Kent, DA3 8ND
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If I could only spend 10 minutes with a patient presenting with:
NICE has recently issued guidance on this subject which both simplifies and clarifies the management of urinary incontinence in women. Although I need to remember that serious conditions occasionally present with incontinence, my priority in this consultation will be to determine whether my patient has an overactive bladder (OAB) or "genuine" stress incontinence (GSI) - due to a weak bladder neck. The initial treatments for these conditions are conservative in nature and are easy to commence in Primary Care.
Red flag symptoms: The duration of symptoms is important as recent onset of leakage raises the possibility of tumour or infection. These women won't leave today without a careful examination and urinalysis. Ask all women about haematuria and dysuria. Send an MSU if the woman has symptoms of a UTI or if the urinalysis shows leukocytes / nitrites.
NICE guidance for urgent referral of women with incontinence is:
Moving on, the 7 symptoms I concentrate on are:
- Incontinence + microscopic haematuria in woman >49 years.
- Incontinence + visible haematuria in woman >49 years.
- Incontinence + recurring or persisting UTI with haematuria in woman >39 years.
- Incontinence + suspected malignant mass arising from urinary tract.
In the text book
- Frequency - 8 or more voids per day is abnormal (unless intake is excessive).
- Urgency - sudden-onset strong desire to void
- Nocturia - two or more voids per night.
- Stress incontinence - Leak with cough, sneeze, exertion etc.
- Urge incontinence - Leak with urgency
- The volume of leakage - a large amount will go through a pad and down her leg!
- Symptoms of voiding difficulty
Women with an overactive bladder (OAB) typically have frequency, nocturia, urgency and urge incontinence of large volumes of urine.
Women with genuine stress incontinence (GSI) typically have stress incontinence of small volumes of urine.
In real life!
Most women present with a mixture of symptoms. Some women even have both OAB and GSI. Women with GSI often have frequency, urgency and urge incontinence. Women with OAB sometimes have overactive bladder contractions induced by cough or exertion and so appear to have stress incontinence.
The volume of leakage is one of the best discriminators - women with OAB rarely leak just small amounts.
GSI is rare in women who have never had a pregnancy go to term (caesarean section does not offer much protection).
OAB is more common in later life - so are UTIs and the symptoms can be identical.
So far, so good after about 3 minutes. With a combination of the woman's history and around half a dozen additional questions, I have a good idea of the diagnosis in around 80% of cases. Finishing this consultation within 10 minutes is unrealistic if I am to perform an examination and talk about management in the remaining time. The woman was probably not expecting an intimate examination today and it is preferable to defer this to another day. Ask her to have a comfortably full bladder when she comes for the examination. Also ask her to complete bladder voiding diary of 3 days' duration.
Make a provisional diagnosis at the first consultation
If GSI - Advise weight loss if BMI > 30.
- Advise pelvic floor exercises and give out an information leaflet.
If OAB - Advise about fluid intake if excessive (as judged by urine output).
- Reduce caffeine intake.
- Talk about bladder training and give out information leaflet.
If you can't decide between the two diagnoses, give both sets of advice and information.
Ask the woman to provide a urine sample before she leaves the surgery. Send an MSU if a UTI is suspected.
At the next appointment
Look at the bladder voiding diary (whilst she is getting ready to be examined) This should be completed over 3 days. The woman measures the voided volume and notes this along with the time on a sheet of paper. Leakage episodes should also be recorded along with the presence of any urge or physical stress eg. a cough. This will identify the polydipsics and women with severe symptoms. In women with mixed urge and stress incontinence, the predominant symptom will usually be obvious. Women with OAB usually void small amounts (<250ml) frequently.
Palpate the abdomen to exclude any large masses that could be pressing on the bladder. Fibroids would be the most common.
Inspect the vulva. Separate the labia and ask her to cough. If she doesn't leak, ask her to do 3 strong coughs in quick succession. If you see a jet of urine leak with a cough, the diagnosis is GSI. Absence of this leakage does not exclude GSI.
Look for prolapse when she coughs. Significant prolapse is usually visible at this stage. If the vaginal walls or uterus have prolapsed down to the level of the introitus and the woman has symptoms from her prolapse then specialist referral should be offered. Smaller degrees of prolapse and asymptomatic prolapse should not affect your management plan.
Speculum examination. This will occasionally provide additional information, perhaps about atrophic vaginitis (treatment with topical oestrogen may help symptoms of urgency). It is more important if blood has been found in the urine (tumours).
Bimanual pelvic examination. In the absence of a lower abdominal mass or suspicion of tumour, this will not often reveal anything of relevance. A mildly enlarged uterus is unlikely to affect bladder function significantly.
Check that the woman can contract her pelvic floor with a finger in the vagina. There is no point asking a woman to do more pelvic floor exercises if she cannot contract her pelvic floor. A physiotherapist may be able to teach her but if the leakage is severe, refer her to a urogynaecologist.
After the examination:
You should now have a clear idea of what is causing the leakage. You should consider specialist referral if:
Fir the majority of women, conservative treatment should continue with an appointment for review in around 8 weeks.
- Symptomatic prolapse
- Palpable bladder after voiding
- Persisting bladder or urethral pain
- Clinically benign pelvic mass
- Symptoms of voiding difficulty
- Suspected neurological disease
- Associated faecal incontinence
- Suspected fistula
After 8 weeks
If no improvement is seen after 8 weeks, retake the history of leakage to make sure you understood it correctly the first time.
- If you still suspect an overactive bladder, offer treatment with an antimuscarinic drug. If this doesn't work, offer specialist referral.
- If you still suspect genuine stress incontinence and no improvement has occurred, offer specialist referral. If some improvement has been seen, advise continuing the exercises and offer Duloxetine.
- If you aren't sure what is causing the incontinence, offer specialist referral.