Improving the management of urinary incontinence.

Urinary incontinence (UI) is the complaint of any involuntary loss of urine and is a common condition that is likely to be under-reported. In the UK, the prevalence is estimated to be 17-40%, and rates are higher in the elderly. UI is more common in women than men. Its frequency increases with age, parity, high BMI, and associated comorbidities. The common types are stress UI, overactive bladder (OAB) or urge UI, and mixed UI a combination of the two. In stress UI there is involuntary loss of urine that occurs in association with an increase in intra-abdominal pressure. OAB is caused by overactivity of the detrusor muscle. This may be idiopathic or secondary to lesions affecting the motor or sensory pathways to the muscle. The history should include the circumstances in which the incontinence occurs, the duration and how it affects the patient's quality of life. The initial assessment should include enquiring for symptoms of urinary tract infection and carrying out a urine dipstick test. Abdominal examination should exclude a large pelvic-abdominal mass and a palpable bladder post micturition. Vulval-vaginal examination should assess for atrophic vaginitis and prolapse, masses and pelvic floor muscle contraction. Involving a skilled continence nurse or dedicated pelvic physiotherapist will improve care and can reduce referrals to secondary care. When conservative measures for OAB are unsuccessful, the next step is pharmacological treatment. Referral to secondary care should be offered when the response to two drugs has not been satisfactory. For stress UI, referral is indicated after failure of pelvic floor muscle training.