Urinary incontinence is a common and potentially debilitating condition. It affects about 10%–40% of adult women and is considered severe in approximately 3%–17%.¹ The true magnitude of this problem is unknown due to underreporting. About 60%–75% of incontinent patients do not seek treatment for their condition because of embarrassment, the belief that incontinence is a normal condition of aging, fear of needing surgery, the lack of knowledge about the treatments available, and skepticism about the effectiveness of the available therapies.^2,3,4,5,6,7 The World Health Organization has identified urinary incontinence as an important global health issue.

Although urinary incontinence usually does not affect a woman’s physical well-being, it creates a significant social problem. Urinary incontinence has been found to reduce social interactions and physical activities and is associated with poor health, impaired emotional and psychological well-being, and interference with sexual relations.^8,9,10,11 In older patients, urinary incontinence doubles the risk of injury and bone fracture from falling and being admitted to a nursing home.^12,13 Because of these reasons, clinicians should routinely screen all their female patients for this prevalent condition.

Urinary incontinence in overweight and obese patients is evaluated and managed in a similar fashion as their normal-weight counterparts.^{14,15,16,17,18} The efficacy of available treatments for urinary incontinence is determined almost exclusively from randomized controlled trials (RCTs) that included patients from all weight classes. The evaluation and treatment presented are based on findings from these trials with minor modifications for overweight and obese patients. Emphasis is on these modifications when applicable.

Although urinary incontinence may be caused by numerous conditions, almost all incontinent patients seen by clinicians have either stress urinary incontinence (SUI), overactive bladder (OAB), or both, which account for about 50%, 25%, and 25% of the incontinent cases, respectively.¹⁹ The initial evaluation of an incontinent patient is relatively straightforward. In addition to the standard history and physical examination used to evaluate any new gynecologic patient, we also assess the impact of urinary incontinence on the patient’s quality of life (QoL); determine whether the patient has SUI, OAB, or both; and inquire about previous treatments.

Impact of Urinary Incontinence on Quality of Life

Urinary incontinence frequently has a negative effect on the patient’s QoL, which is the major factor that determines whether she seeks care for her condition and the intensity of evaluation and treatment. Consequently, QoL assessment is an important part of evaluating urinary incontinence. For busy clinicians, the most convenient method to perform this assessment is to use one of the validated questionnaires designed to evaluate the impact of incontinence symptoms on a patient’s QoL. At my facility, we use the International Consultation on Incontinence Modular Questionnaire—Urinary Incontinence Short Form, which consists of 4 questions related to the incontinence (Table 35-1). Clinicians can request permission to use this copyrighted questionnaire by writing to the Bristol Urological Institute (nikki.cotterill@bui.ac.uk).

Determine Whether the Patient Has SUI, OAB, or Both

Stress Urinary Incontinence

The International Continence Society (ICS) defined SUI as involuntary urine loss that occurs during periods of intra-abdominal pressure increase, such as when coughing, sneezing, and jumping.²⁰ If our initial evaluation identifies a patient with an uncomplicated problem (i.e., does not have pain, hematuria, recurrent infections, suspected or proven voiding problems, significant pelvic organ prolapse, persistent or recurrent incontinence after pelvic irradiation, prior radical pelvic surgery, previous incontinence surgery, and suspected fistula) and produces a reasonably certain diagnosis of SUI, we routinely perform a urine analysis and possible culture and provide instructions on how to perform pelvic floor muscle exercises (PFMEs) prior to prescribing nonsurgical treatment.

We always perform a cough stress test and assess for postvoid residual (PVR) and the degree of urethral support when a patient with uncomplicated SUI is considering invasive, potentially morbid, or irreversible treatments or when a patient with a complicated presentation is considering nonsurgical or surgical treatment for her SUI.

We perform 3 tests in the following order:

1. 
   

   Perform a cough stress test immediately after the patient has voided and evaluate the degree of her urethral support. A positive cough stress test objectively demonstrates that the patient has SUI, while a positive test in the supine position immediately after voiding indicates severe SUI and may require urodynamic studies (UDS) preoperatively to diagnose an associated intrinsic sphincter deficiency (ISD) because some procedures may be less effective in SUI associated with ISD.^21,22,23. The degree of urethral support is often assessed by the Q-tip test. We rarely use this test because inserting a cotton swab into the urethra is painful, and urethral hypermobility can be similarly diagnosed by observing the distal anterior vaginal wall descended close to the hymen with Valsalva or cough.^24,25

   
   
2. 
   

   If the postvoid cough stress test is positive, we conclude the evaluation by measuring the PVR using a bladder scanner or a red rubber catheter. The exact definition of an elevated PVR volume that is clinically relevant remains unclear. One frequently mentioned guideline considers a PVR less than 100 mL as normal and more than 200 mL as abnormal, while a volume between 100 mL and 200 mL requires clinical correlation to determine its significance. A single elevated PVR should always be confirmed with a second measurement. Patients with elevated PVR may be at increased risk for transient or permanent postoperative voiding difficulty after a continence procedure.

   
   
3. 
   

   If the postvoid cough stress test is negative, we insert a red rubber catheter to measure the PVR and then attach the catheter to a 60-mL catheter tip syringe and fill the bladder in a retrograde fashion with room temperature saline. At maximum bladder capacity, we remove the catheter and repeat the cough stress test with the patient in the supine and standing position, if indicated. The cough stress test is reliable when it is performed at a bladder volume of 300 mL or symptomatic fullness. A negative cough stress test after bladder filling usually indicates that the patient does not have SUI, while a negative test without bladder filling may misdiagnose SUI in up to 80% of patients.^{26,27,28,29,30}

Bladder filling may occasionally trigger detrusor overactivity, which manifests as a sudden rise in the meniscus in the syringe while the patient experiences urgency or urgency incontinence. If detrusor overactivity occurs prior to a positive cough stress test, the patient needs to be evaluated with a UDS.^26,30 Similarly, if the incontinence continues after the cough or Valsalva, the patient may have stress-induced detrusor overactivity, which also requires further testing with a UDS.

Overactive Bladder

Overactive bladder is defined as the presence of urinary urgency with or without urgency incontinence, usually with frequency and nocturia in the absence of infection or obvious pathologic conditions that could account for these symptoms (Table 35-2).²⁰ The first step in diagnosing OAB is to determine whether the patient has the characteristic symptoms of urinary urgency, frequency, nocturia, and urgency incontinence. The diagnosis of OAB requires the presence of urinary urgency, its hallmark symptom, plus 1 of the other 3 symptoms.²⁰

Urinary urgency is defined as complaint of a sudden compelling desire to pass urine that is difficult to defer.²⁰ Increased daytime urinary frequency is defined as the complaint that micturition occurs more frequently during waking hours than previously deemed normal by the patient.²⁰ Frequency associated with OAB is typically characterized by small-volume voids.¹⁸ Nocturia is defined as the complaint of interruption of sleep 1 or more times because of the need to micturate.²⁰ Each void is preceded and followed by sleep. Urgency incontinence is involuntary leakage from the urethra synchronous with the sensation of a sudden, compelling desire to void that is difficult to defer.²⁰

The second part of diagnosing an OAB is to determine whether the patient’s symptoms are precipitated or exacerbated by the following pathologic conditions:

Cystitis—Cystitis may cause OAB symptoms and SUI, especially in older patients.

Neurogenic Bladder—When a neurologic disease disturbs the normal bladder function, the patient is considered to have a neurogenic bladder (NGB). Neurologic diseases that more commonly affect the lower urinary tract function are listed in Table 35-2. Bladder dysfunction may occur early in the course of the disease or as it progresses, either abruptly or gradually. NGB is extremely rare in patients who have no history of neurologic disease, are fluent in their speech, can give organized and appropriate responses to questions about past medical and family history, and have demonstrated normal mobility. These patients may be screened with a focused neurologic examination that evaluates sacral spinal cord segments 2 to 4 by testing the perineal sensation and sacral reflexes. If the history or general assessment suggests a neurologic disorder, the patient should be referred for a thorough evaluation.

Metabolic Disturbances—Metabolic conditions that may cause lower urinary tract symptoms include poorly controlled diabetes mellitus (DM), pregnancy, atrophic changes in the urogenital tract, and rarely, diabetes insipidus. Because DM is prevalent and often undiagnosed, all patients who present with OAB, especially if they are overweight or obese, should be screened for glycosuria and, if indicated, a random plasma glucose level.³¹ Glycosuria and the associated osmotic diuresis often cause urinary frequency, urgency, and nocturia. The presence of these symptoms and a random plasma glucose level of 200 mg/dL or greater is one criterion used to diagnose DM.

Physiologic Causes—The evaluation of OAB (and SUI) should include an inquiry into the type and amount of fluid intake each day because increased fluid, caffeine, and alcohol intake may precipitate or exacerbate an OAB (and SUI).^32,33,34 Patients who are uncertain or unable to provide such information accurately should be asked to fill out a 3-day bladder dairy, which records the type and amount of fluid intake and measures urine output. Patients with polydipsia and the resulting polyuria have frequent normal or large-volume voids and a closely matched intake and output, while those with OAB have frequent small-volume voids. These two conditions can be distinguished by a bladder diary.

Pelvic Malignancy—Ovarian and bladder malignancy and pelvic radiation may cause OAB symptoms or SUI. Patients who present with OAB should always have an abdominal and pelvic examination, and, if needed, a pelvic ultrasound, to screen for ovarian malignancy. Similarly, they should have a urine dipstick test or analysis to screen for bladder cancer, which most frequently manifests as painless hematuria and second most commonly with urinary urgency and frequency. Hematuria diagnosed by a urine dipstick test should always be confirmed or refuted by a microscopic examination.³⁵

Gastrointestinal Condition—Constipation has frequently been cited as a transient cause of urinary incontinence, especially in older patients. Although it is significantly more prevalent among patients who have OAB than asymptomatic controls, we are uncertain whether relieving constipation would improve OAB symptoms.³⁶ Because it may cause abdominal and pelvic pain and discomfort, fecal incontinence, anal fissure, rectal and pelvic organ prolapse from prolonged straining, and possibly exacerbated OAB symptoms, we routinely screen for constipation using the Rome III criteria (Table 35-3) and treat this prevalent gastrointestinal condition when present.^37,38

Mobility Disorder—Frequently, OAB coexists with other disorders, such as dementia, severe arthritis, morbid obesity, or hemiplegia, that severely restrict a patient’s mobility and exacerbates her urinary incontinence because she cannot get to the bathroom after experiencing an urge to void. Clinicians should recognize that these patients may need other measures, such portable commodes and assistance to get to a toileting facility in addition to the standard therapy to manage their OAB.

Previous Treatments for Urinary Incontinence

Clinicians should inquire about previous therapies, duration of treatment, outcome, associated adverse events, and the reason for discontinuing each therapy.

Pelvic floor muscle exercises, which have a reported subjective cure rate of 53%–97% and an objective cure rate of 5%–49%, are widely accepted as the first-line treatment for SUI.^15,16,38,39 However, PFMEs are less effective in patients with more severe SUI (more than 1–2 leaks per day), and their efficacy is infrequently maintained long term.^{38,39,40,41,42} The only sustained benefit of PFME was attributed largely to knack, which is contraction of the pelvic floor muscles before coughing, sneezing, and other similar activities to prevent involuntary urine loss.^41,42

In many patients, PFMEs in the long run just postponed the surgery. After 3 to 15 years, 25%–50% of patients initially treated with PFMEs have proceeded to surgery.^41,42,43 Patients who did not respond to PFMEs initially had incontinence surgery sooner than those who responded well.⁴¹

The minimally invasive synthetic midurethral sling is widely regarded as an effective treatment for SUI, with subjective and objective cure rates between 57% and 92%. It is often performed in an ambulatory setting with minimal complications.^44,45,46

This difference in the reported frequencies of a successful outcome between these two treatments raises the question whether all patients, especially those with more severe SUI, should be initially treated with PFMEs or the minimally invasive sling.

In a large, multicenter, prospective, randomized Dutch trial, which involved 460 patients with moderate-to-severe SUI, 49% assigned to PFMEs crossed over to the surgical option within 12 months, while 11% assigned to the surgical group crossed over to the PFME group.⁴⁰ Intent-to-treat analysis at 12 months showed that the surgery group had significantly higher subjective and objective cure rates and greater improvement in urogenital distress inventory scores than the PFME group. The authors concluded that patients with moderate-to-severe SUI should be counseled regarding both PFME and surgery as initial treatment options.

Given the variability in a patient’s tolerance for incontinence and moderate at best correlation among various severity of incontinence measures, we routinely offer all patients who present with bothersome SUI both PFMEs and surgery as initial treatment options.⁴⁷

We usually prescribe PFME with behavioral therapies, which include bladder retraining, weight loss, avoidance of bladder stimulants, and fluid reduction and constipation treatment, if indicated, as the first-line nonsurgical treatment for SUI. PFMEs are significantly more effective than placebo and topical estrogen and are either superior or similar to vaginal cone and pelvic floor electrical stimulation in managing SUI.^48,49,50,51

A 2011 Cochrane review concluded that contracting the correct muscles at the right time and performing a sufficient number of PFMEs were important for successful treatment, but there were insufficient data to determine the best approach (such as frequency of training, type of contraction) to train the pelvic floor muscles.⁵² Its only recommendation is to offer patients reasonably frequent follow-ups during the training period because such follow-ups improved the efficacy of PFMEs.⁵³ One or 2 additional sessions may be just as or more effective than more numerous follow-up visits. We recommend that clinicians follow the National Institute for Health and Care Excellence and American Urogynecologic Society guidelines, which recommend 10 PFMEs 3 times each day with frequent follow-up visits as suggested by the Cochrane review.^17,53,54

Modifying caffeine and fluid intake has a significant beneficial effect on SUI. A 4-week prospective study found that by eliminating caffeine and limiting fluid intake to no more than 750 mL daily reduced the incontinence episodes by 65% among 39 subjects with mild-to-moderate SUI.³²

Weight loss, which includes massive loss in obese women after bariatric surgery and more modest loss in overweight and obese subjects with nonsurgical treatments, is an effective treatment for SUI.^55,56 We rarely recommend weight loss as the initial treatment for SUI because most, if not all, overweight and obese patients had already attempted to lose weight numerous times using different methods and failed. Also, we do not recommend or encourage bariatric surgery or pharmacologically induced weight loss for urinary incontinence because both are associated with significant morbidity, while involuntary urine loss rarely affects patients’ physical health. We do inform them that a moderate amount of weight loss (about 15 pounds) would improve their QoL by significantly lessening their chances of experiencing incontinence.⁵⁶

For patients actively trying to lose weight, we rarely prescribe time-consuming and labor-intensive bladder retraining because managing several treatments that require significant time and effort simultaneously may exceed their ability to incorporate each into their daily activities and cause them to abandon their treatments. We do, however, take time during each office visit to recognize their effort to lose weight and encourage them to persist in their endeavor.