Urinary Incontinence

Urinary IncontinenceUrinary Incontinence

Jorge G. Ruiz, MD, FACPJorge G. Ruiz, MD, FACPDivision of Gerontology and Geriatric MedicineDivision of Gerontology and Geriatric MedicineUniversity of Miami School of MedicineUniversity of Miami School of Medicine

Urinary IncontinenceUrinary Incontinence

• EpidemiologyEpidemiology

• Quality of LifeQuality of Life

• Risk Factors and CausesRisk Factors and Causes

• Types of Urinary IncontinenceTypes of Urinary Incontinence

• EvaluationEvaluation

• TreatmentTreatment

EpidemiologyEpidemiology

Urinary incontinenceUrinary incontinenceEpidemiologyEpidemiology

• UI affects approximately 13 million UI affects approximately 13 million Americans, with the highest prevalence in Americans, with the highest prevalence in the elderly (community and institutions)the elderly (community and institutions)

• Although the prevalence of UI increases Although the prevalence of UI increases with age, UI should not be considered a with age, UI should not be considered a normal part of the aging process.normal part of the aging process.

• Reported prevalence rates of UI vary Reported prevalence rates of UI vary considerably.considerably.


• Among the population between 15 and 64 Among the population between 15 and 64 years of age, the prevalence of UI in men years of age, the prevalence of UI in men ranges from 1.5 to 5 percent and in women ranges from 1.5 to 5 percent and in women from 10 to 30 percent from 10 to 30 percent

• Although UI is usually regarded as a Although UI is usually regarded as a condition affecting older multiparous women, condition affecting older multiparous women, it is also common in young, nulliparous it is also common in young, nulliparous women, particularly during physical activitywomen, particularly during physical activity


• For non institutionalized persons older than For non institutionalized persons older than 60 years of age, the prevalence of UI ranges 60 years of age, the prevalence of UI ranges from 15 to 35 percent, with women having from 15 to 35 percent, with women having twice the prevalence of mentwice the prevalence of men

• Between 25 and 30 percent of those Between 25 and 30 percent of those identified as incontinent have frequent identified as incontinent have frequent incontinence episodes, usually daily or incontinence episodes, usually daily or weeklyweekly


• Approximately 53% of the homebound elderly Approximately 53% of the homebound elderly are incontinent are incontinent

• A random sampling of hospitalized elderly A random sampling of hospitalized elderly identified 11% as having persistent UI at identified 11% as having persistent UI at admission and 23% at dischargeadmission and 23% at discharge

• Among the more than 1.5 million nursing facility Among the more than 1.5 million nursing facility residents, the prevalence of UI is >50%, with the residents, the prevalence of UI is >50%, with the majority of nursing home residents having majority of nursing home residents having frequent UIfrequent UI

Urinary incontinenceUrinary incontinenceCostsCosts

• A recent estimate of the direct costs of caring A recent estimate of the direct costs of caring for persons of all ages with incontinence is for persons of all ages with incontinence is $11.2 billion annually in the community and $11.2 billion annually in the community and $5.2 billion in nursing homes (based on 1994 $5.2 billion in nursing homes (based on 1994 dollars) dollars)

• This cost estimate is more than 60 percent This cost estimate is more than 60 percent greater than a previous estimate an, increase greater than a previous estimate an, increase greater than that for the cost of services in the greater than that for the cost of services in the medical care sectormedical care sector

Quality of LifeQuality of Life

Urinary incontinenceUrinary incontinence Quality of Life Quality of Life • UI imposes a significant psychosocial UI imposes a significant psychosocial

impact on individuals, their families, and impact on individuals, their families, and caregivers. caregivers.

• UI results in a loss of self-esteem and a UI results in a loss of self-esteem and a decrease in ability to maintain an decrease in ability to maintain an independent lifestyle. independent lifestyle.

• Dependence on caregivers for activities of Dependence on caregivers for activities of daily life increases as incontinence worsensdaily life increases as incontinence worsens.

Urinary incontinenceUrinary incontinence Quality of Life Quality of Life • Consequently, excursions outside the home, Consequently, excursions outside the home,

social interaction with friends and family, and social interaction with friends and family, and sexual activity may be restricted or avoided sexual activity may be restricted or avoided entirely entirely

• UI is often undetected and underreported by UI is often undetected and underreported by hospital and nursing home personnel, masking hospital and nursing home personnel, masking its true extent and clinical impact and reducing its true extent and clinical impact and reducing the opportunity for effective management.the opportunity for effective management.

Urinary incontinenceUrinary incontinenceRisk factorsRisk factors

• Immobility/chronic Immobility/chronic degenerative disease degenerative disease

• Impaired cognitionImpaired cognition• Medications Medications • Morbid obesity Morbid obesity • Diuretics Diuretics • Smoking Smoking • Fecal impactionFecal impaction

• DeliriumDelirium• Low fluid intake Low fluid intake • Environmental Environmental

barriers barriers • High-impact physical High-impact physical

activities activities • Diabetes Diabetes • Stroke Stroke

Urinary incontinenceUrinary incontinenceRisk factorsRisk factors

• Estrogen depletionEstrogen depletion• Pelvic muscle weaknessPelvic muscle weakness• Childhood nocturnal enuresis Childhood nocturnal enuresis • Race Race • Pregnancy/vaginal delivery/episiotomyPregnancy/vaginal delivery/episiotomy

Risk Factors and CausesRisk Factors and Causes

Urinary incontinenceUrinary incontinenceCausesCauses

• Conditions affecting the lower urinary tractConditions affecting the lower urinary tract

• Drug side effectsDrug side effects

• Increased urine productionIncreased urine production

• Impaired ability or willingness to reach aImpaired ability or willingness to reach a

• toilet toilet

Urinary incontinenceUrinary incontinence Conditions affecting the lower urinary Conditions affecting the lower urinary

tract tract

• Urinary tract infection Urinary tract infection

• Atrophic vaginitis/urethritis Atrophic vaginitis/urethritis

• Pregnancy/vaginal delivery/episiotomy Pregnancy/vaginal delivery/episiotomy

• Post prostatectomy Post prostatectomy

• Stool impaction Stool impaction

Urinary incontinenceUrinary incontinenceDrug side effectsDrug side effects • Diuretics Diuretics • Caffeine Caffeine • Anticholinergic agentsAnticholinergic agents• Psychotropics: Psychotropics:

– AntidepressantsAntidepressants– AntipsychoticsAntipsychotics– Sedatives/hypnotics/CNS depressantsSedatives/hypnotics/CNS depressants

Urinary incontinenceUrinary incontinenceDrug side effectsDrug side effects • Narcotic analgesicsNarcotic analgesics

• Alpha-adrenergic blockers Alpha-adrenergic blockers

• Alpha-adrenergic agonistsAlpha-adrenergic agonists

• Beta-adrenergic agonistsBeta-adrenergic agonists

• Calcium channel blockers: Calcium channel blockers:

• AlcoholAlcohol

Urinary incontinenceUrinary incontinence Increased urine production Increased urine production • Metabolic (hyperglycemia, hypercalcemia) Metabolic (hyperglycemia, hypercalcemia)

• Excess fluid intake Excess fluid intake

• Volume overload Volume overload

• Venous insufficiency with edema Venous insufficiency with edema

• Congestive heart failure Congestive heart failure

Urinary incontinence Urinary incontinence Impaired ability or willingness to reach a Impaired ability or willingness to reach a

toilettoilet

• Delirium Delirium

• Chronic illness, injury, or restraint that Chronic illness, injury, or restraint that interferes with mobility interferes with mobility

• Psychological Psychological

Types of Urinary IncontinenceTypes of Urinary Incontinence

Urinary incontinence Urinary incontinence TypesTypes • UrgeUrge

• StressStress

• MixedMixed

• OverflowOverflow

• FunctionalFunctional

Urinary incontinence Urinary incontinence Urge Incontinence Urge Incontinence • Involuntary loss of urine associated with a Involuntary loss of urine associated with a

strong desire to void (urgency). strong desire to void (urgency).

• It is usually associated with the urodynamic It is usually associated with the urodynamic finding of involuntary detrusor contractions finding of involuntary detrusor contractions or or detrusor instability (DI). detrusor instability (DI).

• Although DI can be associated with Although DI can be associated with neurologic disorders, it also occurs in neurologic disorders, it also occurs in individuals who appear to be normal. individuals who appear to be normal.

Urinary incontinence Urinary incontinence Urge Incontinence Urge Incontinence • The uninhibited bladder contractions The uninhibited bladder contractions

associated with DI can cause UI with and associated with DI can cause UI with and without symptoms of urgency.without symptoms of urgency.

• It can also cause symptoms of urgency It can also cause symptoms of urgency without concomitant incontinence.without concomitant incontinence.

• When a causative neurologic lesion is When a causative neurologic lesion is established, the DI is called established, the DI is called detrusor detrusor hyperreflexia (DH) .hyperreflexia (DH) .

Urinary incontinence Urinary incontinence Urge Incontinence Urge Incontinence • Stroke is associated with DH.Stroke is associated with DH.• Suprasacral spinal cord lesions/multiple Suprasacral spinal cord lesions/multiple

sclerosis: DH is commonly accompanied by sclerosis: DH is commonly accompanied by detrusor sphincter dyssynergia (DSD)detrusor sphincter dyssynergia (DSD) (inappropriate contraction of the external (inappropriate contraction of the external sphincter with detrusor contraction). sphincter with detrusor contraction).

• This can result in the development of urinary This can result in the development of urinary retention, vesicoureteral reflux, and subsequent retention, vesicoureteral reflux, and subsequent renal damage renal damage

Urinary incontinence Urinary incontinence Urge Incontinence Urge Incontinence • Elderly: Elderly: detrusor hyperactivity with detrusor hyperactivity with

impaired bladder contractility is common impaired bladder contractility is common (DHIC)(DHIC)– involuntary detrusor contractions, yet must involuntary detrusor contractions, yet must

strain to empty their bladders either strain to empty their bladders either incompletely or completely.incompletely or completely.

Urinary incontinence Urinary incontinence Urge Incontinence Urge Incontinence • DHIC generally have symptoms of UI and DHIC generally have symptoms of UI and

an elevated PVR, but they may also have an elevated PVR, but they may also have symptoms of obstruction, stress symptoms of obstruction, stress incontinence, or overflow incontinence. incontinence, or overflow incontinence.

Urinary incontinence Urinary incontinence Stress IncontinenceStress Incontinence (SUI) (SUI)• It presents clinically as the involuntary loss It presents clinically as the involuntary loss

of urine during coughing, sneezing, of urine during coughing, sneezing, laughing, or other physical activities that laughing, or other physical activities that increase intra-abdominal pressure. increase intra-abdominal pressure.

• SUI is defined as urine loss coincident with SUI is defined as urine loss coincident with an increase in intra-abdominal pressure, in an increase in intra-abdominal pressure, in the absence of a detrusor contraction or an the absence of a detrusor contraction or an overdistended bladder. overdistended bladder.

Urinary incontinence Urinary incontinence Stress IncontinenceStress Incontinence • The most common cause in women is urethral The most common cause in women is urethral

hypermobility, or significant displacement of hypermobility, or significant displacement of the urethra and bladder neck during exertion the urethra and bladder neck during exertion (pressure) (pressure)

• SUI may also be caused by an intrinsic urethral SUI may also be caused by an intrinsic urethral sphincter deficiency which may be due to sphincter deficiency which may be due to congenital sphincter weakness in patients with congenital sphincter weakness in patients with myelomeningocele, epispadias, or pelvic myelomeningocele, epispadias, or pelvic denervation,denervation,

Urinary incontinence Urinary incontinence Stress IncontinenceStress Incontinence • It may be acquired after prostatectomy, It may be acquired after prostatectomy,

trauma, radiation therapy, or a sacral cord trauma, radiation therapy, or a sacral cord lesion.lesion.

• In womenIn women, Intrinsic Sphincter Deficiency , Intrinsic Sphincter Deficiency (ISD) (ISD) is commonly associated with multiple is commonly associated with multiple incontinence surgical procedures, as well as incontinence surgical procedures, as well as with hypoestrogenism, aging, or both. with hypoestrogenism, aging, or both.

Urinary incontinence Urinary incontinence Stress IncontinenceStress Incontinence • In ISD the urethral sphincter is unable to In ISD the urethral sphincter is unable to

generate enough resistance to retain urine in generate enough resistance to retain urine in the bladder, especially during stressthe bladder, especially during stress

• Patients with ISD often leak continuously or Patients with ISD often leak continuously or with minimal exertion.with minimal exertion.

• In some patients, stress incontinence results In some patients, stress incontinence results from coexisting ISD and hypermobility of from coexisting ISD and hypermobility of the urethra and bladder neck.the urethra and bladder neck.

Urinary incontinence Urinary incontinence Overflow IncontinenceOverflow Incontinence • Involuntary loss of urine associated with Involuntary loss of urine associated with

overdistension of the bladder overdistension of the bladder • It may have a variety of presentations, including It may have a variety of presentations, including

frequent or constant dribbling, or urge or stress frequent or constant dribbling, or urge or stress incontinence symptoms. incontinence symptoms.

• Overflow UI may be caused by an underactive or Overflow UI may be caused by an underactive or acontractile detrusor, or to bladder outlet or acontractile detrusor, or to bladder outlet or urethral obstruction leading to overdistension urethral obstruction leading to overdistension and overflow. and overflow.

Urinary incontinence Urinary incontinence Overflow IncontinenceOverflow Incontinence • The bladder may be underactive or The bladder may be underactive or

acontractile secondary to drugs, neurologic acontractile secondary to drugs, neurologic conditions such as diabetic neuropathy, low conditions such as diabetic neuropathy, low spinal cord injury, or radical pelvic surgery spinal cord injury, or radical pelvic surgery that interrupts the motor innervation of the that interrupts the motor innervation of the detrusor muscle. detrusor muscle.

• The detrusor muscle may also be The detrusor muscle may also be underactive from idiopathic causes.underactive from idiopathic causes.

Urinary incontinence Urinary incontinence Overflow IncontinenceOverflow Incontinence • In men, it is associated with obstruction In men, it is associated with obstruction

commonly caused by BPH and, less commonly caused by BPH and, less frequently, prostatic CA or urethral frequently, prostatic CA or urethral stricture. stricture.

• Although an outlet obstruction is rare in Although an outlet obstruction is rare in women, it can occur as a complication of an women, it can occur as a complication of an anti-incontinence operation and because of anti-incontinence operation and because of severe pelvic organ prolapse.severe pelvic organ prolapse.

Urinary incontinence Urinary incontinence Overflow IncontinenceOverflow Incontinence • In patients with suprasacral spinal cord In patients with suprasacral spinal cord

injury or multiple sclerosis, DSD can cause injury or multiple sclerosis, DSD can cause obstruction when the external sphincter obstruction when the external sphincter muscle inappropriately and involuntarily muscle inappropriately and involuntarily contracts rather than relaxes at the same contracts rather than relaxes at the same time the detrusor contractstime the detrusor contracts

Urinary incontinence Urinary incontinence Functional IncontinenceFunctional Incontinence • Urine loss may be caused by factors outside the Urine loss may be caused by factors outside the

lower urinary tract such as chronic impairment lower urinary tract such as chronic impairment of physical or cognitive functioning, or both.of physical or cognitive functioning, or both.

• This diagnosis should be one of exclusion, This diagnosis should be one of exclusion, however, because some immobile and however, because some immobile and cognitively impaired individuals have other cognitively impaired individuals have other types and causes of UI that may respond to types and causes of UI that may respond to specific therapies.specific therapies.

Urinary incontinence Urinary incontinence Functional IncontinenceFunctional Incontinence • UI can often be improved or "cured" by UI can often be improved or "cured" by

improving the patient's functional status, improving the patient's functional status, treating other medical conditions, treating other medical conditions, discontinuing certain types of medication, discontinuing certain types of medication, adjusting the hydration status, reducing adjusting the hydration status, reducing environmental barriers, or all of the above environmental barriers, or all of the above -- even if a lower urinary tract abnormality -- even if a lower urinary tract abnormality is present.is present.

EvaluationEvaluation

Identifying Urinary IncontinenceIdentifying Urinary Incontinence• Open-ended requests such as Open-ended requests such as

– "Tell me about the problems you are having with your "Tell me about the problems you are having with your bladder" and bladder" and

– "Tell me about the trouble you are having holding your "Tell me about the trouble you are having holding your urine (water)" urine (water)"

• If the patient responds negatively:If the patient responds negatively:– "How often do you lose urine when you don't want to?" "How often do you lose urine when you don't want to?"

and and – "How often do you wear a pad or other protective device "How often do you wear a pad or other protective device

to collect your urine?"to collect your urine?"

Identifying Urinary IncontinenceIdentifying Urinary Incontinence

• In licensed nursing facilities, assessment of In licensed nursing facilities, assessment of continence status using the Minimum Data Set continence status using the Minimum Data Set (MDS) is required within 14 days of admission (MDS) is required within 14 days of admission and every 3 months thereafterand every 3 months thereafter

• If UI is identified by questioning, detecting an If UI is identified by questioning, detecting an odor, observing wetness, or by a patient odor, observing wetness, or by a patient complaint, and represents a problem for the complaint, and represents a problem for the patient or caregiver, evaluation should be patient or caregiver, evaluation should be undertakenundertaken

Identifying Urinary IncontinenceIdentifying Urinary IncontinenceBasic EvaluationBasic Evaluation

• All patients with UI should undergo a basic All patients with UI should undergo a basic evaluation that includes a evaluation that includes a – historyhistory– physical examinationphysical examination– measurement of postvoid residual volumemeasurement of postvoid residual volume– urinalysis. urinalysis.

• Risk factors that are associated with UI should Risk factors that are associated with UI should be identified and attempts made to modify them. be identified and attempts made to modify them.

Identifying Urinary IncontinenceIdentifying Urinary IncontinenceOther testsOther tests

• Blood testing (BUN, creatinine, glucose, Blood testing (BUN, creatinine, glucose, and calcium) is recommended if and calcium) is recommended if compromised renal function is suspected or compromised renal function is suspected or if polyuria (in the absence of diuretics) is if polyuria (in the absence of diuretics) is present. present.

• Urine cytology is not recommended in the Urine cytology is not recommended in the routine evaluation of the incontinent routine evaluation of the incontinent patient.patient.

Identifying Urinary IncontinenceIdentifying Urinary IncontinenceCriteria for further evaluationCriteria for further evaluation

• Uncertain diagnosis and inability to develop a Uncertain diagnosis and inability to develop a reasonable treatment plan reasonable treatment plan

• Failure to respond to the patient's satisfaction Failure to respond to the patient's satisfaction to an adequate therapeutic trial, and the patient to an adequate therapeutic trial, and the patient is interested in pursuing further therapy. is interested in pursuing further therapy.

• Consideration of surgical intervention, Consideration of surgical intervention, particularly if previous surgery failed or the particularly if previous surgery failed or the patient is a high surgical risk. patient is a high surgical risk.


• Hematuria without infection. Hematuria without infection.

• The presence of comorbid conditions:The presence of comorbid conditions:– incontinence associated with recurrent incontinence associated with recurrent

symptomatic UTI symptomatic UTI – persistent symptoms of difficult bladder persistent symptoms of difficult bladder

emptying emptying – history of previous anti-incontinence surgery or history of previous anti-incontinence surgery or

radical pelvic surgery radical pelvic surgery


• The presence of comorbid conditions:The presence of comorbid conditions:– prostate nodule, asymmetry, or other suspicion prostate nodule, asymmetry, or other suspicion

of prostate cancer of prostate cancer – abnormal PVR urine abnormal PVR urine – neurologic condition, such as multiple sclerosis neurologic condition, such as multiple sclerosis

and spinal cord lesions or injuryand spinal cord lesions or injury

Identifying Urinary IncontinenceIdentifying Urinary IncontinenceSpecialized diagnostic testsSpecialized diagnostic tests

• Urodynamic tests. Urodynamic tests.

• Endoscopic tests. Endoscopic tests.

• Imaging tests.Imaging tests.

TreatmentTreatment

Treatment of Urinary Treatment of Urinary IncontinenceIncontinence• The three major categories of treatment are The three major categories of treatment are

– Behavioral. Behavioral.

– Pharmacologic. Pharmacologic.

– Surgical. Surgical.

Behavioral TechniquesBehavioral Techniques• They decrease the frequency of UI in most They decrease the frequency of UI in most

individuals when provided by knowledgeable individuals when provided by knowledgeable health care providers, have no reported side health care providers, have no reported side effects, and do not limit future treatment options.effects, and do not limit future treatment options.

• Behavioral therapies can be divided into (1) Behavioral therapies can be divided into (1) caregiver-dependent techniques for patients with caregiver-dependent techniques for patients with cognitive and motor deficits (2) those requiring cognitive and motor deficits (2) those requiring active rehabilitation and education techniques.active rehabilitation and education techniques.

Behavioral TechniquesBehavioral Techniques• They are listed below in the order of those They are listed below in the order of those

requiring passive involvement to those requiring passive involvement to those requiring active participation: requiring active participation: – Toileting assistance -- routine/scheduled Toileting assistance -- routine/scheduled

toileting, habit training, and prompted voiding. toileting, habit training, and prompted voiding. – Bladder retraining. Bladder retraining. – Pelvic muscle rehabilitation -- Pelvic muscle Pelvic muscle rehabilitation -- Pelvic muscle

exercisesexercises

Behavioral TechniquesBehavioral Techniques Pelvic Muscle Exercises Pelvic Muscle Exercises

• Teaching exercises to strengthen pelvic Teaching exercises to strengthen pelvic muscles may decrease the incidence of UI.muscles may decrease the incidence of UI.

• They are recommended for women with They are recommended for women with SUI. SUI.

Behavioral TechniquesBehavioral Techniques Pelvic Muscle Exercises (PMEs) Pelvic Muscle Exercises (PMEs)

• PMEs are also recommended in men and PMEs are also recommended in men and women in conjunction with bladder training women in conjunction with bladder training for urge incontinence. for urge incontinence.

• PMEs may also benefit men who develop PMEs may also benefit men who develop urinary incontinence following urinary incontinence following prostatectomyprostatectomy

Behavioral TechniquesBehavioral Techniques Pelvic Muscle Exercises Pelvic Muscle Exercises• PMEs, also called Kegel exercises and PMEs, also called Kegel exercises and

pelvic floor exercises, are performed to pelvic floor exercises, are performed to strengthen the voluntary periurethral and strengthen the voluntary periurethral and perivaginal muscles (i.e., voluntary urinary perivaginal muscles (i.e., voluntary urinary sphincters and levator ani) that contribute to sphincters and levator ani) that contribute to the closing force of the urethra and to the the closing force of the urethra and to the support of the pelvic visceral structures.support of the pelvic visceral structures.

Pharmacologic treatmentPharmacologic treatmentUrge Incontinence. Detrusor instabilityUrge Incontinence. Detrusor instability• Anticholinergic agents: oxybutynin, Anticholinergic agents: oxybutynin,

dicyclomine hydrochloride, and dicyclomine hydrochloride, and propantheline propantheline (First Line).(First Line).

• Tricyclic antidepressants: imipramine, Tricyclic antidepressants: imipramine, doxepin, desipramine, and nortriptyline. doxepin, desipramine, and nortriptyline.

• Oxybutynin Oxybutynin is the anticholinergic agent of is the anticholinergic agent of choice.choice.

• Anticholinergic agents block contraction of Anticholinergic agents block contraction of the normal bladder and unstable bladderthe normal bladder and unstable bladder

Pharmacologic treatmentPharmacologic treatmentStress Incontinence: Urethral Sphincter Stress Incontinence: Urethral Sphincter

InsufficiencyInsufficiency • The rationale for pharmacologic therapy: The rationale for pharmacologic therapy:

high concentration of high concentration of -adrenergic -adrenergic receptors in the bladder neck, bladder base, receptors in the bladder neck, bladder base, and proximal urethra.and proximal urethra.

• Sympathomimetic drugs with alpha-Sympathomimetic drugs with alpha-adrenergic agonist activity presumably adrenergic agonist activity presumably cause muscle contraction in these areas and cause muscle contraction in these areas and thereby increase bladder outlet resistance. thereby increase bladder outlet resistance.

Pharmacologic treatmentPharmacologic treatmentStress Incontinence: Urethral Sphincter Stress Incontinence: Urethral Sphincter

InsufficiencyInsufficiency • Pharmacotherapeutic strategies include: Pharmacotherapeutic strategies include:

– drugs with drugs with -adrenergic agonist activity,-adrenergic agonist activity,– estrogen supplementation both for direct effect estrogen supplementation both for direct effect

on urethral mucosal and periurethral tissues and on urethral mucosal and periurethral tissues and for enhancement of for enhancement of -adrenergic response -adrenergic response

--adrenergic-blocking drugs that may allow adrenergic-blocking drugs that may allow unopposed stimulation of unopposed stimulation of -receptor-mediated -receptor-mediated contractile muscle responses.contractile muscle responses.

Surgical treatmentSurgical treatment

• The decision should be made only after a good The decision should be made only after a good assessment that includes a clinical evaluation assessment that includes a clinical evaluation with confirmation of the pathophysiologic with confirmation of the pathophysiologic diagnosis and severity of urinary loss, a diagnosis and severity of urinary loss, a correlation of the anatomic and physiologic correlation of the anatomic and physiologic findings with the surgical plan, an estimation findings with the surgical plan, an estimation of surgical risk, and an estimation of the impact of surgical risk, and an estimation of the impact of the proposed surgery on the patient's quality of the proposed surgery on the patient's quality of life.of life.

Surgical treatmentSurgical treatment• Surgery is recommended for stress incontinence in Surgery is recommended for stress incontinence in

men and women and may be recommended as men and women and may be recommended as first-line treatment for selected patients who are first-line treatment for selected patients who are unable to comply with other nonsurgical therapies. unable to comply with other nonsurgical therapies.

• Surgery in the management of urge incontinence is Surgery in the management of urge incontinence is uncommon. uncommon.

• Surgical treatment is considered only in highly Surgical treatment is considered only in highly symptomatic patients in whom nonoperative symptomatic patients in whom nonoperative management has failed.management has failed.

Surgical treatmentSurgical treatment

• Symptoms of overflow or incontinence Symptoms of overflow or incontinence secondary to urethral obstruction can be secondary to urethral obstruction can be addressed with a surgical procedure to relieve addressed with a surgical procedure to relieve the obstruction.the obstruction.

• Intermittent catheterization or an indwelling Intermittent catheterization or an indwelling catheter may be considered in patients who are catheter may be considered in patients who are not candidates for surgery and suffer overflow not candidates for surgery and suffer overflow incontinence due to urethral obstructionincontinence due to urethral obstruction

Urinary IncontinenceUrinary IncontinenceOther measuresOther measures• Intermittent catheterization. Intermittent catheterization.

• Indwelling urethral catheterization. Indwelling urethral catheterization.

• Suprapubic catheters. Suprapubic catheters.

• External collection systems. External collection systems.

• Penile compression devices. Penile compression devices.

• Pelvic organ support devices (pessaries)Pelvic organ support devices (pessaries)

• Absorbent pads or garmentsAbsorbent pads or garments

Urinary Incontinence

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