Urinary Incontinence in Women

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This tool is designed to support primary care providers in managing urinary incontinence (UI) in women ≥ 18 years. UI is the involuntary loss of urine and it is an under-diagnosed disorder.1 The treatment of UI involves a step-wise approach of non-pharmacological, pharmacological and in some cases surgical interventions. Providers should work with patients to create a treatment plan that considers patients’ preferences, as well as the practicality, availability and affordability of treatment options.

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Screening

Screening for urinary incontinence in women is important because many women live with this condition for years without bringing it to the attention of their primary care provider. The screening and diagnostic measures below will help to identify if your patient has:

  • stress urinary incontinence (SUI)
  • overactive bladder (OAB)
  • mixed urinary incontinence (MUI)

Identifying your patient’s type of UI will help direct their treatment plan.

Opportunities to screen for UI

Patients who are:

  • Over 65 years of age
  • Postmenopausal
  • Presenting with urinary concerns
  • Diagnosed with conditions associated with an increased risk of UI (e.g. diabetes, obesity and neurologic disease)

 

Scheduled for a:

  • Periodic health examination
  • Pap smear
  • Postpartum visit
Talking points
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Talking points

  • “It can be embarrassing to talk about urinary incontinence, but it is a very common and treatable condition.”3
  • “Many people with incontinence can regain bladder control or at least reduce the amount of leakage they have.”4
Medical History

Assessing the medical history of your patient helps identify any predisposing risk factors5 that can help clarify patient’s urinary symptoms severity and identify potential underlying causes that may be treatable or require further evaluation.2

Ask Patient:

  • When they started experiencing urinary incontinence12
  • The number of vaginal deliveries12
  • If they had urological or gynaecological surgeries such as a total hysterectomy, cystocele repair, pelvic surgery (see referral indicators), history of laparoscopic or open bladder suspension,3,7,8,16
  • If they are postmenopausal (last period over 1 year ago)3,8
  • If they smoke cigarettes12
  • If they experience constipation8
  • If they feel pain or a burning feeling when they urinate12
  • If they have an occupation that requires regular lifting7
  • If they are taking medication that can effect urogenital system and urine retention, such as:5
    • Medications with anticholinergic side effects such as antihistamines, antidepressants, and antipsychotics
    • Calcium-channel blockers
    • Alpha-adrenergic agonists

If patient has or had one or more of the following conditions, consider conducting a work-up/or refer patient to an appropriate specialist:

  • Difficulty urinating6
  • Constant leakage of urine16
  • Unable to control bowel movements6
  • Blood in the urine16
  • Persisting bladder or urethral pain6
  • A history of recurrent urinary tract infection (UTI) (≥2 infections in six months or ≥3 infections in one year)16,19
  • Pelvic surgery16
  • Radiation therapy16
  • Clinically benign pelvic masses6
  • Suspected urogenital fistulae6
  • Previous continence surgery6
  • Suspected neurological disease6
Physical Examination

When examining a patient to rule out a pelvic mass or other pathology, complete the following examination and assessment to determine if prolapse is present.

Examine the perineum:

  • Assess estrogen levels by looking for signs of vaginal atrophy: pale, dry, thin vagina and perineal skin.7

Assess the pelvic floor muscles:

  • Ask the patient to contract the pelvic floor muscles around the examining fingers.13 Consider that:
    • Normal pelvic floor muscles can voluntarily contract and relax13
    • Overactive pelvic floor muscles do not relax12
    • Underactive pelvic floor muscles cannot voluntarily contract13
    • Non-functioning pelvic floor muscles present when no pelvic floor muscle action is palpable13
Stack of papers. Is pelvic organ prolapse suspected?
Yes

Pelvic organ prolapse (POP) is the herniation of the pelvic organs to or beyond the vaginal walls. Many women with POP experience symptoms that impact daily activities, sexual function, and exercise.14 The degree of POP doesn’t always co-relate with the degree of UI symptoms that a patient experiences.

Screening for POP

POP

If examination of the perineum and assessment of pelvic floor muscles leads to suspected POP, treat POP concurrently with UI and proceed with the following steps:3

  • After conducting the examination to detect signs of POP, use the Pelvic Organ Prolapse Quantitation (POP-Q) system to confirm signs of prolapse. POP-Q is an objective, site-specific system for describing and staging POP in women.13,15
  • If a patient has symptoms of prolapse, not explained by a physical examination, consider repeating the examination at another scheduled appointment or with the woman in a standing or squatting position.6
  • If patient with POP presents with any of the following symptoms, refer them to the appropriate specialist (gastroenterologist, gynaecologist or urologist):6,7
    • Pain
    • Symptoms of obstructed defecation or faecal incontinence
    • Symptoms not explained by examination findings
Treatment options

Discuss management options with women who have pelvic organ prolapse, including no treatment, non-surgical treatment and surgical options, taking into account:6

  • Patient’s preferences
  • Site of prolapse
  • Lifestyle factors
  • Comorbidities, including cognitive or physical impairments
  • Age
  • Desire for childbearing
  • Previous abdominal or pelvic floor surgery
  • Benefits and risks of individual procedures
Management options

Non-Surgical options

  • Lifestyle interventions
  • Pelvic floor training
    • Appropriate for: All patients if they can tolerate vaginal examinations.3,7
    • How to: Consider referring patient to a pelvic floor physiotherapist/physiotherapist for supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP-Q stage 1or stage 2 pelvic organ prolapse. If the program is beneficial, advise women to continue pelvic floor muscle training afterwards.6
    • Consider referring patients to Patient Resources section for additional pelvic floor training support
  • Pessaries
    • Appropriate for: Patients with symptomatic pelvic organ prolapse
    • How to: Obtain a pessary fitting kit. As wait times for pessary fitting and care may vary, providers can learn to do this either by themselves by referring to the Canadian Family Physician article on pessary fittings or by shadowing an expert in this area.3,48
      • If the patient has vaginal odour, bleeding, or is post-menopausal, consider a low-dose of topical estrogen in conjunction with pessary use after clinical examination.50,51
      • Refer patients with vaginal erosion and ongoing bleeding to a specialist.3
      • Instruct the patient on pessary insertion/removal and care (cleaning and examination), as needed. Also ask about comfort and side effects.34
    • Follow-up: Every 6 months with a gynaecological examination included

Surgical options

If your patient is considering surgical procedures for POP, use decision aids found in Patient resources to promote informed preference and shared decision making. Refer the patient to a specialist with an interest in incontinence if they choose elective surgery.3,32,33
Proceed to Diagnosis to treat UI symptoms concurrently with POP.

No

Continue to to Diagnosis

Additional screening tools

The following screening tools will help further confirm the type of UI that your patient has and identify if there are any other underlying conditions that need to be treated as well.

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Urine culture/urine analysis

  • Perform urinalysis as a part of the initial assessment of a patient with suspected UI.16
    • Treat confirmed UTIs with antibiotics.6
    • Have patient return after UTI has been treated for further assessment.16

Assessing residual urine

  • Assess residual urine for patients who:
    • Had bladder surgery
    • Have prolapse
    • Have a neurological condition (multiple sclerosis, strokes, spine/nerve surgeries, diabetic patients with peripheral neuropathy)
    • Have symptoms of incomplete emptying of bladder
    • Have symptoms of frequency and urgency

  • Measure post-void residual volume by catheterisation or ultrasound/bladder scan.6,16

Diagnosis

After taking patient’s medical history and conducting a physical examination, use a UI symptom questionnaire to assess and diagnose your patient9
The Questionnaire for Female Urinary Incontinence Diagnosis (QUID) is a validated tool that has the potential to identify the different types of UI in women.16

Mixed urinary incontinence (MUI)

Mixed UI includes both urge and stress scores7. Treat the most bothersome symptom first in patients with MUI. 16

Conservative management of UI

If the patient has minor UI or presents concerns of UI symptoms, the first-line treatments are conservative therapies. These treatments usually carry the least risk of harm.16

Options

Advise your patient to incorporate the following into their daily lifestyle routine:

  • Recommend a trial of caffeine reduction to women with overactive bladder.6
  • Recommend eating more fiber (this can also prevent constipation which can be a cause of UI).8
  • Provide smoking cessation strategies to patients who smoke.16
  • Review type and amount of fluid intake in patients with UI.16
    • Advise a light reduction in the amount of liquid that the patient drinks.4
    • Advise patient to cut back on alcohol consumption.3
  • Advise patients who have a BMI greater than 30 kg/m2 to lose weight.6

All patients are eligible for pelvic floor therapy if they can tolerate vaginal examinations.3,7 Consider referring your patient to a pelvic floor physiotherapist/physiotherapist for supervised pelvic floor muscle training.6

  • Consider training for at least 3 months’ duration.6
  • Pelvic floor muscle training program should comprise of at least 8 contractions holding for a minimum of 10 seconds, performed 3 times per day.6
  • Continue an exercise program if pelvic floor muscle training is beneficial.6
    • Consider referring patients to Patient resources for additional pelvic floor training support

Only offer absorbent containment products, hand-held urinals or toileting aids to treat UI after other treatments have been tried: 6

  • as a coping strategy pending definitive treatment
  • as an adjunct to ongoing therapy
  • as long-term management options only after exploring other treatments

Conduct a review (at least once a year) for women who use absorbent containment products for the long-term management of UI

Talking points
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Talking points

  • “Have you considered cutting down on any foods or drinks that make your symptoms worse?”4
  • “When taking diuretics, aka “water pills”, make sure to take them when you will be near a bathroom for a few hours. This medicine can increase your need to urinate.”4

Patients with diabetes

  • “Keep your blood sugars as close to normal as possible, this may help some of your symptoms”4

Pharmacological management of UI

Conservative management of OAB and MUI is the first choice of treatment. Pharmacological interventions are the second choice of treatment3 when conservative treatment is not successful.16

Do not start medication if there is clinical evidence of acute angle glaucoma or cognitive impairments.7

Exercise caution with older patients especially those who are at risk of, or have, cognitive dysfunction.16

Considerations before prescribing pharmacological treatment
  • For anticholinergic medication, side effects can include dry mouth, constipation as well as a reduction of incontinence.7
  • The adverse effects of blurred vision and cognitive impairment indicate that the medication is to be discontinued. Reassess for a new medication to try.7

What not to do:
Do not offer women flavoxate, propantheline or imipramine to treat urinary incontinence or overactive bladder.6

Do not use duloxetine as a first-line treatment for women with predominant stress urinary incontinence. Do not routinely offer duloxetine as a second-line treatment for women with stress urinary incontinence, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects.6

Do not offer systemic hormone replacement therapy to treat urinary incontinence.6

Pharmacological Options
  • Offer intravaginal estrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy.6
  • Offer antimuscarinic (anticholinergic) medicine to treat overactive bladder or mixed urinary incontinence in women.6
    • Immediate release (IR) formulation of oxybutynin is the archetype medication in the treatment of OAB16
  • If the first medicine for OAB or MUI is not effective or well- tolerated, offer another medicine6 while considering cost and Ontario Drug Benefit (ODB) coverage
    • Mirabegron, a beta-3 adrenoceptor agonist, is recommended as an option for treating the symptoms of overactive bladder only for people who have unacceptable side effects or for whom anticholinergic drugs are contraindicated or clinically ineffective.27
  • To ensure that medications do not contraindicate with other medicines that your patient is taking, consider consulting each product monograph or a pharmacist
Talking point
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Talking point6

  • “You may not see a lot of benefits until you’ve been taking the medicine for at least 4 weeks and your symptoms may continue to improve over time.”
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  • Anticholinergic
    Darifenacin, extended-release 20,23,24

    ODB covered

    Dosage

    • 7.5 mg once daily. If response is not adequate after a minimum of 2 weeks, dosage may be increased to 15 mg once daily.30

    Formulations

    • Tablet23

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $$
  • Anticholinergic
    Fesoterodine fumarate, extended- release 20,25,26

    ODB covered

    Dosage

    • 4 mg daily PO.20,31
    • May increase to 8 mg daily PO if needed.20,31
    • Limit dose to 4 mg daily if ClCr <30 mL/min.20,31

    Formulations

    • Tablet26

    Adverse effects

    • Back pain, constipation, cough, dry eyes, dry mouth.20

    Cost20*

    • $$
  • Anticholinergic
    Oxybutynin, immediate-release generics 20,52 †

    ODB covered

    Dosage

    • 5 mg 2 to 3 times daily; adjust dose as needed and tolerated in 5 mg increments every 1 to ≥2 weeks.37
    • In patients with overactive bladder associated with neurodegenerative diseases, may consider initiation at 2.5 mg 2 to 3 times daily.37
    • Maximum: 5 mg 4 times daily.37
    • Note: 2.5 mg is not covered.52

    Formulations

    • Tablet

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $
  • Anticholinergic
    Oxybutynin, extended-release
    20,41

    Not Covered by ODB

    Dosage

    • 5 to 10 mg once daily; adjust dose as needed and tolerated in 5 mg increments every 1 to ≥2 weeks
    • Maximum: 30 mg once daily.37

    Formulations

    • Tablet41

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $$$$
  • Anticholinergic
    Oxybutynin, 10% transdermal gel 20,42

    Not Covered by ODB

    Dosage

    • 1 g (contents of 1 sachet or 1 metered-dose pump) applied once daily to dry, intact skin on the abdomen, thighs or upper arms/shoulders.20

    Formulations

    • Gel42

    Adverse effects

    • Application site pruritus, dizziness, dry mouth.20

    Cost20*

    • $$$
  • Anticholinergic
    Oxybutynin, transdermal patch
    20,43

    Not Covered by ODB

    Dosage

    • 1 patch applied to skin twice weekly (alternating sites); delivers 3.9 mg/day.20

    Formulations

    • Patch43

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia). Application site reactions.20

    Cost20*

    • $$
  • Anticholinergic
    Solifenacin
    20,35,36

    ODB Covered

    Dosage

    • 5 mg daily PO.20
    • May increase to 10 mg daily PO if tolerated.20,40

    Formulations

    • Tablet36

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $
  • Anticholinergic
    Tolterodine, immediate- release 20,38,44

    Partially Covered by ODB

    Dosage

    • 2 mg twice daily; the dose may be lowered to 1 mg twice daily based on individual response and tolerability.45

    Formulations

    • Tablet44

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $
  • Anticholinergic
    Tolterodine, extended-release 20, 38,46

    Partially Covered by ODB

    Dosage

    • 4 mg once daily; dose may be lowered to 2 mg once daily based on individual response and tolerability.45

    Formulations

    • Capsule46

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $
  • Anticholinergic
    Trospium
    20,39,47

    Partially Covered by ODB

    Dosage

    • 20 mg BID on an empty stomach.20
    • In older patients or those with severe renal impairment, do not exceed 20 mg QHS.20

    Formulations

    • Tablet47

    Adverse effects

    • Primarily anticholinergic effects (dry mouth, constipation, tachycardia).20

    Cost20*

    • $$
  • Beta3-adrenergic agonists
    Mirabegron, extended- release 20,28,29

    ODB Covered

    Dosage
    25–50 mg once daily PO.20

    Formulations
    Tablet29

    Adverse effects
    Hypertension, nasopharyngitis, urinary tract infection, tachycardia.20

    Cost20*
    $$

Cost of 30 day supply: $<$30 $$=$30–60 $$$=$60–90 $$$$=$90–120;
* Please note that dispensing fees have not been included
† Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.6

Surgical management of UI New

Discuss the benefits and risks of surgical treatment options for stress urinary incontinence. Refer the patient to a specialist with an interest in incontinence (i.e. gynaecologist or urologist) to discuss all surgical options.3,6,7

For women with overactive bladder that have not responded to non-surgical management or pharmacological treatment and who wish to discuss further treatment options6 refer patient to a specialist with an interest in incontinence (i.e. gynaecologist or urologist).3, 7

Follow-up and maintenance

Review and follow-up for conservative management

Follow-up with patients depending on the severity of their condition (e.g. at 3 months, 6 months or at a year) after starting conservative treatment options
• If patients symptoms have worsened, consider using pharmacological management options

Review of medications and follow-up for OAB
  • Offer a face-to-face, telephone or virtual review 4 weeks after starting a new medication. Ask the patient if they are satisfied with the treatment, and: 6
    • If the improvement is optimal, continue treatment
    • If there is no or suboptimal improvement, or intolerable adverse effects, then increase the dose or try an alternative medication, and review again 4 weeks later
  • Review before 4 weeks if the adverse events of a medication are intolerable
  • Refer women who have tried taking medication, but for whom it has not been successful or tolerated, to secondary care to consider further treatment6
  • If a medication stops working after an initial successful 4-week review
  • Offer a review in primary care to women who remain on long-term medication every 12 months, or every 6 months if they are aged over 75

Resources

Patient Resources

References