Understanding Urinary Incontinence: Diagnosis and Treatment Options

Diagnostic Test & Investigations

Diagnosing urinary incontinenceinvolves a comprehensive assessment using various medical tools and tests to determine the underlying cause and type of incontinence.

• Medical History and Patient Assessment
• Physical Examination
• Laboratory and Urine Tests such as Urinalysis, Urine culture, Blood tests may be conducted to identify infections or other underlying issues
• Imaging Tests such as Cystogram (X-ray Imaging of the Bladder), Ultrasound, Cystoscopy, Electromyography (EMG)

Bladder function tests evaluate how well the bladder and urethra store and release urine. These include:

This noninvasive test used to identify abnormal voiding patterns. It measures the volume of urine voided, speed and duration of urination. Consistently low flow rates may indicate bladder outlet obstruction or weak bladder muscles.

Cystometry assesses the pressure and capacity of the bladder during filling and emptying. It helps detect Overactive bladder (detrusor overactivity), Bladder compliance issues and Bladder outlet obstruction. A catheter is inserted into the bladder to measure pressure changes as it fills and empties.

This test measures the amount of urine left in the bladder after urination. High residual volumes may indicate, Bladder muscle weakness, Nerve dysfunction and Bladder outlet obstructions. PVR volume is measured using ultrasound or a catheter.

This test evaluates the resting and dynamic pressures in the urethra to assess sphincter function.

This measures the amount of abdominal pressure required to cause urine leakage, helping differentiate stress incontinence from urge incontinence.

Cystoscopy involves inserting a thin tube with a camera into the urethra to examine the bladder lining. This test helps detect anomalies such as bladder tumors, Bladder stones, inflammation or anatomical abnormalities

EMG measures nerve activity in the bladder and urethral sphincter. Sensors are placed near the urethra and rectum to record muscle signals, helping assess nerve damage or dysfunction.

The pad test objectively measures urine leakage. Patients wear an absorbent pad that is weighed before and after to determine urine loss over a specific period one hour or 24-hour period. (1 gram of increased weight=1 mL of urine lost). To indicate fluid lost, the patient may be asked to take a medication that colors the urine. As fluid leaks onto the pad, it changes color indicating that the fluid lost is urine

Used in female patients, a sterile cotton swab is inserted into the urethra to measure urethral mobility. Significant movement may indicate stress incontinence due to weakened support structures.

Patients may be asked to keep a detailed voiding diary to track fluid intake, urination frequency, leakage episodes, and urgency levels over several days.

Treatment of Urinary Incontinence

The treatment and management of urinary incontinencedepend on its type and severity.Treatment options range from conservative approaches to pharmacologic and surgical interventions. It is recommended to begin with the least invasive methods and escalate as needed.

Stress Urinary Incontinence (SUI) Treatment

• Behavioral Therapy: Fluid intake management, prompted voiding, bladder training, and constipation management.
• Pelvic Floor Muscle Training (PFMT): Kegel exercises and biofeedback to strengthen pelvic muscles.
• Electrical Stimulation: Helps improve pelvic muscle control.
• Mechanical Devices: Pessaries, vaginal cones, and urethral plugs provide structural support.
• Weight Loss: Reduces excess pressure on the bladder.
• Absorbent Products: Pads and condom catheters for symptom management.
• Dietary Adjustments: Avoid caffeine, alcohol, and other bladder irritants.

• Alpha-Adrenergic Agonists: Phenylpropanolamine (off-label) and imipramine.
• Duloxetine: Not FDA-approved but used in some cases.
• Vaginal Estrogen Cream: May improve symptoms in postmenopausal women.

• Bulking Agents: Trans- or periurethral injections increase urethral resistance.
• Sling Procedures: Mesh or tissue slings support the urethra.
• Urethropexy: Lifts and secures the urethra and bladder neck.
• Implantable Devices: Artificial urinary sphincters or dual-balloon continence devices.

Urge Urinary Incontinence (UUI) Treatment

• Bladder Training: Gradually increasing the time between voiding.
• Pelvic Floor Muscle Training: Strengthening muscles to reduce urgency.
• Lifestyle Modifications: Managing fluid intake and avoiding bladder irritants.

• Antimuscarinics: Oxybutynin, tolterodine, solifenacin, darifenacin, fesoterodine, trospium.
• Beta-3 Agonists: Mirabegron, vibegron.
• Topical Vaginal Estrogen: Not FDA-approved but used in select cases.
• Imipramine: A tricyclic antidepressant used off-label.

• Sacral Neuromodulation: Implantable device to regulate bladder control.
• Tibial Nerve Stimulation: Non-invasive nerve stimulation for bladder control.
• Botulinum Toxin - A Injections: Reduces detrusor overactivity.
• Augmentation Cystoplasty: Expands bladder capacity in severe cases.

Mixed Urinary Incontinence (MUI) Treatment

Treatment is based on the most dominant symptoms,often combining strategies from both stress and urge incontinence management.

Overflow Urinary Incontinence (OUI) Treatment

• Intermittent Catheterization: Helps manage urinary retention.
• Indwelling Urethral Catheter: Used in chronic cases.
• Relief of Obstruction: Addressing underlying causes such as prostate enlargement.

• Detrusor Stimulants: Bethanechol to enhance bladder contractions.
• Alpha-Adrenergic Antagonists: Doxazosin, terazosin, tamsulosin to reduce urethral resistance.

• Suprapubic Catheterization: Long-term management option.
• Transurethral Prostate Resection (TURP): Recommended if bladder muscle tone is sufficient.

Functional Urinary Incontinence

Management focuses on treating underlying conditions contributing to incontinence, such as cognitive impairment, mobility limitations, or environmental barriers. Strategies include:

• Environmental Modifications: Ensuring easy access to restrooms.
• Mobility Aids: Walkers or bedside commodes to assist patients.
• Scheduled Toileting: Encouraging routine voiding schedules.

• Bladder Training: certain exercises, such as pelvic floor exercises help to increase your bladder control and capacity.
• Timed Voiding: Urinating on a fixed schedule to reduce urgency episodes.
• Kegel Exercises: Strengthening the pelvic floor muscles.
• Pre-Activity Voiding: Emptying the bladder before physical exertion.
• Avoiding Caffeine and Alcohol: Reducing bladder irritants.
• Weight Management: Reducing excess pressure on the bladder.
• Absorbent undergarments: Using discreet pads or protective garments from disposable panties to washable and reusable ones
• Creating a Clear Path to the Bathroom to reduce barriers, especially at night.

• Mirabegron (Myrbetriq)
• Oxybutynin (Ditropan)
• Fesoterodine (Toviaz).
• Darifenacin (Enablex).
• Trospium (Sanctura XR).
• Tolterodine (Detrol).
• Solifenacin (Vesicare).
• Antidepressant medication — Imipramine (Norfranil, Tipramine, Trofranil).