CME

Urinary incontinence

Non-surgical management by family physicians

K.N. Moore, RN, PHD   A. Saltmarche  B. Query

ABSTRACT

OBJECTIVE To review current evidence on conservative management of urinary incontinence (UI) by family physicians.
QUALITY OF EVIDENCE Articles were sought through MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CINAHL, PsycLit, ERIC, two consensus meetings, and review of abstracts presented at urology meetings. References of these articles were searched for relevant trials. Strong evidence supports bladder training, pelvic floor exercises, and some medications, but only fair evidence supports fluid adjustment, caffeine reduction, and stopping smoking. Weight loss and exercise are supported by expert opinion only. Consensus opinion is that, whenever possible, conservative management should be considered first.
MAIN MESSAGE Good evidence shows that initial management by primary care physicians is effective. After basic assessment and tests, strategies such as bladder retraining, pelvic floor exercises, and lifestyle modifications, augmented by appropriate medications, can be successful. If initial strategies are unsuccessful, patients can be referred.
CONCLUSION More than a million Canadians suffer from UI. In almost all cases, family physicians are the first health professionals contacted by patients. Basic assessment and conservative management can go far to ameliorate the problem.

RÉSUMÉ

OBJECTIF Passer en revue les données actuelles sur le rôle du médecin de famille dans le traitement conservateur de l’incontinence urinaire (IU).
QUALITÉ DES PREUVES On a utilisé MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CINAHL, PsycLit, ERIC, deux congrès de consensus et l’examen des résumés de communications d’un congrès d’urologie comme sources de données. Les références bibliographiques des articles retenus ont été examinées pour identifier les essais thérapeutiques pertinents. Les méthodes fondées sur des preuves solides incluent la rééducation vésicale, le renforcement du plancher pelvien et certaines médications; par contre, l’ajustement des liquides, la réduction de la caféine et l’arrêt du tabac sont moins bien appuyés scientifiquement. La réduction du poids et l’exercice sont recommandés seulement par les experts. Le consensus général est qu’ on doit débuter par un traitement conservateur chaque fois que possible.
PRINCIPAL MESSAGE Les données montrent clairement que le médecin de première ligne peut effectuer le traitement initial efficacement. Après l’évaluation et les examens de base, des méthodes comme la rééducation vésicale, le renforcement des muscles du plancher pelvien et les modifications du mode de vie peuvent avoir du succès. En cas d’échec de ces stratégies, le patient peut être dirigé en spécialité.
CONCLUSION Plus d’un million de canadiens souffrent d’IU. Dans presque tous les cas, le médecin de famille est le premier professionnel de santé consulté. Une évaluation de base et un traitement conservateur peuvent faire beaucoup pour améliorer ce problème.

This article has been peer reviewed. Cet article a fait l’objet d’une évaluation externe.
Can Fam Physician 2003;49:602-610.

Ms Moore is an Assistant Professor in the Faculty of Nursing and an Adjunct Professor in the Faculty of Medicine at the University of Alberta in Edmonton. Ms Saltmarche and Ms Query are nurses.

A national Angus Reid poll noted that 1.5 million Canadians (7%) had suffered from urine loss in the previous year and that the prevalence increased with age to 12% of women and 2.5% of men older than 55. At least 16% of seniors living at home need assistance for urinary incontinence (UI).1 People with UI report restrictions on physical activity,2,3 stress, frustration, thoughts of suicide,4 confusion, depression, anger, less well-being,5 low self-esteem, social isolation, and poor sleep.6,7 Family physicians are the first contact for most people with UI; initial assessment and intervention for UI by family physicians is effective and long lasting.8-10

Despite the prevalence of UI and the fact that family physicians are the first point of entry, recent graduates of family practice residency training in Ontario stated they received inadequate training in assessment and management of UI.11 In this paper, we review available evidence and describe initial assessment and conservative management of UI. Conservative management in this article means lifestyle adjustments and pelvic floor muscle exercises (PFME) with or without medications.

Quality of evidence

The Cochrane Database, MEDLINE, CINAHL, EMBASE, PsycLit, and ERIC were searched from January 1995 to January 2001. Because an authoritative literature review was done in 1994,12 we chose 1995 as the start date for our search. We used the search terms incontinence, electrical stimulation, biofeedback, pelvic muscle/Kegel exercises, behaviour/modification, conservative, physiotherapy, and quality of life. Consensus documents,12-16 conference proceedings, and all reference lists of articles retrieved were consulted. Levels of evidence follow the recommendations of the Canadian Medical Association.17

Classification of UI

At presentation, UI is classified by symptoms. Cause is presumed rather than confirmed and is described as urge (or overactive bladder), stress, mixed urge and stress, or retention with overflow. Definitive diagnosis requires a detailed, expert assessment, usually including urodynamics.

Because the bladder can be an “unreliable witness,”18,19 if initial strategies are ineffective, referral to a specialist is indicated. Table 1 summarizes symptoms, presumed cause, and usual treatment strategies at the primary care level.

Assessment

A plan for initial assessment of patients with UI was recently suggested.20 It emphasized sensitive questioning about the effect of UI on daily life; detailed history; focused pelvic, rectal, and neurologic examinations; urinalysis (microscopy or dipstick); using a voiding diary; and assessing postvoid residual (PVR) volume, if indicated (Table 220). Although most guidelines for UI recommend initial PVR testing,12 the value in family practice has only recently been investigated. In a study of 408 women who came to an incontinence clinic for initial assessment, only six had clinically significant residual urine; the authors concluded that a PVR test is unnecessary in primary assessment of women with UI.21

Vaginal or rectal examination can be used to assess pelvic floor muscle tone, sensation, contractile ability, and atrophic changes. A fluid volume chart (voiding diary, Figure 1) is easy for most patients to complete22 and can be used to assess voiding patterns and fluid intake over 1 to 3 days. A voiding diary can reliably discriminate between urge and stress UI23: patients with stress UI usually wake once or not at all to void; patients with urge UI usually wake more than twice and as often as every hour. A dietary and stool record is helpful if constipation or fecal soiling are problems.

Several transient problems exacerbate UI: urinary tract infections, constipation, dementia or delirium, atrophic vaginitis, and medications. Medications that most frequently cause problems are -blockers, which relax the smooth muscle of the bladder neck and worsen stress UI.24 In at-risk patients, angiotensin-converting enzyme inhibitors can cause a dry cough that also exacerbates stress UI.25 Finally, hypnotics, some antipsychotics, narcotics, and anticholinergics put people at risk of urinary retention. Patients who develop UI after a medication change should be reviewed for side effects.

Conservative management

Conservative management (also called behavioural strategies or lifestyle adjustments) is noninvasive and includes PFMEs, bladder training, fluid adjustment, caffeine elimination, smoking cessation, bowel management, weight reduction, and physical exercise. Experts suggest that most people will benefit from and should be offered behavioural strategies as first-line treatment.12-16

Table 1. Symptom presentation and usual treatment strategies in primary care
PRESUMED CAUSE	DESCRIPTION	TREATMENTS OFFERED THROUGH PRIMARY CARE
Overactive bladder, urge incontinence	Loss of urine associated with a strong desire to void; might be accompanied by frequency and nocturia; nocturia is typically described by patients with overactive bladder but not by those with stress UI	Bladder training, timed toileting, fluid management, medication review Constipation management PFME and PFME with biofeedback Electrical stimulation (10-20 Hz) Estrogen therapy Anticholinergic or antimuscarinic medications Incontinence pads Environmental modifications, such as bedside commodes, night lights, and clearly marked toilets
Stress UI	Loss of urine on physical exertion or increases in abdominal pressure due to laughing, coughing, or sneezing, or due to sphincter deficiency; patients with stress UI are usually dry at night and do not complain of nocturia	Weight loss Fluid increase or decrease Smoking cessation Constipation management PFME and PFME with biofeedback Pessary (occasionally) Incontinence pads
Mixed UI (overactive bladder and stress UI)	Loss of urine with both urge and increases in abdominal stress; symptoms are mixed with urgency, frequency, nocturia, and leaking with increased abdominal pressures	Combination of above conservative measures with an initial focus on dominant symptom
Overflow	Leakage associated with bladder distension or urinary retention; leakage with increased abdominal pressure; might be confused with stress UI; due to a contractile or poorly contractile detrusor or outlet obstruction; chronic retention is usually painless	Refer Clean intermittent catheterization Relief of obstruction (in women, cystocele, uterine prolapse, tumour; in men, prostatic enlargement hyperplasia, urethral stricture, bladder tumour) Medication review -Blockers Last resort: indwelling catheter
PFME—pelvic floor muscle exercises, UI—urinary incontinence.

Table 2. Clinical assessment of patients with urinary incontinence
INVESTIGATION	DESCRIPTION
Focused neurologic examination	General assessment of sacral (S2-5) dermatomes: evaluates perineal and saddle sensation, rectal tone and sensation, and ability of rectal sphincter to remain contracted with stimulus of digital examination; abnormalities suggest some neurologic impairment and possibly referral to a neurologist
Rectal or vaginal examination	Rectal examination will reveal prostate enlargement, stool impaction (which might affect continence), and rectal tone and sensation (above); vaginal examination will reveal atrophic vaginitis, cystocele, uterine prolapse, rectocele, and pelvic floor tone when patient coughs or strains. A rectocele does not cause urinary incontinence; however, stool can collect in the rectocele and might need to be evacuated manually or by placing a finger in the vagina or on the perineum to provide resistance while defecating. Such maneuvers can be embarrassing. Referral to a gynecologist or urogynecologist is indicated if methods to reduce stool pocketing, such as stool softeners, fibre, and lubricants, are ineffective
Postvoid residual test with ultrasound scan or in-out catheterization (generally >150 mL is considered significant, but treatment should be based on symptoms rather than PVR volume alone)20	Recommended if symptoms suggest incomplete emptying typically described as straining to void, intermittent stream or hesitancy, and for some, never feeling empty or leaking with increased abdominal pressure Physical examination might reveal distended bladder but abdominal palpation might be accurate only when bladder is grossly distended Patients at risk for incomplete emptying are those with neurologic diseases (eg, multiple sclerosis), history of urethral strictures, peripheral neuropathies (diabetes, alcohol abuse, B12 deficiency), or medications with anticholinergic properties. Women with uterine prolapse or marked cystocele and men with prostatic hyperplasia are at risk. Patients with symptoms and PVR volume can be managed initially with -blockers or intermittent catheterization. Referral to a urologist is indicated if symptoms persist.
PVR—postvoid residual. For more strategies, see Borrie and Valiquette.20

Pelvic floor muscle exercises. Exercises should increase awareness of pelvic muscle function and increase the strength and endurance of voluntary muscles. The benefits to women without prolapse who follow an intensive exercise regimen are well known26-29 and long lasting.30,31 Primiparous women who practise PFME have fewer episodes of UI during pregnancy and afterward than controls.32 The benefits of PFMEs in men after radical prostatectomy are not as clear. In a Cochrane review of six randomized controlled trials,33 only one showed a significant effect of postprostatectomy exercises. Although further research is required, the reviewers concluded that PFMEs after radical prostatectomy might enhance continence recovery and had several quality-of-life benefits, and that men should not be discouraged from participating in programs should they wish to do so.

Exercises are most effectively taught with vaginal or rectal palpation to help patients identify the correct muscles and timing of contractions. Men should see the base of the penis, pull up and in. Without adequate instruction, between 30% and 70% of patients cannot perform effective PFMEs.34 Figure 2 shows the PFME illustrations provided by the Canadian Continence Foundation (www.continence-fdn.ca). This basic information is best combined with teaching, support, and ongoing follow up by a physiotherapist or nurse (level I evidence). Augmenting PFMEs with biofeedback or electrical stimulation35,36 might increase the effectiveness of therapy (level II evidence).

Bladder training. Bladder training (also called urge suppression or scheduled voiding) is an important first-line strategy.37 The intent is to increase the voiding interval by consciously suppressing the urge to void; patient education, scheduled voiding, positive reinforcement, and ongoing support are helpful.12 Keys to success are good sensation of bladder fullness, adequate pelvic muscle tone (assessed by a pelvic examination), motivation, and cognitive ability.

Adding other behavioural methods or short-term anticholinergics38 might increase effectiveness. A recent Cochrane review on bladder training identified seven randomized controlled trials39 that noted improvement in subjects who had participated in bladder training compared with no treatment or no bladder training (level I evidence). Table 3 outlines a bladder-training protocol.

Fluid adjustment and caffeine reduction. Controlled fluid reduction, such as restricting fluids in the evening, and nighttime toileting might reduce UI symptoms in elderly people.40 If fluid intake is low (less than 30 mL/kg), however, increased fluid intake might improve symptoms.41 Physiologic evidence suggests that caffeine precipitates symptoms of UI,42 but clinical evidence of the effectiveness of caffeine reduction is unclear.43,44 In one study, subjects randomly assigned to ingest no caffeine at all had significantly fewer episodes of incontinence (as recorded by bladder diary) than controls45 (level II evidence).

Reducing or stopping of cigarette smoking. Smoking is a risk factor for UI in women older than 60 who have chronic obstructive pulmonary disease and chronic respiratory symptoms46,47; in younger women, the relationship is less clear.48 Chronic coughing might cause gradual anatomic and pressure transmission defects that could contribute to stress UI.49 A retrospective case-control study of women who never smoked and women who currently smoked showed that the relative risk of urge or stress incontinence increased by 2.2 for women who previously smoked and by 2.5 for those who currently smoked. Risk increased with number of cigarettes and years as a smoker.50

Men aged 50 to 70 who smoke or are former smokers have an increased risk of lower urinary tract symptoms (odds ratio 1.47 and 1.38, respectively) compared with those who never smoked.51 No studies were found that measured the effect of smoking cessation on immediate improvement in lower urinary tract symptoms or continence (level II evidence).

Weight reduction. Obesity is a known risk factor for UI in women and is independent of obstetric history, surgery, smoking, and family history.52 Defined as greater than 120% of the average weight for height and age, obesity is significantly more prevalent in women with stress UI and overactive bladder than in the general population.53 Women with profound weight loss after bypass surgery report a marked improvement in stress UI.54 Results of more modest weight-loss programs are not reported13 (level II evidence for profound weight loss, level III evidence for modest weight loss).

Bowel management. Growing evidence links UI, constipation, fecal incontinence, and pelvic organ prolapse with each other and each of these conditions, in turn, to pelvic floor denervation, pudendal neuropathy, and progressive chronic dysfunction.55-57 Constipation can cause bladder neck obstruction and obstructive voiding58; fecal incontinence can cause social isolation far beyond that of UI and remains a taboo topic.59 Referral is required if initial dietary and nonstimulant bowel preparations are ineffective in ameliorating constipation or fecal incontinence (level III evidence).

Physical activity and regular exercise. Men aged 40 to 75 who undertake moderate exercise (walking 2 to 3 hours weekly) have a 25% lower risk of benign prostatic hyperplasia than men who do not exercise,60 but there are no similar studies in women. People limit their activities or stop exercising because of UI, thereby increasing the risk of other weight-related problems (level III evidence).

Medications

Table 4 describes medications commonly prescribed for UI. Good evidence shows that treatment with the anticholinergic medications oxybutynin and tolterodine results in increased bladder capacity, increased time between urge to void, and delayed initial desire to void.61 Oxybutynin as low as 2.5 mg at bedtime is effective, particularly for elderly patients. Increasing the dose gradually by 2.5 mg until tolerance is reached reduces side effects and increases the likelihood that patients will continue the medication. Side effects are the main reason for discontinuing the drug, particularly xerostomia, which places patients at risk of dental caries; mouth moisturizers plus regular dental care are important. Tolterodine is consistently reported to have fewer side effects than oral oxybutynin.62 Both oxybutynin and tolterodine extended-release formats are reported to have fewer side effects with once-a-day dosing (level I evidence).

Finally, local treatment of urogenital atrophy with low-dose estrogen appears to have clinical benefit for postmenopausal women experiencing urgency, urge UI, vaginal dryness, and dyspareunia. A recent Cochrane review63 showed that women with symptoms of overactive bladder had marked improvement in nocturia, urgency, and daytime frequency, but little benefit was found for women with stress UI. Doses and administration varied in the studies, but topical, intermittent estrogen or sustained-release estradiol appeared to be as effective as oral or patch medication in relieving symptoms. Excessive use of topical creams can result in systemic effects, but when used as directed, effects are minimal. In low doses, the additional systemic benefits of estrogens are probably minimal, but because of the low dose, endometrial stimulation is unlikely, and progestin protection is seldom necessary (level I evidence for relief of urge symptoms).

Conclusion

Urinary incontinence is a common health problem that seriously affects patients’ lives. Although family physicians are often patients’ first contact, physicians feel unprepared to address the issue of UI, and both parties feel disappointed. Consensus opinion and clinical trials suggest that conservative management is safe, effective, and can be offered through primary care. Referral is indicated if symptoms do not resolve with initial interventions or if symptoms suggest underlying urologic or gynecologic problems. The best available evidence supports family physicians as pivotal in identifying patients with UI, initiating discussion, beginning assessment, and implementing basic management strategies.

Competing interests

None declared

Correspondence to: Katherine N. Moore, Assistant Professor Faculty of Nursing, Faculty of Medicine, 3rd floor, Clinical Sciences Building, University of Alberta, Edmonton, AB T6G 2G3; telephone (780) 482-1541; fax (780) 482-2551; e-mail katherine.moore@ualberta.ca

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