Chapter 105: Urinary Incontinence

KEY CONCEPTS

• In evaluating urinary incontinence (UI), drug-induced or drug-aggravated etiologies must be ruled out.

• Accurate diagnosis and classification of UI type are critical to the selection of appropriate pharmacotherapy.

• Goals of treatment for UI are reduction of symptoms, minimization of adverse effects, and improvement in quality of life.

• Nonpharmacologic, nonsurgical treatment is the first-line treatment for several types of UI, and should be continued even when drug therapy is initiated.

• Antimuscarinic agents are second-line treatments for urgency incontinence. Choice of agent should be based on patient characteristics (eg, age, comorbidities, concurrent medications, and ability to adhere to the prescribed regimen).

• β₃-Adrenergic agonists (mirabegron, vibegron) can be considered in patients who failed to achieve optimal efficacy or cannot tolerate adverse effects of antimuscarinic agents.

• Duloxetine (approved in Europe only), α-adrenergic receptor agonists, and topical (vaginal) estrogens (alone or together) are the drugs of choice for urethral underactivity (stress urinary incontinence).

• Assessment of patient outcomes should include efficacy, adverse effects, adherence, and quality of life.

• Management of UI should target individualized goals and treatment preferences, which may change over time. If therapeutic goals are not achieved with a given agent at optimal dosage for an adequate duration of trial, consider switching to an alternative agent and/or surgery.

Patient Care Process for Urinary Incontinence

Collect

• Patient characteristics (eg, age, sex, pregnancy status, drug allergy profile)

• Patient medical and genitourinary surgical history including coexisting conditions that may influence UI

• Obstetric and menstrual history in women

• Past conservative, medical, and surgical treatment of UI

• Social history (tobacco/ethanol use; caffeine and fluid intake; environmental issues; exercise; availability of family caregiver, if relevant)

• Current medications (see Table 105-1) including over-the-counter (OTC), herbal products, and dietary supplements

• Objective data

  • Lab tests: urinalysis ± urine culture; if infected, treat and reassess if appropriate

  • Cough stress test to demonstrate stress UI (if appropriate)

  • Postvoid residual urine by bladder ultrasound or catheterization (if suspected urinary retention/overflow incontinence)

Assess

• Urinary symptoms including bladder diary (see Table 105-2)

• Presence of bowel symptoms or vaginal prolapse symptoms (in women); estrogen status in women

• Quality of life, treatment preferences, and goals

• Mental status, body mass index, physical dexterity, and mobility

• Abdominal, rectal, prostate (in men), neurological, and pelvic examination (in women)

Plan^*

• Nonpharmacological interventions based on UI severity and subtype (see Table 105-3)

• Drug therapy regimen for urgency UI, if indicated (see Table 105-5)

• Monitoring parameters (see Tables 105-6 and 105-7); frequency and timing of follow-up

• Patient education (eg, purpose of treatment, dietary and lifestyle modification, drug-specific information)

• Self-monitoring for resolution of UI symptoms and drug adverse events (if indicated)

• Referrals to other providers when appropriate (eg, urologist, urogynecologist, continence nurse practitioner, physical therapist)

Implement^*...