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Mixed Urinary Incontinence

Author: Shauna Harris Author: Stephen W. Leslie Editor: John Riggs Updated: 6/8/2024 10:37:46 AM

Introduction

Urinary incontinence is the involuntary leakage of urine, causing symptoms of wide-ranging severity and often significantly affecting patients' quality of life. The International Urogynecological Association (IUGA), the International Incontinence Society (ICS), and the American Urological Association (AUA) have divided urinary incontinence into 3 main classifications.[1][2] See StatPearls' companion reference, "Urinary Incontinence," for more information.[2] 

Stress incontinence is the involuntary loss of urine with increased intraabdominal pressure or physical exertion (eg, coughing, sneezing, jumping, lifting, laughing, straining, exercising).[3] Urge incontinence is the involuntary loss of urine preceded by a sudden and severe desire to pass urine.[4] See StatPearls' companion references, "Urge Incontinence" and "Stress Incontinence," for more detailed information on these respective conditions.[4][3] Mixed urinary incontinence (MUI) is a combination of stress and urge incontinence and may take on the pathophysiology of both.[2][5] MUI is particularly prevalent in women older than 65, affecting >37% of older female patients, and often necessitates significant lifestyle changes due to its impact on both physical and psychosocial well-being.[6][7][8] 

Although incontinence is not itself a terminal disease, a meta-analysis of 6 studies with a total of 1,656 individuals indicated that urinary incontinence contributes to overall mortality, at least in nursing home residents, where it increases the death rate by 20%.[9] However, urinary incontinence more often affects other aspects of the patient's health and quality of life. Health conditions associated with MUI include skin, perineal, and vaginal infections (eg, cellulitis and yeast), as well as an increased risk of falls and fractures from excess trips to the bathroom.[10][11] The incidence of falls in postmenopausal women with urinary urgency and urge incontinence is twice that of comparatively aged women without such urinary symptoms.[11][12] Additionally, quality of life is significantly affected as incontinence causes depression, anxiety, embarrassment, limitation of social interactions, increased isolation, work issues, sleep deprivation due to nocturia, and loss of self-esteem in those affected.[13][14][15][16][17] Sexual dysfunction is also common in incontinent patients, as up to 33% will have coital incontinence (ie, leakage during sexual activity). Consequently, the fear of coital incontinence tremendously affects sexual enjoyment in many patients.[18][19][20][21][22][23] MUI also places a substantially increased burden on family caregivers as well as nursing facilities.[24][25][26] Up to 10% of all nursing home admissions in the United States are solely due to urinary incontinence.[27] 

A careful clinical history is usually sufficient to identify the type of the patient's incontinence; however, noninvasive diagnostic evaluations, including urinalysis, postvoid residual urine volume, and a pelvic examination in women, should be utilized to help clarify the clinical characteristics and etiology.[28][29][30][31][32][33] Many behavioral, medical, and surgical techniques are available to improve lifestyles due to incontinence.[1][34] The initial treatment for incontinence typically begins with a conservative lifestyle approach and various nonsurgical measures, including Kegel exercises, caffeine avoidance, vaginal estrogen in women, physical therapy, and oral medications.[35][36] For conditions unresponsive to such conservative therapies, consideration of more invasive therapies may be indicated. 

Etiology

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Etiology

MUI is associated with advanced levels of female pelvic organ prolapse, which has been demonstrated from the finding that restoration of normal anatomy through vaginal pelvic reconstructive surgery for prolapse cured >50% of the patients who had concomitant MUI.[6] Pelvic organ prolapse leads to bladder outlet obstruction, which causes detrusor muscle neuropathy from ischemia and hypoxia from inappropriate overstretching.[37] This bladder overstretching leads to a heightened reaction to neurotransmitters while the number of contracting muscle fibers decreases, resulting in reduced cellular propagation of membrane potential changes and loss of detrusor muscle fiber synchronization.[38][39][40] The net result is an irritable and overactive bladder.

Incontinence occurs when the endopelvic fascia weakens, which causes urethral distortion, malposition, hypermobility, decreased urethral tension, support, and loss of normal bladder positioning, which collectively results in involuntary urine loss.[6][41] Various incontinence subtypes have been identified, including genitourinary (eg, fistula, infectious, congenital, overflow) and nongenitourinary (eg, functional, environmental, pharmacological, and metabolic). Of these, the most clinically significant would be overflow and functional incontinence. Overflow is the involuntary urinary leakage caused by an overdistended bladder, usually due to bladder outlet obstruction or reduced detrusor contractility from spinal cord injuries, multiple sclerosis, or diabetes; functional incontinence is leakage from environmental, logistical, or physical barriers to reaching the toilet.[2] 

Mixed Urinary Incontinence Risk Factors

Factors that increase the risk of a patient developing MUI include the following:

  • Advanced age 
  • Comorbidities (eg, depression, diabetes, stroke, fecal incontinence, atrophic vaginitis, cognitive impairment, history of recurrent UTIs, multiple sclerosis, hydrocephalus, and childhood enuresis)
  • Ectopic ureters
  • Exercise, especially high-impact (eg, running and jumping)
  • Family history 
  • Interstitial cystitis
  • Multiparity
  • Neuropathy
  • Nursing home residence
  • Obesity
  • Pelvic radiation history
  • Prior pelvic surgery (eg, transurethral resection of the prostate, hysterectomy)
  • Smoking [23][42][43][44][45][46][47]

Epidemiology

Due to embarrassment, many patients with urinary incontinence fail to report symptoms, so the actual prevalence is likely to be far greater than reported.[23] Urinary incontinence affects 25% to 45% of all adult American women.[2] More than 25% of teenage and college-aged female athletes experience incontinence, with more than 90% withholding incontinence information from their primary care clinicians.

Among homebound older individuals, the incidence of incontinence is 53%.[2] In nursing homes, approximately 6% of all admissions are due to urinary incontinence, but the prevalence of urinary leakage in nursing home residents is estimated to be ≥50%.[48] Urinary incontinence in women is twice the rate of men, and over 33% of women with significant pelvic organ prolapse will also have MUI.[48][49]

The cost to treat urinary incontinence, medically or surgically, is well over $10 billion annually. Urinary incontinence, particularly mixed type, is an issue across all age groups.[50] The worldwide incidence of incontinence is approximately 423 million individuals aged 20 and older.[51] The following are the estimated prevalences for the different types of chronic urinary incontinence:

  • Functional urinary incontinence: uncertain
  • MUI: 20% to 30%
  • Overflow urinary incontinence: 5% of those with chronic incontinence
  • Stress urinary incontinence: 24% to 45% of females older than 30 years
  • Urge urinary incontinence
    • Women aged 40 to 44 years: 9%
    • Men older than 75 years: 42% 
    • Women older than 75 years: 31% [52]

Pathophysiology

The underlying mechanisms leading to MUI comprise stress and urge incontinence. The pathophysiology of stress incontinence is primarily pelvic floor weakness, prolapse, or loss of the normal urethrovesical angle.[3] The posterior urethrovesical angle with straining should usually be less than 120 degrees.[3] Stress incontinence also includes intrinsic sphincter deficiency, where there are deficiencies in the closure of the urinary sphincter.[3] 

The pathophysiology of urge incontinence is uninhibited bladder contractions caused by the loss of neurologic control of bladder contractions.[4] These unstoppable bladder contractions can be triggered or stimulated by a change in body position, from supine to upright, or with sensory stimulation (eg, running water, hand washing, cold weather).[4] Uninhibited bladder contractions are caused by detrusor muscle overactivity, poor detrusor compliance, loss of neurologic control of bladder contractions, and bladder hypersensitivity.[4] Underlying etiologies may include neurologic disorders, pelvic radiation, changes in the microbiome of the bladder, prolonged Foley catheterization, or idiopathic.[4][53][54][55][56][57] See StatPearls' companion references, "Urge Incontinence" and "Stress Incontinence," for more detailed information on these respective conditions.

History and Physical

Clinical History

A thorough history needs to be obtained to help diagnose MUI. The clinician should initiate the conversation by inquiring about symptoms directly since the patient may be too embarrassed to discuss increased frequency, urgency, or dysuria symptoms.[2] Clinical features include hesitancy, slow stream, straining to void, incomplete emptying, or wetting pads or clothes. Obtaining past surgical and obstetrical history is also essential to help diagnose the type of incontinence.[2] Details about the nature of incontinence symptoms are needed for diagnosis, including when the problem started, duration, precipitating events, voiding frequency, leakage volume, pad usage, nocturia, and fluid intake.[2][4] Caffeine intake should also be documented as caffeine can worsen urgency symptoms.[2][4] 

Many assessment questionnaires are available to help quantify the symptomatic effects on daily living. Comorbidities and confounding factors should also be explored. Medications that affect urinary incontinence should be reviewed, particularly cholinergic drugs and diuretics. In women, the effects of decreased estrogen levels during perimenopause or postmenopause should also be discussed, and the potential benefits of vaginal estrogen cream.[58] A 24-hour voiding diary prepared by the patient is helpful for objectively quantifying incontinence and helping evaluate the condition.[31][32][33][59] A voiding diary comprising 3 days is preferred, but even a 24-hour voiding diary from 1 day can be helpful.

Physical Examination

Findings of both stress and urge incontinence are consistent with MUI. The physical exam of patients with MUI should focus on the abdominal and pelvic areas. A large panniculus, prior surgical incisions, and suprapubic muscle tone should be noted. The patient should be examined with a full and empty bladder in standing and supine positions.[2] In women, the grade of uterine, vaginal prolapse should be assessed along with any apparent stress urinary incontinence with coughing.[1] A rectal examination should also be performed to evaluate rectal sphincter tone and prostate size in men.

A cough stress test is typically used to assess stress incontinence. For this test, 250 to 300 mL of fluid is instilled into the bladder using a catheter. The catheter is removed, and the patient is asked to cough. If no leakage is observed in the supine position, the patient is asked to stand, and the test is repeated.[59] The cough stress test is considered a fairly definitive test for stress incontinence, with a positive predictive value of 78% to 97%.[60][61] A negative test is less reliable as the bladder may have insufficient volume, or the patient may be inhibiting leakage due to anxiety or embarrassment.

Evaluation

Initial Urinary Incontinence Diagnostic Testing

The following simple office incontinence evaluations should be initially utilized to help differentiate the different types of urinary incontinence.[28][29][30][31][32][33]

  • Urinalysis and culture: Urine testing should be performed to exclude an infectious process (eg, acute cystitis).
  • Postvoid residual urine volume: This assessment is recommended to check for overflow incontinence and incomplete bladder emptying.[28][62] About 20% of women with overactive bladder symptoms will have elevated postvoid residual urine volumes.[63] Risk factors of high postvoid residuals include individuals 55 years and older, previous surgery for incontinence, multiple and more severe urinary symptoms, multiple sclerosis, vaginal prolapse, and more than 2 previous vaginal deliveries.[63] 
  • A 24-hour voiding diary: Tracking the frequency and volume of incontinence helps evaluate the severity and nature of the patient's leakage, particularly the urgency component.[29][31][32][33][64][65][66][67]
  • Cough stress test: A positive cough stress test in both the sitting and supine positions is highly diagnostic for stress incontinence.[29][68]
  • Pelvic examination: Vaginal prolapse may mask or decrease incontinence symptoms; therefore, areas of prolapse surrounding the urethra should be corrected (ie, elevated to the correct anatomical position) followed by assessment of incontinence with stress (eg, cough stress test).[29] The levator ani muscle should also be examined for strength.[29]
  • Q-tip test: This assessment is performed with a cotton-tipped swab placed gently into the urethra to check for mobility. A displacement of the urethral angle of at least 30 degrees with Valsalva is suggestive of urethral hypermobility.[29][30][69][70]
  • Neurological evaluation: All patients with urinary incontinence should undergo a neurologic assessment to exclude neurogenic causes of their incontinence.
  • Ultrasound: Transperineal/translabial ultrasound has proven useful in the evaluation of women with MUI with a significant stress component.[71] Ultrasound demonstrates the posterior urethral angle and the degree of urethral inclination.[71][72] Ultrasound imaging also allows visualization of the degree of bladder neck descent and the distance between the pubic bone, urethra, and bladder neck.[71][72] For example, female patients with MUI with an urge predominance tended to have thicker bladder walls, while those women with equivalent urge and stress components demonstrated greater bladder neck descent.[72] Additionally, ultrasound is substantially quicker and much better tolerated by patients than urodynamics.[71]
  • Additional evaluation procedures: Further incontinence assessment and exclusion of differential diagnoses can be achieved with additional studies, including cystoscopy, urodynamics, and video-urodynamic testing.[29]

Specialized Urodynamic Testing

For more complex or atypical presentations of incontinence, the patient may require urodynamic testing for further evaluation by a urology specialist.[73] Many experts consider MUI alone as an indication for urodynamics testing.[73][71] Urodynamic confirmation of MUI would demonstrate both stress incontinence and detrusor overactivity.[71] Cough-induced detrusor overactivity needs to be differentiated from true mixed incontinence.[74] Other indications for multi-channel urodynamics include: [73][75][76]

  • Abnormal office cystometric testing
  • Preoperative assessment before invasive surgical incontinence procedures, especially complex or high-risk cases 
  • Continuous or unpredictable leakage
  • Diagnostic uncertainty, even after the initial history and physical
  • History of previous radical pelvic surgery
  • Incontinence treatment failures
  • Neurological disease or symptomatology
  • Patient symptoms do not correlate with their physical findings
  • Pelvic organ prolapse
  • Pelvic radiation
  • Previous failed incontinence surgery 

Treatment / Management

Conservative Therapy

The initial treatment for incontinence typically begins with conservative, nonsurgical measures, including bladder training, biofeedback, Kegel exercises, dietary modifications (eg, avoidance of excess caffeine intake), acupuncture, electroacupuncture, vaginal estrogen in postmenopausal women, weight loss, and physical therapy.[35][77][78][79][80][81][82][83][84][85][86][87] The treatment of MUI should always begin with the least invasive management option to determine if the symptoms become tolerable or minimized by the patient. If invasive procedures are avoided, the patient may be satisfied with improved rather than complete continence, particularly if the patient has a high surgical risk.(A1)

Bladder training

Bladder training is generally the first step in management.[71][88] Bladder training typically works best in conjunction with regular Kegel exercises and limiting caffeine intake. It typically requires 6 to 12 weeks to be effective. See StatPearls' companion reference, "Kegel Exercises," for more information. Standard patient instructions for bladder training typically include the following protocol:(B3)

  • Void first thing in the morning.
  • Try to wait a minimal amount of time before voiding. Then, gradually increase this time.
  • Keep a voiding diary to establish a urination pattern; add 10 or 15 minutes to typical urination times.
  • Add another 10 or 15 minutes when this regimen becomes comfortable and manageable. Continue to add 10 to 15 minutes until an interval of 3 to 4 hours between daytime voids is reached.
  • Wait at least 5 minutes to void after the urge to void is noted; then, gradually increase the amount of time by an additional 5 to 10 minutes. 
  • If the urge to void cannot be controlled, void and return to the previous regimen.
  • Maintain the voiding diary to track progress.[88][89]

Bladder training typically works best when combined with regular Kegel exercises and limiting caffeine intake. Bladder training typically requires 6 to 12 weeks to be effective. Scheduled voiding may also be used.

Knack tutorial

The Knack tutorial is a self-administered story-based video program that helps train patients to anticipate high-risk urinary leakage situations.[90] They are then taught to perform preemptive pelvic floor muscle contractions at the optimal time to eliminate leakage.[90][91] Physiologically, the knack technique reduces stress incontinence by reducing bladder excitability and improving urethral closing pressure.[90][92][93][94] Detrusor contractions are suppressed; therefore, less urgency and urge incontinence are present.[90][94][95][96][97] In a randomized controlled trial, 71% of patients reported significant improvement in their incontinence with this technique compared to just 21% using diet and exercise alone.[90] The Knack tutorial video for incontinence training is available for free viewing on YouTube.(A1)

Ancillary conservative therapies

Several noninvasive treatments have been developed to facilitate pelvic floor muscle and bladder training, including vaginal cones, intravaginal biofeedback, percutaneous tibial nerve stimulation, and pelvic floor muscle training via direct electrical vaginal activation or with extracorporeal magnetic innervation therapy.[78][79][98][99][100][101][102][103][104][105] While helpful in some patients, their benefit may not be substantially better overall than properly performed bladder training programs, Kegel exercises, and pelvic floor muscle training.[106] Combination treatments typically provide substantially better results than monotherapies.[79][107] Particularly effective treatments in comparative randomized controlled studies were bladder training with electrical stimulation, with or without biofeedback, and percutaneous tibial nerve stimulation.[79][108][109](A1)

Initially, conservative treatments are primarily utilized for symptom relief, which for most patients involves reduction of incontinence frequency and urgency.[35] Urgency symptoms and urge incontinence can be treated pharmacologically with a variety of medications.[4][110][111][112][113] Conservative measures for MUI have the disadvantage that the improvement noted with treatment usually does not last, and most of the therapies require hospitalization or specialized clinics.[79] Resistant cases may require tibial nerve stimulation, botulinum A toxin detrusor injections, or sacral neuromodulation therapy.[4] External catheters, condom catheters for men and low-pressure vacuum wick units for women, can be used for nocturnal enuresis and overnight incontinence management but will not cure the underlying problem.[114][115][116][117][118][119](A1)

Stress incontinence is typically treated surgically (eg, sling, repair of prolapse, or cystocele repair); however, for some patients, a pessary may provide satisfactory continence less invasively.[3][106] A pessary supports the urethra and bladder neck, increases urethral length, and gently compresses the urethra against the pubic bone, increasing urethral resistance and reducing or eliminating stress incontinence.[120][121][122][123][124][125][126] When properly sized and fitted, no discomfort or unpleasant sensation is typically noted; however, pessaries must be periodically removed and cleaned with soap and water. Side effects of using a pessary include irritation to the vaginal mucosa with subsequent pain and bleeding. Pessaries may also increase the risk of vaginal infections or interfere with bowel movements. Since pessaries are minimally invasive and their effects can be easily reversed by simple removal, pessaries are a reasonable clinical option, especially when avoiding or delaying surgery is desirable. Proper sizing and fitting are critical.(A1)

Behavioral therapies

Treatment approaches that assist in changing behaviors that exacerbate MUI include:

  • Biofeedback
  • Bladder retraining (eg, timed voiding)
  • Dietary changes, including avoidance of alcohol, coffee, tea, caffeine, soda, chocolates, or methylxanthines
  • Electrostimulation
  • Extracorporeal magnetic innervation therapy
  • Pelvic floor physical therapy [127]
    • (A1)

Pharmacologic agents

In patients who are unresponsive to nonpharmacologic therapies, medications that may improve symptoms include: 

  • Alpha-adrenergics (eg, mirabegron, vibegron)
  • Anticholinergics (eg, oxybutynin, solifenacin, tolterodine, and trospium)
  • Calcium channel blockers (amlodipine, nifedipine, verapamil).
  • Estrogen (in females)
  • Selective serotonin and norepinephrine reuptake inhibitors (eg, duloxetine)
  • Tricyclic antidepressants (eg, imipramine) [128][77][129][130]
    • (A1)

Duloxetine has good evidence in studies that urinary stress incontinence is improved with the medication by increasing urethral closing pressure, while imipramine appears to have only minimal effect.[131][132][133][134][135][136] In Europe, duloxetine is approved for female stress incontinence, where it has shown efficacy in studies.[133][128][137] Still, consideration must also be given to the significant adverse side effects involving mental health issues, increased suicide rates, and other issues.[133][137][138][139] Nocturia not relieved by the above measures may require separate evaluation and treatment.[140] Nocturnal polyuria, for example, may require desmopressin.[140] Changing the administration timing of furosemide to 6 hours before bedtime may also be helpful.[140] See StatPearls' companion reference, "Nocturia," for more detailed information. (A1)

If standard pharmacological agents are inadequate, alternative therapies for intractable bladder overactivity include tibial nerve stimulation, botulinum A toxin detrusor injections, and sacral neuromodulation therapy may also be utilized.[4][141] See StatPearls' companion references, "Urge Incontinence" and "Sacral Neuromodulation," for more detailed information.[4][141] 

Indications for Specialist Referral

Primary care clinicians typically treat MUI initially using noninvasive therapies, including behavioral techniques or pharmacologic agents, when urinary retention, overflow, and UTIs have been excluded. However, referral to a urogynecologist or urologist is recommended, particularly when surgical intervention appears necessary or conservative treatments fail. Indications for referral to a specialist include: [142]

  • Abdominal or pelvic pain
  • Comorbidities (eg, cerebral palsy, multiple sclerosis, spinal cord injury, Parkinson disease)
  • Hematuria without evidence of an infection
  • Nerve stimulation therapy
  • Neurogenic bladder, primarily if associated with new symptoms
  • Pelvic organ prolapse
  • Prior failed incontinence surgery
  • Recurrent urinary tract infections
  • Sacral neuromodulation therapy
  • Surgical intervention is being considered when a patient is not satisfied even when the urge component of the MUI is cured or well-controlled
  • Suspected or diagnosed vesicovaginal fistula
  • Symptomatic pelvic organ prolapse
  • Uncertain diagnosis
  • Underlying neurologic condition
  • Unsuccessful medical therapy
  • Unusually "heavy" stress urinary incontinence (ie, multiple pads per day)
  • Urinary retention or overflow
  • Urodynamics required
  • Voiding dysfunction (eg, elevated postvoid residual) [142]

Surgical Therapy

Surgery provides the best overall cure for MUI when significant prolapse with bothersome stress urinary incontinence and pelvic pressure symptoms are present. However, surgery deals only with the stress incontinence component; the urgency portion must be treated separately, usually with pharmacological agents. Furthermore, controlling the overactive bladder component before surgery and ensuring patients fully understand the benefits and limitations of surgical procedures before the operation may help improve outcomes and patient satisfaction. Surgery aims to restore and reinforce the paraurethral connective tissue, the pubourethral ligaments, and the suburethral vaginal hammock at the mid-urethra level. Pelvic organ prolapse, rectoceles, and cystoceles may also require surgical repair.[143][144][145]

The standard surgical therapy for stress urinary incontinence is a sling procedure (eg, mid-urethral slings). However, several abdominal and vaginal surgical options are available, including Marshall Marchetti Krantz, Burch, paravaginal repairs, laparoscopic procedures, modified Pereyra procedures, Stamey, Raz, and other sling surgeries. Most of these have similar cure rates.[146][147] See StatPearls' companion references, "Stress Incontinence" and "Pubovaginal Sling," for more detailed information on these respective sling procedures.[3][146] See StatPearls' companion references, "Cystocele," "Rectocele," "Pelvic Organ Prolapse," and "Uterine Prolapse," for more detailed information on these respective topics.[143][144][145][148]

More than 50% of female patients who have significant pelvic organ prolapse can see significant improvement in their incontinence symptoms from surgical repair of the prolapse with or without a surgical sling. Appropriate anticholinergic therapy can then help control remaining bladder overactivity.[6][149][150][151] Perurethral bulking agents, adjustable continence therapy periurethral balloons, and artificial sphincters may also be used for stress incontinence.[3] While slings are generally a good option for isolated urinary stress incontinence, patients with MUI who have significant urinary urgency may not be satisfied with the postoperative results.[152] Predictors of poor patient satisfaction with stress incontinence surgery include significant preoperative overactive bladder symptoms, prolonged duration of incontinence, >9.5 years, requiring preoperative anticholinergic medications, and diabetes, as well as unrealistic patient expectations.[152] (B2)

Adjustable continence therapy devices

Adjustable continence therapy devices consist of implantable periurethral balloons placed at the level of the bladder neck.[153][154] A special trocar creates a tunnel through which the balloons are placed.[153][154] Each balloon has an adjustment port placed in the scrotum or under the skin for percutaneous access.[153][154] Adjustments can easily be made in the office or clinic. An open perineal approach has also been described for patients where the usual trocar tunneling procedure is unsafe or unsuitable.[154][155](B3)

Overall results are excellent, with continence rates consistently reported as over 50% in properly selected patients.[153][154][155][156][157][158] The surgery is simpler and less expensive than artificial sphincters. While the device creates a static degree of urethral compression, it is adjustable so the degree of urethral obstruction can be modified. Adjustable continence therapy devices are a less invasive and simpler surgical option for many male and female patients, with a success rate comparable to the artificial urinary sphincter.[154][159][160][161][162][163] (B2)

Adjustable continence therapy devices constitute a significantly underutilized therapeutic option for patients with stress incontinence as they offer a significantly less invasive option to artificial urinary sphincters.[154][158] While effective in both sexes, these devices are only FDA-approved for men in the United States.[154][164][165] See StatPearls' companion reference, "Artificial Urinary Sphincters and Adjustable Dual-Balloon Continence Therapy in Men," for more detailed information on these devices.[154](B2)

Artificial urinary sphincters

Artificial urinary sphincters are devices FDA-approved for use in both men and women with significant incontinence not amenable to other treatments. The usual indication for an artificial sphincter is neurogenic stress incontinence and persistent incontinence after prior surgery.[166] Artificial sphincters are essentially a treatment of last resort when lesser invasive options have failed. In this complex group of patients, outcomes with the artificial sphincter are reportedly quite good, even in women older than 75 with otherwise intractable stress incontinence.[167][168][169][170][171][172] Unlike other surgical corrective procedures for stress incontinence, an artificial sphincter can uniquely adjust and lower urethral resistance during voiding while maintaining high resistance and continence, making it particularly suitable for patients with significant detrusor weakness.[166] (A1)

Complications of artificial sphincters include atrophy, erosion, device failure, scarring, and infection.[173] Due to cost and technical difficulty in implantation, artificial sphincters are a significantly underutilized treatment modality. Recent innovations in implantation using laparoscopic and robotic techniques have reduced postoperative complications, and worldwide usage is increasing.[173][174][175] Further improvements in the device and implantation techniques should help increase its utilization.[176] See StatPearls' companion reference, "Artificial Urinary Sphincters and Adjustable Dual-Balloon Continence Therapy in Men," for more detailed information.[154](A1)

Intrinsic sphincter deficiency is due to the loss of urethral muscle tone from neuromuscular damage (eg, repeated incontinence or pelvic surgeries). Intrinsic sphincter deficiency may sometimes be associated with urethral hypermobility. Leakage tends to be severe and may be continuous. Even minimal increases in abdominal pressure can cause significant incontinence. Treatment is similar to standard stress incontinence therapies, but the condition is more challenging to treat, and surgical outcomes are generally not as good. Midurethral slings are usually the preferred surgical option. Still, other sling types, urethral bulking agents, adjustable continence therapy device periurethral balloons, and artificial sphincters may also be considered for both male and female incontinence patients.[156][159][163][177][178][179][180] Artificial sphincters tend to provide a better functional result in female patients with intrinsic sphincter deficiency than other surgeries, but they also have a higher rate of intraoperative and postoperative complications, take more operating room time to implant, are more prone to device failures, and require a longer inpatient hospital stay.[181] (A1)

Differential Diagnosis

Differential diagnoses that should be considered include:

  • Acute or chronic cystitis
  • Benign prostatic hyperplasia 
  • Cough-induced detrusor overactivity
  • Cystocele, rectocele
  • Interstitial cystitis
  • Multiple sclerosis
  • Neurogenic bladder
  • Prostatitis
  • Radiation cystitis
  • Spinal cord abscess
  • Spinal cord neoplasms
  • Spinal cord trauma
  • Urethral strictures
  • Urge incontinence
  • Urinary obstruction
  • Urinary tract infections in males
  • Uterine prolapse
  • Vaginitis

Prognosis

If a patient desires stress urinary incontinence to be cured with no leakage, proper informed consent for surgical treatment should be discussed and explained to the patient. Counseling regarding surgical success rates must be included. Abdominal and vaginal surgical approaches offer similar overall success rates of approximately 86% for cure, 7% for improvement, and a 7% failure rate.[147] A clinical cure, meaning no further incontinence, indicates that the patient will not need further postoperative treatment or urodynamic testing.

Clinical improvement with occasional intermittent incontinence or failed procedures may require urodynamic testing to differentiate stress versus urge incontinence or any other subtypes and variations. Behavioral or medical therapy may be necessary in refractory cases, with the possibility of another reoperation as a last resort. Newer surgical approaches (eg, periurethral bulking agents, adjustable continence device therapy, and artificial sphincters) can successfully relieve stress incontinence symptoms in both men and women who have failed other treatments.[3] Sacral neuromodulation, botulinum A toxin detrusor injections, and tibial nerve stimulation can often help patients with otherwise intractable urgency and overactive bladder symptoms refractory to standard pharmacological therapy.[4][141]

Complications

The risk of surgical treatment pertinent to stress urinary incontinence should also be documented and explained to the patient. Risks include the following:[147]

  • Bleeding
  • Infection
  • Injury to the genitourinary or gastrointestinal tract
  • Persistent or recurrent urinary incontinence or prolapse
  • Postop dyspareunia 
  • Urethral erosion [147]

Postoperative and Rehabilitation Care

Postoperative patients may require prolonged catheterization either with a urethral or suprapubic catheter. The postvoid residual urine should be <100 mL. Any voiding dysfunction after catheter removal usually resolves spontaneously within a few days to weeks. Coital activity should be avoided at least 6 weeks following surgery to prevent disruption of the surgical site until healing is complete. The patient also should be told no heavy lifting over 25 lbs to avoid increasing intraabdominal pressure that may result in treatment failure with recurrent prolapse and incontinence.

Deterrence and Patient Education

Education involving the patient, the public in general, and healthcare clinicians is necessary to provide the best patient outcomes according to evidence-based medicine. Websites of reliable sources that offer free patient education and informational resources on incontinence include:

  1. The American College of Obstetrics and Gynecology Website: [acog.org/womens-health/faqs/urinary-incontinence]
  2. Patient education from the American Urological Association and the Urology Care Foundation Website: [urologyhealth.org/urinary-incontinence]
  3. National Association for Continence (NAFC) Website: [nafc.org/mixed-incontinence] Phone: 800-252-3337
  4. The Simon Foundation for Continence Website: [simonfoundation.org] Phone: 800-237-4666
  5. European Association of Urology Patient Education on Incontinence Website: [urinary-incontinence]
  6. Continence Worldwide (Continence patient educational resources outside the United States) Website: [www.ics.org/public]
  7. International Urogynecological Association (IUGA) Website: [yourpelvicfloor.org]
  8. United Kingdom National Health Services Patient Information Website: [nhs.uk/conditions/urinary-incontinence] 
  9. Continence Foundation of Australia Website: [continence.org.au/urinary-incontinence]

Pearls and Other Issues

Key facts to keep in mind with urinary incontinence include:

  • Giving patients realistic treatment expectations right at the beginning can help them accept a less-than-perfect outcome.
  • Treat the most bothersome symptoms first, which are usually urgent, frequent, and amenable to pharmacological treatments.
  • While post-void residual determinations are not required before initiating clinical treatment, many experts suggest checking this to avoid overlooking possible overflow incontinence.
  • A 24-hour voiding diary, including void frequency and volume, can be very helpful in sorting out a complex incontinence problem.[65][66]
  • Consider using a pessary as it can immediately relieve stress incontinence symptoms. If unsatisfactory for any reason, it can be removed.
  • Adjustable continence devices and artificial sphincters are underutilized procedures that should be discussed and offered to appropriate patients, especially women.
  • A disposable self-inserted intravaginal pessary is undergoing clinical trials. Over 87% of female users have reported a reduction in leakage by at least 50% with no severe adverse effects.[182]
  • Consider using low-pressure external vacuum wick incontinence units for nocturnal enuresis and nighttime incontinence management in women.[118][119] While it does not cure incontinence, it minimizes side effects, keeps the skin dry, and helps manage wetness at least overnight. A male pad for this device is now available, or a properly fitted and secured condom catheter can be used for men.[118][119][183] 

Enhancing Healthcare Team Outcomes

Urinary incontinence is a salient issue in any primary care clinician's practice, necessitating a thorough history and workup to establish an accurate differential diagnosis before discussing treatment strategies. Clinicians must inform patients of all available treatment options, ensuring patients understand that not all treatments completely cure symptoms. Success should be defined as a reduction in severity that satisfies the patient's quality of life. Clear communication of reasonable expectations and potential reasons for unmet expectations is crucial. Ethically, all health professionals must advise patients of the least invasive treatment options, such as behavioral modification or medications, before considering surgical plans. An interprofessional approach involving physicians, advanced practitioners, nurses, pharmacists, and other health professionals, coupled with excellent communication and consistent messaging, is essential when urogynecologists, urologists, or other specialists are involved in managing mixed urinary incontinence. This collaborative effort enhances patient-centered care, outcomes, patient safety, and overall team performance.

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