Urinary Incontinence: Management Guidelines, Screening, Diagnosis

Urinary incontinence (UI) is defined as the complaint of involuntary leakage of urine. As a condition, UI becomes more common with age and affects all genders. However, women are far more likely to experience urinary incontinence than men.

"Many people experience occasional, minor leaks of urine. Others may lose small to moderate amounts of urine more frequently. Your signs or symptoms are directly related to what kind of urinary incontinence you have," said Jeannine Miranne, M.D., a urogynecologist at Brigham and Women's Hospital at Harvard Medical School in Boston.

To differentiate the types of UI, it is helpful to understand the human urinary system. Bodies constantly produce waste, and the role of the kidneys is to filter the blood by transforming some of this waste into urine. Afterward, the urine is channeled into the bladder, where it is contained until the body decides to flush it out through the urethra.

One of the reasons women are significantly more likely to experience urinary incontinence is simply because they have shorter urethras compared to men.

UI is ultimately a bladder control problem. The urinary system has many main muscles that work together in conjunction to control the flow of urine.

The first is the detrusor muscle, which surrounds the bladder itself, followed by the internal and external sphincter muscles of the urethra. Last, the pelvic floor muscles also play an important role in a person's ability to contain urine.

What are the types of urinary incontinence?

Some of the several types of UI a person can experience include the following:

• Urge incontinence is sometimes described as an overactive bladder; the "overactive" part is typically the detrusor muscle. When it contracts, it forces urine out, giving the patient a sudden and/or strong urge to urinate and very little time to act.
• Stress incontinence is usually observed in women and is caused by external pressures or triggers such as coughing, laughing, sneezing or jumping. When a person has weak bladder control, they typically have weak sphincter and pelvic floor muscles. One of the treatments for this type of UI is actually basic kegel and pelvic floor exercises, which can be performed at home.
• Mixed incontinence is a mixture of urge and stress characteristics. It is not uncommon to observe multiple types of UI in a single case file.
• Overflow incontinence is the opposite of urge incontinence in a certain sense. Overflow incontinence is sometimes referred to as a "lazy bladder." It can be caused by a failure of the detrusor muscle to contract, causing urine to fill the bladder and eventually leak in dribbles. It may also be caused by a blockage of the urethra by an enlarged prostate, which tends to happen to men as they age.
• Functional incontinence is not a bladder control issue but more of a mobility issue. It's commonly observed in the frail elderly, when conditions such as arthritis may prevent the patient from getting to the toilet in time.

Treatment relies on the frequency, severity and type of UI a patient exhibits. Studies have shown that UI causes a significant reduction in the quality of life of many women, including their sexual health and function.

Without treatment, women may experience the following sexual complications:

• Sexual avoidance
• Body image problems
• Anxiety over smelling like urine
• Fear of urine leakage during sex
• Increased stress
• Reduction in sex drive and satisfaction

"Some individuals have urinary incontinence during penetrative activities," said Aleece Fosnight, M.S.P.A.S., a board-certified physician's assistant and a medical advisor at Aeroflow Urology in North Carolina. "This can happen for AMAB (assigned male at birth) individuals that have undergone prostatectomy for prostate cancer and/or BPH (benign prostatic hyperplasia).

Screening for incontinence can be an easy question when taking a history from your patient. We should be asking this question as providers.

"And then AFAB (assigned female at birth) individuals can have incontinence during penetration if pelvic floor muscles are weak or if stress incontinence occurs with other activities. People tend to think of incontinence as embarrassing and avoid activities where incontinence may happen—especially sexual activity."

UI doesn't directly cause problems with fertility, but certain complications could indirectly make it difficult to get pregnant.

"In terms of reproductive health, for those AFAB, the lower urinary tract is separate from the female reproductive organs and should not interfere with fertility or menstrual cycles," Fosnight said. "However, if the incontinence causes increased risks of urinary tract infections and the need for antibiotics, this could cause disruption of the reproductive microbiome.

Hormonal birth control alters the natural hormone balance in the urogenital tissues, she added. That can cause urinary frequency, urgency and infections, in addition to genital dryness that may cause dyspareunia.

"For AMAB, erections can cause pelvic pain in those with urinary retention, and for those with BPH, painful ejaculation can occur as well," Fosnight said. "If there is urinary incontinence from lack of bladder neck closure, retrograde ejaculation can occur and make it difficult for conception to happen."

Screening and diagnosing urinary incontinence

"Screening questionnaires are great options for people and can be done at any time, not just before an appointment," Fosnight said. "We often think about screening women that have had vaginal deliveries, are older and may live in a larger body, but the reality is that anyone can have urinary incontinence."

Screening questionnaires include the following:

• Bladder Control Self-Assessment (B-SAQ). Simple self-reported questionnaire
• Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS). A much longer questionnaire with 19 questions but very thorough
• American Urological Association (AUA) Symptom Score Questionnaire. Usually for men, but can be applied to women

"Screening for incontinence can be an easy question when taking a history from your patient. We should be asking this question as providers," Fosnight said. "There are several other screening questionnaires out there; however, these are the ones that I tend to use more frequently."

Diagnosing incontinence and finding the cause includes:

• A thorough history and physical examination (assessing enlarged prostates, pelvic organ prolapse, assessment of pelvic floor muscles)
• Urinalysis, urine culture if indicated, microscopic urinalysis, urine cytology, voiding diary and post-void residual
• Potential further testing, including cystoscopy and urodynamics, as well as imaging including a voiding cystourethrogram, KUB and pelvic MRI

"Monitoring incontinence is essential after diagnosing and treatment has been implemented," Fosnight said. "You want to ensure that the recommendations are working for that individual and if a medication was prescribed, that the patient/person is tolerating well with no side effects and is seeing improvement of their incontinence."

How is urinary incontinence treated?

Pelvic floor physical therapy (PFPT) one to two times a week for eight to 12 weeks is a starting point for everyone, according to Fosnight. This is typically covered by insurance, but copays, costs and allowed frequency will vary by insurance company and plans.

Unfortunately, some pelvic floor physical therapists do not take insurance, so the sessions would be an out-of-pocket expense, ranging from $75 to $300 a visit.

For men, prostate medications such as Flomax, Avodart, Rapaflo, Hytrin, Proscar and others can help, depending on the insurance company and plan.

"Beyond medications, other BPH interventions include procedures and surgeries ranging from Rezum, Urolift, prostate artery embolization and TURP surgeries," Fosnight said. "Those costs vary as anesthesia (local or general) is necessary for those procedures."

There are lots of treatment options for females, depending on the cause and type of incontinence, Fosnight said.

Women with urge incontinence may be treated in the following ways:

• Anticholinergics (oxybutynin, tolterodine, solifenacin, etc). The price ranges from $10 for a 90-day supply to more than $100 for better-known brand-name products.
• Beta adrenergics (Myrbetriq or Gemtesa). The price for this treatment can range from $100 to $400 per month but also depends on insurance drug coverage, type of insurance and whether the medication company has any copay discounts. Gemtesa has a cost-savings program (as little as $0 for a 90-day supply for people with commercial insurance).
• Neuromodulators (such as a posterior tibial nerve modulator). This is a weekly treatment for 12 weeks with booster treatments once a month or once a quarter during the year. The other option is a battery-operated, surgically implanted, rechargeable and MRI-compatible sacral stimulator. This also works for fecal incontinence and costs more than $10,000 if paid for out of pocket; however, insurance will often cover most of, or a majority of, the treatment. The ultimate cost will depend on the insurance plan and deductibles.

'People tend to think of incontinence as embarrassing and avoid activities where incontinence may happen—especially sexual activity.'

Women with stress incontinence may be treated in the following ways:

• Supportive devices such as a pessary can be helpful, especially for people who do not wish to have any surgical intervention. Costs are absorbed by insurance or can run from $100 to $200 if paid out of pocket, but this treatment is typically a one-time expense as they can be used repeatedly.
• There are also procedures and surgeries that can be performed, such as mid-urethral slings, obturator slings and urethral bulking agents.

For women with overflow incontinence, isolating the cause and treating it will help the most. Urinary retention typically causes overflow incontinence and typically occurs with pelvic organ prolapse, chronic constipation, BPH and neurological conditions (e.g., multiple sclerosis, Parkinson's, spinal cord injuries).

Side effects may vary and will depend on the treatment.

Other treatment interventions

Experts say behavioral therapy has been used in UI treatment since the 1940s and has been shown to reduce the frequency of UI by 57 percent to 86 percent. Behavioral therapy is recommended for both stress and urge incontinence. This includes, but is not limited to, the following:

• Bladder drills or training (learning to gradually hold urine for longer periods)
• Prompted voiding (making a toilet schedule based on your patterns and setting a reminder/alarm)
• Yoga
• Mindfulness-based stress reduction
• Weight loss
• Smoking cessation

A few home and DIY remedies can help patients, too. Melissa Nassaney, D.P.T., P.T., a board-certified women's health clinical specialist in Warwick, Rhode Island, shared the following:

• Drink mostly water and do it throughout the day but not all at once.
• Allow the bladder to be the storage tank it is.
• Don't empty the tank too soon; let it fill to a good capacity.
• Don't go pee every time you walk past a bathroom.
• Try to encourage yourself to sleep through the night or at least uninterrupted during the first four hours of your sleep.

"Remember, if you must wake to pee at night, then you are going back to bed with an empty bladder," Nassaney said. "You probably don't need to wake to go again; it is more likely just habit or fear of wetting the bed."

Don't be afraid to reach out for help

Urinary incontinence is a common concern, but that doesn't make it a normal part of aging. Seeking treatment can significantly improve someone's quality of life and general sexual health. If you have UI, consult a doctor for a more comprehensive assessment of your condition.

Keep in mind that healthcare professionals deal with UI all the time and can help you resolve your health issues.

"Urinary incontinence is not necessarily a disease, but rather can be a symptom caused by weakening of the pelvic floor, underlying medical conditions or even just everyday habits," Miranne said. "It is important to consult a healthcare professional to identify what type of UI you have, as well as help determine what underlying issues might be causing your bladder leakage."