HealthCert Blog

Urinary incontinence affects an estimated 38 per cent of Australian women, and it is estimated that up to 70 per cent of sufferers do not consult with a healthcare professional, possibly due to embarrassment. Therefore general practitioners need to ask about urinary incontinence in a sensitive manner.

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in Women’s Health.

Urinary incontinence can be categorised as stress incontinence, whereby urine leakage occurs with effort, for example, during physical activity, lifting, sneezing or laughing; and urgency incontinence, where the main symptom is an uncontrollable sense of urgency.

Mixed incontinence also occurs as a combination of both. Other associated symptoms may include increased frequency, nocturia, and vulvovaginal discomfort. It is also important to ask about associated urinary symptoms such as dysuria which may indicate an acute problem such as a urinary tract infection (UTI).

In addition, it is important to screen for underlying conditions such as diabetes and menopause, which may exacerbate the condition, and to assess bowel function, sexual function and psychological wellbeing.

Generally, incontinence is a clinical diagnosis, and often does not require any specialist investigations. Preliminary investigations are likely to include urinalysis to assess for the presence of leukocytes and nitrites, which may indicate UTI, and physical examination.

Physical examination should include an abdominal examination, palpating for any masses (e.g. uterine fibroids) or evidence of a distended bladder. A pelvic examination should be considered to assess for vaginal atrophy or pelvic organ prolapse and to assess the genital skin for irritation.

Specialist referral should be considered in those with haematuria, abdominopelvic mass, significant pelvic organ prolapse, pain or any other red-flag symptoms of underlying pathology.

Asking the patient to keep a diary of urinary activity, including frequency and symptomatology, can help delineate the type and extent of urinary incontinence.

Initial management of urinary incontinence is patient-centred and typically involves lifestyle changes such as stopping smoking, weight loss, reducing caffeine and alcohol intake and managing constipation. Any underlying conditions such as diabetes and constipation should be addressed. For women with vulvovaginal atrophy, a trial of vaginal oestrogen or systemic hormone replacement therapy may be helpful.

In stress incontinence, a referral for supervised pelvic floor physiotherapy is likely warranted. For women with stress incontinence who have not responded to conservative measures, there is limited evidence for pharmacological agents such as Pseudoephedrine and Duloxetine; however, these are not licensed for this indication in Australia.

Surgical management may be considered, for example, in those with refractory and problematic stress incontinence or in those with concurrent pelvic organ prolapse.

Similarly, lifestyle modification may benefit urge incontinence, including reducing fluid intake in the evenings and bladder training. Bladder training involves introducing timed voiding to increase bladder distensibility.

Medical therapy with antimuscarinic drugs is also indicated for urge incontinence – these include Oxybutynin and Tolterodine.

It is important to signpost all women to continence products such as pads and pants.

In conclusion, urinary incontinence is a common yet under-represented problem in women attending primary care. Therefore, the general practitioner must be comfortable asking about, investigating and managing this problem.

Dr Samantha Miller, MBChB

Read another article like this one: Supporting post-menopausal women in primary care

References

1. National Institute of Clinical Excellent (NICE)(2019). NICE Guideline [NG123] Urinary incontinence and pelvic organ prolapse in women: management. https://www.nice.org.uk/guidance/ng123
2. Clinical Knowledge Summary. Incontinence – urinary, in women. https://cks.nice.org.uk/topics/incontinence-urinary-in-women/
3. Barkin, J., Habert, J. and Wong, A (2017) The practical update for family physicians in the diagnosis and management of overactive bladder and lower urinary tract symptoms. Canadian journal of urology 24(5S1), 1-11. https://pubmed.ncbi.nlm.nih.gov/29151006/
4. BMJ Best Practice (2020). Urinary incontinence in women. https://bestpractice.bmj.com/topics/en-gb/169
5. Continence Foundation of Australia (2022). continence.org.au
6. Australasian Menopause Society https://www.menopause.org.au/
7. Department of Health, State Government of Victoria, Australia. Better Health Channel: Incontinence and continence problems. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/incontinence-and-continence-problems
8. Australian Family Physician (2008). Urinary incontinence: Assessment in Women: Stress, Urge or Both. https://www.racgp.org.au/afp/backissues/2008/22877
9. Australian Family Physician (2008). Urinary Incontinence: Pathophysiology and Management Outline https://www.racgp.org.au/getattachment/9168d17f-0cec-4c20-9263-8e6d44db899d/attachment.aspx