Stress incontinence

Definition/diagnostic criteria Stress incontinence is defined as the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. This condition typically results from the weakening or dysfunction of the pelvic floor muscles and the urethral sphincter mechanism.
Diagnostic criteria for stress incontinence include:

• Complaints of involuntary urine leakage during activities that increase intra-abdominal pressure.
• Objective evidence of urine leakage on examination or clinical testing.

Epidemiology Stress incontinence is a prevalent condition in the UK, with a substantial impact on individuals’ quality of life. The epidemiology of stress incontinence varies by gender and age group:

• Women are more commonly affected than men, with a peak incidence during and after pregnancy and menopause.
• In women, the prevalence of stress incontinence increases with age, affecting up to 50% of women over the age of 60.
• In men, stress incontinence can occur following prostate surgery or other pelvic procedures.

Diagnosis
Clinical features: GPs can diagnose stress incontinence based on clinical features and patient history. Key clinical features include:

• Involuntary urine leakage during activities that increase intra-abdominal pressure.
• A detailed medical history, including factors such as childbirth, previous surgeries, and medications.
• Physical examination to assess pelvic floor muscle strength and assess for pelvic organ prolapse.
• Evaluation of any associated symptoms, such as urgency, frequency, or nocturia.

Investigations: In some cases, additional investigations may be necessary to confirm the diagnosis or identify underlying abnormalities. Common investigations for stress incontinence include:

• Urinalysis: To rule out urinary tract infections or haematuria.
• Urodynamic studies: To assess bladder function and pressure during voiding.
• Imaging studies: Imaging such as ultrasound or cystoscopy, to evaluate bladder and urethral anatomy.

Typical abnormalities found in patients with stress incontinence include:

• Urodynamic studies may reveal reduced urethral closure pressure during stress.
• Imaging studies may show urethral hypermobility or bladder neck descent during activities that increase intra-abdominal pressure.
• Physical examination may identify weakened or damaged pelvic floor muscles.

Treatment The management of stress incontinence depends on the severity of symptoms and individual patient preferences. Treatment options include:

• Lifestyle modifications: Encourage patients to make dietary and behavioural changes, such as reducing caffeine intake, maintaining a healthy weight, and practicing pelvic floor exercises (Kegels).
• Pelvic floor physiotherapy: Refer patients to specialized physiotherapists for pelvic floor muscle training and biofeedback.
• Pharmacotherapy: Consider prescribing anticholinergic medications or alpha-adrenergic agonists for patients with moderate to severe symptoms.
• Surgical interventions: Evaluate patients for surgical options such as mid-urethral slings or urethral bulking agents in cases of severe incontinence resistant to other treatments.

Prognosis The prognosis for patients with stress incontinence is generally favourable, with many experiencing significant improvement in symptoms with appropriate treatment. Lifestyle modifications and pelvic floor exercises can be effective for mild cases. In more severe cases, surgical interventions can provide long-term relief.

In conclusion, stress incontinence is a prevalent condition in the UK, particularly affecting women and older individuals. GPs play a crucial role in diagnosing and managing this condition, using clinical features, investigations, and appropriate treatments to improve patients’ quality of life.