Clinical Consult

Each month, questions with a common theme will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

This Month's Question:

In a busy clinical setting, what are ways to ensure that urinary incontinence and its treatment options are addressed with patients?

Response by Carolyn M. Sampselle, PhD, RNC, posted 03/28/2005:

Urinary incontinence is an underreported and undertreated condition that has traditionally been regarded as a symptom of an underlying disorder, an inevitable consequence of aging, or a hygienic problem. However, studies of the adverse effects of urinary incontinence have shown that it is a clinically relevant disorder that negatively impacts the patient's quality of life and physical and psychosocial well-being.¹ Moreover, evidence suggests that urinary incontinence frequently occurs in younger adults as well as women across the life span. The prevalence of urinary incontinence and the potential success of treatment and improved quality-of-life outcomes justify routine screening, assessment, and treatment.¹

It is important for clinicians in primary care to elicit urinary complaints from their patients.² Embarrassment, low expectations of the efficacy of treatment, or the invalid belief that urinary incontinence is part of the normal aging process are some of the reasons many women don't broach the subject of urinary incontinence with their clinicians.³ It is a challenge for the primary care clinician to provide appropriate treatment for urinary incontinence when only an estimated 1 in 4 incontinent women seek help.⁴ Additionally, it has been reported that clinicians may fail to query their patients about incontinence symptoms or to diagnose the underlying cause and recommend treatment.⁵ It is incumbent on clinicians to be aware of the subtypes of urinary incontinence, know the risk factors and symptoms of each, and proactively identify patients who suffer from any form of urinary incontinence.^6,7

Stress urinary incontinence (SUI) is a type of urinary incontinence characterized by the involuntary loss of urine during an increase in intra-abdominal pressure produced by activities such as coughing, laughing, or exercising. Urge urinary incontinence (UUI) is defined as the involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full. By asking a few simple questions, such as “Do you leak urine when you laugh, sneeze, or lift something?” and “Do you ever leak urine when you have a strong urge on the way to the bathroom?” the clinician can screen the patient for urinary incontinence and differentiate between SUI, UUI, or a combination of SUI and UUI, referred to as mixed urinary incontinence.⁸ If indicated, the clinician can then give the patient a daily bladder diary to complete before returning for a comprehensive urinary incontinence evaluation at a subsequent office visit. The diary will provide the clinician with valuable information about the pattern and frequency of the incontinence episodes.^7,8

In primary care, patient information can be provided in the waiting room via brochures, handouts, books, and television programs about urinary incontinence and good bladder health. In addition, an incontinence symptom questionnaire can be completed by patients in the waiting room to screen for incontinence.^9,10 It is noteworthy that a series of 4 queries incorporated into the standard history completed by patients in ambulatory women's healthcare settings yielded a 57% positive report of incontinence.¹¹

In the examination room, the clinician can begin by reviewing the patient questionnaire to identify symptoms and differentiate the subtype of urinary incontinence. “Red flags” that should prompt further questions from the clinician include urine odor, wearing sanitary pads for nonmenstrual reasons, and depression. Particularly, clinicians should be alert to heavily perfumed patients who are using deodorant spray or dusting powder to conceal their urinary incontinence.^12,13 Moreover, chronic constipation and side effects of certain medications, such as diuretics and alpha-adrenergic blockers, may trigger incontinence.⁷ Next, a focused history, including all current medications; a physical examination, including a pelvic floor muscle assessment; and a urinalysis are done. Referral for more extensive urodynamic testing is indicated for patients with hematuria without infection, recurrent urinary tract or periurethral infections, severe pelvic organ prolapse, or suspected incomplete bladder emptying (elevated postvoid residual urine volume). Patient desire or clinician recommendation for surgical intervention requires referral to a specialist.⁷

Behavioral interventions, specifically lifestyle changes, pelvic floor muscle training, and bladder training, are nonpharmacologic treatments for SUI that can be recommended in primary care.⁷ Instruction in the Knack is a valuable complement to pelvic floor muscle training; this intentional contraction of the pelvic floor muscles immediately preceding an activity that increases intra-abdominal pressure can eliminate or substantially decrease urine leakage.¹⁴ Motivational and instructional tapes, biofeedback, or electrical stimulation are aids that can be provided by the clinician to promote adherence to a pelvic floor exercise program.¹⁵ The clinician also may recommend medical devices, such as the incontinence pessary, to help the patient manage urine leakage. The ability to improve or resolve urinary incontinence is independent of age; hence clinicians should not hesitate to recommend therapy despite age or frailty.¹⁶

References

1. Gray M. The importance of screening, assessing, and managing urinary incontinence in primary care. J Am Acad Nurse Pract. 2003;15:102-107.

2. Kirby M. A review of the role of primary care in the diagnosis and management of stress urinary incontinence. Health Serv J. 2004;114(suppl):3-7.

3. Newman DK. Stress urinary incontinence in women. Am J Nurs. 2003;103:46-55.

4. Hannestad YS, Rortveit G, Hunskaar S. Help-seeking and associated factors in female urinary incontinence. The Norwegian EPINCONT Study. Scand J Prim Health Care. 2002;20:102-107.

5. Jones TV, Bunner SH. Approaches to urinary incontinence in a rural population: a comparison of physician assistants, nurse practitioners, and family physicians. J Am Board Fam Pract. 1998;11:207-215.

6. Williams K. Stress urinary incontinence: treatment and support. Nurs Stand. 2004;18:45-52.

7. Newman DK. Therapeutic strategies for managing stress urinary incontinence in women. Am J Nurse Pract. 2004;(suppl):23-32.

8. Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2000;62:2433-2444, 2447, 2452.

9. Gunthorpe W, Brown W, Redman S. The development and evaluation of an incontinence screening questionnaire for female primary care. Neurourol Urodyn. 2000;19:595-607.

10. Collaborative to Support Urinary Incontinence and Women's Health (cSUIWH) Web site Clinical Tools. Available at: http://www.stressui.org/clinical_tools.htm.

11. Sampselle CM, Wyman JF, Thomas KK, et al. Continence for women: evaluation of AWHONN's third research utilization project. Association of Women's Health Obstetric and Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2000;29:9-17.

12. Fitzgerald ST, Palmer MH, Kirkland VL, Robinson L. The impact of urinary incontinence in working women: a study in a production facility. Women Health. 2002;35:1-16.

13. Lagro-Janssen T, Smits A, Van Weel C. Urinary incontinence in women and the effects on their lives. Scand J Prim Health Care. 1992;10:211-216.

14. Miller JM. Childbearing-associated risks and strategies for the prevention and management of stress urinary incontinence. Women's Health Care. 2005; (Feb suppl):4-7.

15. Palmer MH. Stress urinary incontinence: prevalence, etiology, and risk factors in women at 3 life stages. Am J Nurse Pract. 2004;(suppl):5-14.

16. Engberg S. Age-associated risks and strategies for the prevention and management of stress urinary incontinence in community-dwelling older women. Women's Health Care. 2005;(Feb suppl):8-12.

17. Dmochowski RR, Miklos JR, Norton PA, Zinner NR, Yalcin I, Bump RC; Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170:1259-1263.

18. Cardozo L, Drutz HP, Baygani SK, Bump RC. Pharmacological treatment of women awaiting surgery for stress urinary incontinence. Obstet Gynecol. 2004;104:511-519.