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Ten tips on managing female urinary incontinence

GP Dr Julian Spinks offers his advice on presentation, examination and initial diagnosis, pharmacological and lifestyle interventions and when to refer.

GP Dr Julian Spinks offers his advice on presentation, examination and initial diagnosis, pharmacological and lifestyle interventions and when to refer.

1 Ask about incontinence in any woman presenting with gynaecological or urinary symptoms. Patients may not present with urinary incontinence. Five million women in the UK have urinary incontinence or overactive bladder but the stigma associated with the condition may prevent them from seeking help. If a women presents with any gynaecological or urinary symptoms it is helpful to ask about urinary incontinence. Attendance for smears, well-woman checks or other check-ups are another opportunity to discuss the problem.

2 It's not just older women. Stress incontinence is largely caused by childbirth so women as young as teenagers can develop the problem. Urge incontinence often appears later in life. In the elderly and frail, diminishing mobility causes a slight fall in the prevalence of stress incontinence but the increased time taken to reach the toilet may worsen the effects of urge incontinence.

3 The history makes the initial diagnosis. The three main types of incontinence – stress, urge and mixed – can normally be distinguished on history. Ask the women whether she leaks on coughing, sneezing or movement (stress), or whether she has an intense need to urinate before the leakage (urge). If she has both, then the picture is mixed. Frequency or nocturia, with low volumes of urine voided, are also signs of overactive bladder which can occur with or without urge incontinence. This should be treated in the same manner as urge incontinence. The medical, gynaecological and obstetric history may point to the aetiology.

4 Examine the patient abdominally and vaginally. The abdominal examination is largely to look for pathology such as masses arising from the pelvis including ovarian cysts and fibroid uteruses. A palpable bladder suggests significant enlargement—normally more than 300ml—and possible bladder outflow obstruction. The vaginal examination can show prolapse, uterine enlargement or atrophic changes. This is also an opportunity to check pelvic muscle tone and the woman's ability to do pelvic floor contractions.

5 Fancy investigations are generally not required. All women should have urinalysis to detect sugar and infection. Any symptoms of UTI or a positive result for infection should lead to an MSU. As the initial diagnosis of incontinence is clinical, confirmation using urodynamics or other imaging is not required in most cases prior to initial treatment.

6 Get a three-day bladder diary. Ask the woman to complete a three-day diary detailing time and volume of fluid input and urine output together with episodes and amount of leakage and the patient's activity at the time. This is a very useful tool to confirm the type of incontinence and estimate the severity of impact on life. It can be repeated to check response to treatment. In working women, it is useful to include both workdays and days off. Charts are available to download at and from some pharmaceutical manufacturers.

7 Treat the predominate symptom. Initial treatment depends on the type of incontinence present. In mixed incontinence, treat the more troublesome symptom. First-line specific therapy for stress incontinence is three months of pelvic floor exercises. These should be taught – an instruction leaflet isn't enough. If nobody at the practice can do this, referral to the local continence adviser or service may be needed. In urge incontinence, bladder training for at least six weeks is the first step. This aims to gradually increase the time between voids, reducing frequency and urgency. Antimuscarinic drugs may be used if bladder training is unsuccessful. The preparations available have similar efficacy so choice is based on cost, convenience to patients and the incidence of side-effects. Standard-release oxybutynin is the cheapest by some margin but has a higher frequency of side-effects – including dry mouth and constipation – and may be less convenient than once-daily alternatives. Compliance is often a problem with these medications but this may be increased by carefully counselling the patient.

8 Some patients may require referral. Many patients can be treated without referral to specialist services. But alarm symptoms or signs may require urgent referral. These include haematuria (all ages with frank haematuria plus women over 50 with microscopic haematuria), pelvic masses and recurrent UTI with haematuria. Routine referral may be required for other reasons including previous pelvic surgery or radiotherapy, bladder pain, difficulty voiding or if there is prolapse at or below the introitus. Patients who fail to respond to first-line therapies, such as pelvic floor muscle training, bladder training or medication, may also require specialist investigations and interventions such as tension-free vaginal tape for stress incontinence.

9 Lifestyle measures can help. Women whose BMI is high should lose weight. Restricting caffeine and stopping smoking can help. Excessive or insufficient fluid intake can worsen incontinence. Do not forget household modifications and mobility aids. In older patients these can make the difference between incontinence or reaching the toilet in time. In residential and nursing homes, the prompting of patients to visit the toilet by staff can reduce incontinence in patients with confusion or memory disorders.

10 Pads, appliances and catheters are not treatments. Although it is tempting to use continence aids as sole management, patients deserve active management of their incontinence. Such aids should only be used as a coping strategy while awaiting treatment or, eventually, if all treatments have failed. The local continence adviser or service should be involved if continence aids are being considered.

Dr Julian Spinks is a GP in Strood, Kent, and was a member of the NICE guideline development group on urinary incontinence

Competing interests: Dr Spinks has received honoraria from pharmaceutical companies in the field of urinary incontinence

All women with urinary incontinence should have urinalysis to detect sugar and infection Urine dipstick

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