Description

• Urinary incontinence: Involuntary loss of urine that is objectively demonstrable and is of medical, financial, social, and hygienic concern
• Stress incontinence: Associated with increased intra-abdominal pressure, such as coughing, laughing, sneezing, or exertion
• Urge incontinence: Sudden uncontrollable loss of urine (also known as overactive bladder or detrusor overactivity)
• Mixed incontinence: Loss of urine from a combination of stress and urge incontinence
• Overflow incontinence: High residual or chronic urinary retention leading to urinary spillage from an overdistended bladder
• Functional incontinence: Loss of urine due to deficits of cognition and/or mobility
• Total incontinence: Continuous leakage of urine; leakage without awareness

Epidemiology

• Affects 25% of premenopausal and 45% of postmenopausal women (1)
• Affects 60–78% of women in nursing homes (2)
• Women 19–64 years of age have predominantly stress incontinence (20–25%), followed by mixed (15–20%), and urge (4–9%) incontinence.
• In women 65–80 years of age, mixed is the most common (18%), followed by stress (16%), and urge (13%)incontinence.
• In women >80 years of age, mixed is the most common (28%), followed by urge (11%), and stress (8%) (3) incontinence.

Risk Factors

Advanced age, impaired functional status, obesity (BMI >30), menopause, pregnancy, vaginal childbirth, pelvic surgery or radiation, urethral diverticula, genital prolapse, smoking, chronic obstructive pulmonary disease (COPD), cognitive impairment, constipation, and pelvic floor dysfunction

General Prevention

Obesity avoidance, smoking cessation, high-fiber diet to reduce constipation

Pathophysiology

• Stress incontinence: Occurs with increased intra-abdominal pressure. 2 types:
  • Anatomic: Due to urethral hypermobility from lack of pelvic support
  • Intrinsic sphincter deficiency (ISD): Impaired closure of urethra. Urethral mucosal seal and inherent closure from collagen, fibroelastic tissue, smooth and striated muscles, etc., may be lost secondary to surgical scarring, radiation, or hormonal and senile changes
• Urge incontinence: May be due to detrusor overactivity (however, association on urodynamic testing is weak), or may be idiopathic (4)
• Overflow incontinence: Urinary retention (usually from lower motor paralytic neurogenic bladder)
• Total incontinence: Constant loss of urine in epispadias–exstrophy complex due to absence of bladder neck and urethra. Ectopic ureters in females usually open in the urethra distal to the sphincter or in the vagina, causing continuous leakage. Also may occur with fistulous connections between bladder, ureters, or urethra and vagina or uterus.

Commonly Associated Conditions

Pelvic organ prolapse, UTI, COPD, diabetes mellitus, neurological disease, obesity, chronic constipation, low libido, dyspareunia, and any disease that results in chronic cough