Collaborative for Education on Urinary Incontinence and Women's Health (ceUIwh)

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:

What patient populations are at increased risk for developing stress urinary incontinence and should be screened on an annual basis?

Response by Mary H. Palmer, PhD, RNC, posted 10/30/04:

Stress urinary incontinence (SUI) is the most common form of lost bladder control in women. Normal activities such as coughing, sneezing, laughing, running, or jumping can cause bladder leakage. Major risk factors for SUI are female gender, increased age, pregnancy, vaginal childbirth, estrogen depletion (menopause), and hysterectomy. In addition, lifestyle influences that may play a role in SUI include obesity, diet, high-impact physical activity, smoking, and some medications. Patients with any of these demographic, medical, or lifestyle characteristics should be screened annually for SUI.

The prevalence of SUI is greater in women than in men.¹ The female anatomy makes a woman more vulnerable for SUI, based on urethral length, structure/support, and innervation.² The two major types of SUI are urethral hypermobility and intrinsic sphincter deficiency. In the case of urethral hypermobility, lack of support by the muscles and fascia of the pelvic floor causes the urethra to be displaced from its normal intrapelvic location and to descend outside of the abdominal cavity. In the case of intrinsic sphincter deficiency, support is normal, but the urethral sphincter is unable to generate enough closing pressure to retain urine in the bladder. In addition to these potential anatomical defects, women are more susceptible to injury to the pelvic floor due to vaginal childbirth, menopause, or hysterectomy. Since increasing age is related to muscle weakening, a woman's risk of urinary incontinence increases throughout adulthood, although it is not an inevitable or even a normal part of aging.

Childbirth may damage innervation of the pelvic floor musculature. Having a cesarean or vaginal delivery, compared with never having given birth, is associated with a higher rate of SUI; however, the rate for women with vaginal delivery is higher than that for women who have had a cesarean section.³ Vaginal childbirth can impact the supportive tissue and muscles, and change the position of the bladder neck. Additionally, studies have shown that forceps delivery places a woman at even higher risk than having a normal vaginal delivery.^4,5 Other factors that increase trauma to the pelvic floor include multiparity, increased duration of second-stage labor, third-degree perineal tear, and high birth weight.⁶

Urinary symptoms may occur in perimenopausal women in the 45- to 55-year age range, who experience declining estrogen levels and a consequent thinning of the mucosal lining of the urethra. Given the evidence that tissue atrophy can be reversed with estrogen, and that in some cases estrogen replacement reduces urinary incontinence, estrogen loss is hypothesized to contribute to the problem. The literature is conflicting, however, with some studies showing no difference in the prevalence of urinary incontinence in premenopausal versus postmenopausal women.⁷ For some women, the onset of urinary incontinence begins immediately after a hysterectomy. It is unclear if the connection between a hysterectomy and urinary incontinence is due to hormonal changes, nerve damage during the procedure, or disturbances of the musculofascial attachments of the bladder to the surrounding pelvic wall.⁷

Several lifestyle components, including weight, diet, smoking, and some medications, may increase the risk for developing SUI. Higher body mass index has been reported to be a risk factor for SUI,⁸ as excess body weight can impair blood flow and innervation to the bladder as well as put pressure on the bladder and pelvic floor.⁹ Research has indicated that symptoms of urinary incontinence decrease in obese women who lose a significant amount of weight. ^7,10 In fact, intakes of total fat, saturated fatty acids, and monounsaturated fatty acids have been linked to an increased risk of SUI 1 year later.¹¹ For example, it has been observed that ingesting 76.6 grams of total fat daily, as compared to 44.4 grams, doubles the likelihood for development of SUI.¹¹ Although a high-fat diet may be a risk factor for SUI, it is independent of the risk associated with obesity.¹¹ In another study, consumption of carbonated drinks was reported to be a significant risk factor for the onset of SUI.¹²

Caffeine, a central nervous system stimulant, is found in many beverages, foods, medications, and appetite suppressants. Effects on the lower urinary tract may include voiding frequency, urinary leakage, and urgency or pain with urination or bladder filling and storage.¹³ Although the amount of evidence remains limited, caffeine reduction has been shown to produce a statistically significant and clinically relevant improvement in urinary incontinence.¹⁴ Nicotine's effects on the bladder may be similar to those of caffeine. Smoking is a primary risk factor for emphysema and chronic bronchitis. It has been shown that women who suffer from “smoker's cough” exert significant pressure on the bladder and urethra, leading to bladder leakage.¹⁵

Some prescription medications, such as various treatments for high blood pressure, may disturb the lower urinary tract. For example, diuretics and alpha-blockers can adversely affect bladder filling or emptying and urethral sphincter function, respectively. Furthermore, a recent study showed that 20 postmenopausal women taking perindopril, an angiotensin-converting enzyme inhibitor, suffered from cough-related SUI, or a nagging, dry cough causing urine leakage. Symptoms subsided within 1 week, however, for 19 patients (95%) after a change in therapy to losartan, an angiotensin II receptor antagonist.¹⁶

Screening for SUI can be easily integrated into primary care practice. A screening and symptom questionnaire is a useful instrument for identification and differential diagnosis of urinary incontinence disorders that can be completed by the patient in the waiting room and reviewed by the clinician prior to the examination. If the woman responds positively for bladder leakage, a proper evaluation should follow, including a more detailed medical history, bladder record, physical examination, pelvic floor muscle assessment, and urinalysis.¹⁷ Clinical tools are available for the assessment of SUI in primary care. These include an Incontinence Questionnaire, Daily Bladder Diary, and Pelvic Floor Muscle Assessment, as well as several other useful resources. For a complete list of clinical tools, visit http://www.stressUI.org/clinical_tools.htm.

Treatment selection for SUI may be influenced by severity of the condition and patient preference. Generally, behavioral modifications, such as pelvic floor muscle exercises, lifestyle changes, and bladder training, should be considered first, although their success often depends on the time and commitment invested by both the patient and clinician.¹⁷ Specifically, pelvic floor muscle training helps the patient to isolate and strengthen the pelvic floor muscles, and bladder training helps her to hold greater volumes of urine and to decrease voiding frequency.¹⁸ If these approaches do not provide relief, other treatment options exist including pharmacotherapy, medical devices, and surgery.

References

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