinence treatments for women (Beyond the Basics)" ) Patients can be referred to incontinence patient advocacy groups. These groups can supply additional information about incontinence and its management, including links to product suppliers. Some useful resources are: ● National Association for Continence: 1-800-BLADDER (252-3337) ● Simon Foundation for Continence : 1-800-23SIMON (237-4666) SUMMARY AND RECOMMENDATIONS

● Urinary incontinence is common in women. Risk factors for urinary incontinence include obesity, parity, mode of delivery, older age, and family history. (See 'Epidemiology'  above.) ● The major clinical types of urinary incontinence are stress incontinence (leakage with maneuvers that increase intra-abdominal pressure), urgency incontinence (sudden urgency followed by leakage), mixed incontinence (symptoms of both stress and urgency), and overflow incontinence. "Overactive bladder" is a term that describes a syndrome of urinary urgency, with or without incontinence. (See 'Classification'  above.) ● Other etiologies for urinary incontinence in women include other less common urologic or gynecologic disorders (eg, urogenital fistulas, cancer), neurologic diseases (eg, multiple sclerosis), and potentially reversible causes (eg, medications ( table 1)). (See 'Etiology'   above.) ● The initial evaluation of urinary incontinence includes characterizing and classifying the type of incontinence, identifying underlying conditions (eg, neurologic disorder or malignancy) that may manifest as urinary incontinence, and identifying potentially reversible causes of incontinence ( algorithm 1). This evaluation includes a thorough history, physical examination, and urinalysis. (See 'Evaluation'  above.) • The history classifies and prioritizes the patient's urinary symptoms, as well as identifies other symptoms that indicate the need to evaluate further for  underlying causes of incontinence due to serious conditions or potentially reversible medical or functional conditions. (See 'History'  above.) • Women presenting with urinary incontinence should have a pelvic examination. A patient's history may suggest other components of the physical exam that are important in diagnosis. (See 'Physical examination'  above.) •  A urinalysis s hould be performed in all patients. If a urinary t ract infection is suspected, then a urine culture is obtained. (See 'Laboratory tests'  above.) •  A bladder stress test is used to diagnose st ress urinary incontinence (SUI). Postvoid residual volume and urodynamic t esting are not routinely performed.

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Evaluation of women with urinary incontinence

(See 'Clinical tests'  above.) ● Referral to a specialist is indicated in a small number of cases: incontinence with abdominal/pelvic pain or hematuria in the absence of urinary tract infection, suspected vesicovaginal fistula, abnormal physical examination findings (eg, pelvic organ prolapse), new neurologic symptoms in addition to incontinence or  suspected overflow incontinence. (See 'Specialist referral'  above.) ACKNOWLEDGMENT  — The editorial staff at UpToDate would like to acknowledge Catherine E DuBeau, MD, who contributed to an earlier version of this topic review.

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1. Abrams P, Cardozo L, Fall M, et al. The standardisation of t erminology of lower urinary t ract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21:167. 2. Mardon RE, Halim S, Pawlson LG, Haffer SC. Management of urinary incontinence in Medicare managed care beneficiaries: results from the 2004 Medicare Health Outcomes Survey. Arch Intern Med 2006; 166:1128. 3. Griffiths AN, Makam A, Edwards GJ. Should we actively screen for urinary and anal incontinence in the general gynaecology outpatients setting?--A prospective observational study. J Obstet Gynaecol 2006; 26:442. 4. Harris SS, Link CL, Tennstedt SL, et al. Care seeking and treatment for urinary incontinence in a diverse population. J Urol 2007; 177:680. 5. Hannestad YS, Rortveit G, Hunskaar S. Help-seeking and associated factors in female urinary incontinence. The Norwegian EPINCONT Study. Epidemiology of Incontinence in the County of Nord-Trøndelag. Scand J Prim Health Care 2002; 20:102. 6. Morrill M, Lukacz ES, Lawrence JM, et al. Seeking healthcare for pelvic floor disorders: a population-based study. Am J Obstet Gynecol 2007; 197:86.e1. 7. Herzog AR, Diokno AC, Brown MB, et al. Urinary incontinence as a risk factor for mortality. J Am Geriatr Soc 1994; 42:264. 8. Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 2008; 101:1388. 9. Yip SK, Cardozo L. Psychological morbidity and female urinary incontinence. Best Pract Res Clin Obstet Gynaecol 2007; 21:321. 10. Ratner ES, Erekson EA, Minkin MJ, Foran-Tuller KA. Sexual satisfaction in the elderly female population: A special focus on women with gynecologic pathology. Maturitas 2011; 70:210. 11. Coyne KS, Wein AJ, Tubaro A, et al. The burden of lower urinary tract symptoms: evaluating the effect of LUTS on health-related quality of life, anxiety and depression: EpiLUTS. BJU Int 2009; 103 Suppl 3:4. 12. Barber MD, Visco AG, Wyman JF, et al. Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002; 99:281. 13. Dubeau CE, Simon SE, Morris JN. The effect of urinary incontinence on quality of life in older nursing home residents. J Am Geriatr Soc 2006; 54:1325. 14. Serati M, Salvatore S, Uccella S, et al. Female urinary incontinence during intercourse: a review on an understudied problem for women's sexuality. J Sex Med 2009; 6:40. 15. Yip SK, Chan A, Pang S, et al. The impact of urodynamic stress incontinence and detrusor overactivity on marital relationship and sexual function. Am J Obstet Gynecol 2003; 188:1244.

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16. Cohen BL, Barboglio P, Gousse A. The impact of lower urinary tract symptoms and urinary incontinence on female sexual dysfunction using a validated instrument. J Sex Med 2008; 5:1418. 17. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 2000; 48:721. 18. Gotoh M, Matsukawa Y, Yoshikawa Y, et al. Impact of urinary incontinence on the psychological burden of family caregivers. Neurourol Urodyn 2009; 28:492. 19. Morrison A, Levy R. Fraction of nursing home admissions attributable to urinary incontinence. Value Health 2006; 9:272. 20. Tennstedt SL, Link CL, Steers WD, McKinlay JB. Prevalence of and risk factors for urine leakage in a racially and ethnically diverse population of adults: the Boston Area Community Health (BACH) Survey. Am J Epidemiol 2008; 167:390. 21. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311. 22. Lawrence JM, Lukacz ES, Nager CW, et al. Prevalence and co-occurrence of pelvic floor disorders in community-dwelling women. Obstet Gynecol 2008; 111:678. 23. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol 2014; 123:141. 24. O'Halloran T, Bell RJ, Robinson PJ, Davis SR. Urinary incontinence in young nulligravid women: a cross-sectional analysis. Ann Intern Med 2012; 157:87. 25. Offermans MP, Du Moulin MF, Hamers JP, et al. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009; 28:288. 26. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 2001; 98:1004. 27. Drennan VM, Rait G, Cole L, et al. The prevalence of incontinence in people with cognitive impairment or dementia living at home: a systematic review. Neurourol Urodyn 2013; 32:314. 28. Legendre G, Ringa V, Panjo H, et al. Incidence and remission of urinary incontinence at midlife: a cohort study. Br J Obstet Gynaecol 2015; 122:816. 29. Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol 2009; 182:S2. 30. Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med 2009; 360:481. 31. Elia G, Bergman J, Dye TD. Familial incidence of urinary incontinence. Am J Obstet Gynecol 2002; 187:53. 32. Hannestad YS, Lie RT, Rortveit G, Hunskaar S. Familial risk of urinary incontinence in women: population based cross sectional study. BMJ 2004; 329:889. 33. Lukacz ES, Lawrence JM, Contreras R, et al. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol 2006; 107:1253. 34. Lawrence JM, Lukacz ES, Liu IL, et al. Pelvic floor disorders, diabetes, and obesity in women: findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care 2007; 30:2536. 35. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000; 107:1460. 36. Romero-Talamás H, Unger CA, Aminian A, et al. Comprehensive evaluation of the effect of bariatric surgery on pelvic floor disorders. Surg Obes Relat Dis 2016; 12:138. 37. Whitcomb EL, Horgan S, Donohue MC, Lukacz ES. Impact of surgically induced weight loss on pelvic floor disorders. Int Urogynecol J 2012; 23:1111. 38. Subak LL, King WC, Belle SH, et al. Urinary Incontinence Before and After Bariatric Surgery. JAMA Intern Med 2015; 175:1378. 39. Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med 2008; 358:1029.

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40. Wennberg AL, Altman D, Lundholm C, et al. Genetic influences are important for most but not all lower urinary tract symptoms: a population-based survey in a cohort of adult Swedish twins. Eur Urol 2011; 59:1032. 41. Nguyen A, Aschkenazi SO, Sand PK, et al. Nongenetic factors associated with stress urinary incontinence. Obstet Gynecol 2011; 117:251. 42. Hannestad YS, Rortveit G, Sandvik H, et al. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trøndelag. J Clin Epidemiol 2000; 53:1150. 43. Lifford KL, Townsend MK, Curhan GC, et al. The epidemiology of urinary incontinence in older women: incidence, progression, and remission. J Am Geriatr  Soc 2008; 56:1191. 44. Brown JS, Nyberg LM, Kusek JW, et al. Proceedings of the National Institute of Diabetes and Digestive and Kidney Diseases International Symposium on Epidemiologic Issues in Urinary Incontinence in Women. Am J Obstet Gynecol 2003; 188:S77. 45. Matthews CA, Whitehead WE, Townsend MK, Grodstein F. Risk factors for urinary, fecal, or dual incontinence in the Nurses' Health Study. Obstet Gynecol 2013; 122:539. 46. Fenner DE, Trowbridge ER, Patel DA, et al. Establishing the prevalence of incontinence study: racial differences in women's patterns of urinary incontinence. J Urol 2008; 179:1455. 47. Goode PS, Burgio KL, Redden DT, et al. Population based study of incidence and predictors of urinary incontinence in black and white older adults. J Urol 2008; 179:1449. 48. Kupelian V, Wei JT, O'Leary MP, et al. Prevalence of lower urinary tract symptoms and effect on quality of life in a racially and ethnically diverse random sample: the Boston Area Community Health (BACH) Survey. Arch Intern Med 2006; 166:2381. 49. Dallosso HM, McGrother CW, Matthews RJ, et al. The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women. BJU Int 2003; 92:69. 50. Tähtinen RM, Auvinen A, Cartwright R, et al. Smoking and bladder symptoms in women. Obstet Gynecol 2011; 118:643. 51. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005; 165:537. 52. Grodstein F, Fretts R, Lifford K, et al. Association of age, race, and obstetric history with urinary symptoms among women in the Nurses' Health Study. Am J Obstet Gynecol 2003; 189:428. 53. Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and urinary incontinence: a systematic review. Lancet 2000; 356:535. 54. Ouslander JG. Management of overactive bladder. N Engl J Med 2004; 350:786. 55. Jackson SL, Scholes D, Boyko EJ, et al. Urinary incontinence and diabetes in postmenopausal women. Diabetes Care 2005; 28:1730. 56. Jura YH, Townsend MK, Curhan GC, et al. Caffeine intake, and the risk of stress, urgency and mixed urinary incontinence. J Urol 2011; 185:1775. 57. Phelan S, Grodstein F, Brown JS. Clinical research in diabetes and urinary incontinence: what we know and need to know. J Urol 2009; 182:S14. 58. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA 2013; 310:1353. 59. Fozzatti C, Riccetto C, Herrmann V, et al. Prevalence study of stress urinary incontinence in women who perform high-impact exercises. Int Urogynecol J 2012; 23:1687. 60. Goldstick O, Constantini N. Urinary incontinence in physically active women and female athletes. Br J Sports Med 2014; 48:296. 61. Wood LN, Anger JT. Urinary incontinence in women. BMJ 2014; 349:g4531. 62. Nygaard I. Clinical practice. Idiopathic urgency urinary incontinence. N Engl J Med 2010; 363:1156.

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63. Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA 2008; 299:1446. 64. Barry MJ, Link CL, McNaughton-Collins MF, et al. Overlap of different urological symptom complexes in a racially and ethnically diverse, community-based population of men and women. BJU Int 2008; 101:45. 65. Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010; 29:213. 66. Steven E Swift and Alfred E. Bent. Basic evaluation of the incontinent female patient. In: Ostergard's urogynecology and pelvic floor dysfunction, 6, Alfred Bent, Geoffrey Cundiff, Steven Swift. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.67. 67. Milson I, Altman D, Lapitan, et al.. Epidemiology of urinary and faecal incontinence and pelvic organ prolapse. In: Incontinence, 4th ed., Abrams P, Cardozo L, Khoury S, Wein A (Eds), Health Publications Ltd., Plymouth, UK 2009. p.35. 68. Rahn DD, Wai CY. Urinary incontinence. In: Willsiam Gynecology, 2nd, Hoffman BL, Schorge JO, Schaffer JI, et al. (Eds), McGraw Hill Medical, New York 2012. p.609. 69. Lim YN, Dwyer PL. Effectiveness of midurethral slings in intrinsic sphincteric-related stress urinary incontinence. Curr Opin Obstet Gynecol 2009; 21:428. 70. Schierlitz L, Dwyer PL, Rosamilia A, et al. Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol 2008; 112:1253. 71. DuBeau CE, Kuchel GA, Johnson T, et al.. Incontinence in the frail elderly. In: Incontinence, 4th ed., Abrams P, Cardozo L, Khoury S, Wein A. (Eds), Health Publications Ltd, Paris 2009. p.961. 72. Smith PP. Aging and the underactive detrusor: a failure of activity or activation? Neurourol Urodyn 2010; 29:408. 73. Resnick, NM, Elbadawi, A, Yalla, SV. Age and the lower urinary tract: What is normal? Neurourol Urodynam 1995; 14:577. 74. Myers DL. Female mixed urinary incontinence: a clinical review. JAMA 2014; 311:2007. 75. Zimmern P, Litman HJ, Nager CW, et al. Effect of aging on storage and voiding function in women with stress predominant urinary incontinence. J Urol 2014; 192:464. 76. Taylor JA 3rd, Kuchel GA. Detrusor underactivity: Clinical features and pathogenesis of an underdiagnosed geriatric condition. J Am Geriatr Soc 2006; 54:1920. 77. Panicker JN, Game X, Khan S, et al. The possible role of opiates in women with chronic urinary retention: observations from a prospective clinical study. J Urol 2012; 188:480. 78. Swinn MJ, Fowler CJ. Isolated urinary retention in young women, or Fowler's syndrome. Clin Auton Res 2001; 11:309. 79. Moore EE, Jackson SL, Boyko EJ, et al. Urinary incontinence and urinary tract infection: temporal relationships in postmenopausal women. Obstet Gynecol 2008; 111:317. 80. Erekson EA, Ciarleglio MM, Hanissian PD, et al. Functional disability and compromised mobility among older women with urinary incontinence. Female Pelvic Med Reconstr Surg 2015; 21:170. 81. DuBeau CE, Kuchel GA, Johnson T 2nd, et al. Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence. Neurourol Urodyn 2010; 29:165. 82. Ruby CM, Hanlon JT, Boudreau RM, et al. The effect of medication use on urinary incontinence in community-dwelling elderly women. J Am Geriatr Soc 2010; 58:1715. 83. Cigolle CT, Langa KM, Kabeto MU, et al. Geriatric conditions and disability: the Health and Retirement Study. Ann Intern Med 2007; 147:156. 84. Staskin D, Hilton P, Emmanuel A, et al. Initial assessment of incontinence. In: Incontinence: 3rd International Consultation on Incontinence, Abrams P,

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Cardozo L, Khoury S, Wein A (Eds), Health Publications Ltd, 2005. p.485. 85. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012; 188:2455. 86. Gormley EA, Lightner DJ, Faraday M, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. J Urol 2015; 193:1572. 87. www.cms.gov/Medicare/Quality-Initiatives-Patient-Ass essment-Instruments/QualityMeasures/Downloads/Eligible-Providers-2014-Proposed-EHR-IncentiveProgram-CQM.pdf (Accessed on April 06, 2015). 88. Brown JS, Bradley CS, Subak LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715. 89. Parsons M, Amundsen CL, Cardozo L, et al. Bladder diary patterns in detrusor overactivity and urodynamic stress incontinence. Neurourol Urodyn 2007; 26:800. 90. Lukacz ES, Whitcomb EL, Lawrence JM, et al. Urinary frequency in community-dwelling women: what is normal? Am J Obstet Gynecol 2009; 200:552.e1. 91. Al Afraa T, Mahfouz W, Campeau L, Corcos J. Normal lower urinary tract assessment in women: I. Uroflowmetry and post-void residual, pad tests, and bladder diaries. Int Urogynecol J 2012; 23:681. 92. Avery K, Donovan J, Peters TJ, et al. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23:322. 93. Barber MD, Kuchibhatla MN, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol 2001; 185:1388. 94. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003; 189:98. 95. Staskin D, Hilton P, Emmanuel A, et al.. Initial assessment of incontinence. In: Incontinence, 3rd ed., Abrams P, Cardozo L, Khoury S, Wein A. (Eds), Health Publications, Plymouth, UK 2005. p.485. 96. Fonda D, DuBeau, C, et al. Incontinence in the Frail Elderly. In: Incontinence, 3rd ed, Abrams P, Cardozo L, Khoury S, Wein A (Eds), Health Publication LTD, Plymouth, UK 2005. p.1163. 97. Milleman M, Langenstroer P, Guralnick ML. Post-void residual urine volume in women with overactive bladder symptoms. J Urol 2004; 172:1911. 98. Nager CW, Albo ME, Fitzgerald MP, et al. Reference urodynamic values for stress incontinent women. Neurourol Urodyn 2007; 26:333. 99. Rosier PF, Gajewski JB, Sand PK, et al. Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for  urinary incontinence and for fecal incontinence. Part 1: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients. Neurourol Urodyn 2010; 29:140. 100. Winters JC, Dmochowski RR, Goldman HB, et al. Urodynamic studies in adults: AUA/SUFU guideline. J Urol 2012; 188:2464. 101. Huang AJ. Nonsurgical treatments for urinary incontinence in women: summary of primary findings and conclusions. JAMA Intern Med 2013; 173:1463. Topic 6874 Version 30.0

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GRAPHICS

Diagram showing neural circuits controlling continence and micturition

(A) Urine storage reflexes. During the storage of urine, distention of the bladder produces low level vesical afferent firing, which in turn stimulates (1) the sympathetic outflow to the bladder outlet (base and urethra) and (2) pudendal outflow to the external urethral sphincter. These responses occur by spinal reflex pathways and represent "guarding reflexes," which promote continence. Sympathetic firing also inhibits detrusor muscle and modulates

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transmission in bladder ganglia. A region in the rostral pons (the pontine storage center, or "L" region) increases external urethral sphincter activity. (B) Voiding reflexes. During elimination of urine, intense bladder afferent firing activates spinobulbospinal reflex pathways passing through the pontine micturition center, which stimulate the parasympathetic outflow to the bladder and internal sphincter smooth muscle and inhibit the sympathetic and pudendal outflow to the urethral outlet. Ascending afferent input from the spinal cord may pass through relay neurons in the periaqueductal gray (PAG) before reaching the pontine micturition center. Reproduced with permission from: Abrams P, Cardozo L, Wein A (Eds). Incontinence: 2nd ed International Consultation on Incontinence, Health Publications Ltd. 2002.  p.88. Copyright © Health Publications. Graphic 62790 Version 2.0

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Effect of selected medicines and other agents on bladder function M edicine s a nd ot he r a ge nt s

Effe ct on bla dde r funct ion

Allergy Antihistamines

First generation H 1 receptor antagonists (eg, brompheniramine, chlorpheniramine, clemastine,

Decreased contractility via anticholinergic effect

cyproheptadine, dimenhydrinate, diphenhydramine, hydroxyzine, others) Decongest ant s

Pseudoephedrin e, phenylephrine

In creased u reth ral sphincter tone

Chlordiazepoxide, clonazepam, temazepam, triazolam,

Impaired micturition via muscle relaxant effect

Analgesic and sedative Benzodiazepines

others Opioids

Codeine, meperidine, morphine, oxycodone, others

Decreased sensation of fullness and increased urethral sphincter tone

Anticholinergic* Antimuscarinics

Darifenacin, fesoterodine, oxybutynin, solifenacin,

(overactive bladder

tolterodine, trospium

Decreased contractility via anticholinergic effect

medications) Spasmolytic

Dicyclomine, hyoscyamine, glycopyrrolate,

Decreased contractility via anticholinergic effect

methscopolamine, propantheline, scopolamine (hyoscine) Anticholinergics

Benztropine, trihexyphenidyl

Decreased contractility via anticholinergic effect

ACE inhibitors (ACEi)

Enalapril, lisinopril, ramipril, others

Decreased contractility; chronic coughing

Alpha-agonists

Midodrine, phenylephrine, vasopressors (various)

Increased urethral sphincter tone

Alpha 1 -blockers

Alfuzosin, doxazosin, prazosin, silodosin, tamsulosin,

Decreased urethral sphincter tone

(antiparkinson medications) Cardiology ¶

terazosin Antiarrhythm ic

Disopyramide, flecain ide

Decreased contractility via local anesth etic effect on

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bladder mucosa or anticholinergic effect Diuretics

Various

Increased urine production, contractility, or rate of   emptying

Psychotropic Antidepressants

Serotonin-norepinephrine reuptake inhibitors (SNRIs):

Increased urethral sphincter tone

duloxetine, reboxetine Δ Tricyclic antidepressants (amitriptyline, clomipramine,

Decreased contractility via anticholinergic effect

desipramine, doxepin, imipramine, nortriptyline, others) Antipsychotics

First generation (chlorpromazine, fluphenazine,

Mixed effects described; decreased contractility via

methotrimeprazine); second generation (clozapine,

anticholinergic effect; increased micturition and stress

olanzapine, risperidone); others have lower effect

incontinence via stimulation of alpha1 receptors, and/or central dopaminergic receptors

Other Skeletal muscle

Orphenadrine, tizanidine (also cyclobenzaprine, baclofen,

Decreased contractility via anticholinergic effect

relaxants

and methocarbamol; but effect is lower)

Estrogens

Oral estrogens (hormone replacement therapy)

Increased urinary incontinence

Beta 3 -agonist

Mirabegron

Decreased contractility via beta 3 -adrenergic effect

Alcohol

Decreased contractility

Caffeine

Increased contractility or rate of emptying

ACE: angiotensin-converting enzyme. * Inhaled antimuscarinic bronchodilators (eg, ipratropium, tiotropium) and ophthalmic drops (eg, atropine, cyclopentolate) can be absorbed systemically in varying degrees; urinary retention has been rarely associated with their use particularly among older adults, men with benign prostatic hyperplasia (BPH), and administration of inhaled anticholinergic drug by nebulizer. ¶ Increased micturition reported by ≤3% of patients in clinical studies of calcium channel blockers; mixed effects have been described. Δ Not available in United States. Prepared with data from: 1. Verhamme K, Sturkenboom M, Stricker B, et al. Drug induced urinary retention. Drug Saf 2008; 31:373. 2. Zyczynski H, Parekh M, Kahn M, et al. Urinary incontinence in women. American Urogynecologic Society (2012); available at  http://eguideline.guidelinecentral.com/i/76622-augs-urinary-incontinence Graphic 101070 Version 1.0

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Evaluation and treatment of urinary incontinence in women

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UI: urinary incontinence; UTI: urinary tract infection. * Refer to UpToDate topic on evaluation of women with urinary incontinence. ¶ Overflow incontinence managed separately. Prepared with data from: 1. Gormley EA, Lightner DJ, Faraday M, Vasavada SP. Diagnosis and Treatment of  Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment. J Urol  2015; Epub ahead of print. 2. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder  (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012; 188:2455. 3. American Urogynecologic Society. Urinary Incontinence in Women pocket guide. http://eguideline.guidelinecentral.com/i/76622-augs-urinary-incontinence  (Accessed  March 3, 2015). Graphic 100050 Version 2.0

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The 3 incontinence questionnaire (3IQ)

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Reproduced with permission from: Brown JS, Bradley CS, Subak LL, et al. The sensitivity and  specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715. Copyright © 2006 American College of Physicians. Graphic 72319 Version 11.0

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Patient global impression of improvement GPI: Global perception of improvement (BeDri) Overall, do you feel that you are: Much better Better About the same Worse Much worse

PGIS: Patient global impression of severity 1. Check the one box that describes how your urinary tract condition is now: Normal Mild Moderate Severe

PGI-I: Patient global impression of improvement 2. Check the one box that best describes how your urinary tract condition is now, compared with how it was before you began taking medication in this study: Very much better Much better A little better No change A little worse Much worse Very much worse Source: Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003; 189:98.

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Contributor Disclosures Emily S Lukacz, MD, MAS Grant/Research Support: Boston Scientific [prolapse surgery (native tissue repair)]; Pfizer [urinary infections (vaginal estrogen cream/ring)]; Uroplasty [urinary incontinence (urethral bulking injection)]. Consultant/Advisory Boards: American Medical Systems, Inc [prolapse and fecal incontinence (Elevate mesh, Topas sling)]; Axonics [urinary and fecal incontinence (neuromodulation)]; Renew Medical [fecal incontinence (anal insert)]. Other  Financial Interest: Med Edicus [urinary incontinence (manuscript authorship honoraria)]. Linda Brubaker, MD, FACS, FACOG Nothing to disclose. Kenneth E Schmader, MD Grant/Research/Clinical Trial Support: Merck [Herpes zoster (Zoster vaccine)]. Lee Park, MD, MPH Nothing to disclose. Kristen Eckler, MD, FACOG Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy