Female urinary incontinence: Evaluation

INTRODUCTION — 

Urinary incontinence, the involuntary leakage of urine, is common and undertreated [1-4]. It is estimated that approximately 60 percent of adult women experience urinary incontinence [3], yet only 25 to 61 percent of symptomatic community-dwelling women seek care [2,5-8]. Patients may be reluctant to initiate discussions about their incontinence and urinary symptoms due to embarrassment, lack of knowledge about treatment options, and/or fear of surgery.

This topic will review the epidemiology, risk factors, etiology, and initial evaluation of the nonpregnant woman with urinary incontinence. Treatment of urinary incontinence in women and urinary incontinence in men are discussed separately:

●(See "Female urinary incontinence: Treatment".)

●(See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment".)

●(See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

●(See "Urinary incontinence in males".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals as they relate to the information presented in this topic.

IMPACT ON HEALTH — 

While generally not a major contributor to overall mortality, in one meta-analysis of nursing home residents, urinary incontinence was associated with a 20 percent increased risk of death (hazard ratio 1.20, 95% CI 1.12-1.28, six cohort studies, 1656 participants) [9]. More commonly, urinary incontinence impacts other important aspects of a patient's health:

●Quality of life – Urinary incontinence is associated with depression and anxiety, work impairment, social isolation, and disability [10-16] in both nursing home residents as well as those who live independently [17]. Increasing incontinence frequency (daily versus monthly or less than weekly) and volume (larger volume versus drops) are associated with worsened mobility outcomes (World Health Organization Disability Assessment Schedule domains of mobility) [16]. Urgency urinary incontinence, particularly nocturnal incontinence episodes, is associated with poor sleep quality [18]. Overactive bladder is also associated with poor sleep quality in up to 70 percent of women [19].

●Sexual dysfunction – Urinary incontinence during sexual activity (coital incontinence) and/or fear of urinary incontinence during sexual activity both contribute to incontinence-related sexual dysfunction [20-22]. Coital incontinence may affect up to one-third of all incontinent individuals and negatively impacts sexual function [23]. Urgency urinary incontinence had a greater negative impact on sexual function compared with urgency or frequency without incontinence [24,25].

●Morbidity – Medical morbidities associated with urinary incontinence include perineal dermatitis and infections (eg, candida or cellulitis) from moisture and irritation, with a reported prevalence between 5 and 56 percent [26]. Urinary incontinence, particularly urgency and mixed types, is believed to contribute to falls and fractures that in turn increase overall morbidity, mortality, and health care costs [26-29]. In older women with urinary urgency or urgency urinary incontinence, falls are twice as common than among women without urinary symptoms [28-30].

●Increased caregiver burden – In addition to being a burden for caregivers, urinary incontinence is negatively associated with the ability to perform other activities of daily living, thus increasing the need for caregiver assistance and nursing home admission [31-33]. Six to 10 percent of nursing home admissions in the United States are attributable to urinary incontinence [34].

EPIDEMIOLOGY

Prevalence — Urinary incontinence is common in women, particularly in pregnancy. Urinary incontinence in pregnancy is discussed separately. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

Estimates of prevalence vary depending on the population studied, the measurement period (eg, daily or weekly), and the instruments and definitions used to assess severity. Overall prevalence of urinary incontinence among nonpregnant women age 20 years and above has been reported to range from 10 to 60 percent [3,8,35-39]. The RISE FOR HEALTH study, a regionally representative cohort study of 3000 adult female community members, reported a prevalence of 45 percent for any stress or urgency incontinence within the past seven days, with 10 percent reporting these symptoms "most of the time" or more [40]. The United States National Health and Nutrition Examination Survey (NHANES), using data from 2000 to 2014, estimated that 9.6 million women >50 years of age experience bothersome stress and/or urgency urinary incontinence [41]. An updated analysis of 5006 United States women enrolled in the 2015 to 2018 NHANES study reported an overall prevalence of any urinary incontinence at 62 percent (78.3 million), with 32 percent reporting at least monthly symptoms and 22 percent reporting moderate to severe symptoms [33]. For women age 60 years and older, prevalence rates of over 50 to 70 percent have been reported [8,42]. The impact of age on urinary incontinence is discussed below. (See 'Risk factors' below.)

One-third of women in the Nurse's Health Study (aged 54 to 79 years) who reported urine leakage once monthly at baseline progressed to leaking at least once a week over two-year follow-up [43]. However, not all women who develop urinary incontinence will have symptoms indefinitely. In a longitudinal cohort study of 4127 middle-aged women, the annual incidence rate of urinary incontinence was 3.3 percent and the annual remission rate was 6.2 percent [44]. Factors associated with persistent symptoms (ie, no resolution) were weight gain and transition to menopausal status.

Risk factors — Risk factors for urinary incontinence include [45-50]:

●Age – Both the prevalence and severity of urinary incontinence increase with age [3,8,33,35,38,39,51]. In large surveys of nonpregnant women, urinary incontinence was reported to affect 3 percent of adult women under age 35, rose to 7 percent for ages 55 to 64 years, and rose to 38 to 70 percent for women over age 60 [8,35,52,53]. Urinary incontinence is particularly common in individuals living in nursing homes, with reported rates ranging from 43 to 77 percent [49,54,55].

However, studies controlling for other comorbid conditions suggest that age alone may not be an independent risk factor for urinary incontinence [56].

●Obesity – Obesity and increased waist circumference is a significant risk factor for urinary incontinence [57-60]. Obese women have a nearly threefold increased odds of urinary incontinence compared with nonobese women [33,38,45,53,61,62], and chronic obesity is associated with increased risk of developing incontinence later in life [63]. Weight reduction is associated with improvement and resolution of urinary incontinence, particularly stress urinary incontinence (SUI). A meta-analysis of 33 studies reported reductions in both SUI and urgency urinary incontinence following weight loss from either bariatric surgery or behavior modification [64].

●Parity – Multiparity is a risk factor for urinary incontinence [33,50,65,66]. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

However, nulliparous women also report bothersome urinary incontinence, with 25 percent of women ages 25 to 34 years reporting urinary incontinence, increasing to 32 percent of women ages 55 to 64 years [53].

●Mode of birth – Compared with women who have had a cesarean birth, women who have a vaginal birth are at higher risk for urinary incontinence, particularly SUI [3,50,67-70]. Vaginal birth appears to increase the risk of urgency urinary incontinence as well but to a lesser degree than for SUI [71]. However, cesarean birth does not fully protect women from urinary incontinence. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Vaginal versus cesarean delivery'.)

●Family history – The risk of urinary incontinence, particularly urgency urinary incontinence, may be higher in patients with a family history. One study found that the risk of urinary incontinence was increased for both daughters (relative risk [RR] 1.3, 95% CI 1.2-1.4) and sisters (RR 1.6, 95% CI 1.3-1.9) of women with incontinence [48]. Twin studies attribute a 35 to 55 percent genetic contribution to urgency incontinence/overactive bladder but only 1.5 percent for stress incontinence [72,73]. Genetic markers have been identified for urgency urinary incontinence but not SUI [74].

●Others – Other factors associated with urinary incontinence in females include:

•Medical comorbidities and medication – Diabetes, stroke, depression, fecal incontinence, genitourinary syndrome of menopause/vaginal atrophy, hormone replacement therapy, genitourinary surgery (eg, hysterectomy), and pelvic radiation have been associated with increased risk of urinary incontinence [1,61,75-82]. However, analyses of the 2015 to 2018 NHANES study failed to identify diabetes or prior hysterectomy as significant risk factors [3]. Additional risk factors for urgency urinary incontinence include impaired functional status, recurrent urinary tract infections, and bladder symptoms in childhood, including childhood enuresis [83,84]. Urinary incontinence is also common in persons with cognitive impairment/dementia, with the prevalence ranging from 10 to 38 percent [55].

For medication, a study of 98 women and men reported that individuals with urgency urinary incontinence were more likely to avoid diuretic medication compared with patients experiencing stress or mixed urinary incontinence as the drugs were associated with worsened urinary symptoms [85].

•High impact exercise – SUI has been associated with participation in high-impact activities, including jumping and running [86,87]. For example, an online study of 423 women reported that those participating in CrossFit had substantially higher rates of urinary incontinence (84 versus 48 percent) than those participating in general fitness classes [88]. In a survey of 480 competitive female powerlifters, 44 percent reported urinary incontinence within the past three months [89].

•Diet and smoking

-Caffeine – Data on caffeine intake have been conflicted. While earlier studies reported an association [90,91], a 2016 meta-analysis of seven studies on caffeine intake did not support an association with urinary incontinence [92]. An analysis of the 2005 to 2018 NHANES database identified high consumption of tea (>481 g/day) as a significant risk factor for urgency urinary incontinence (odds ratio [OR] 1.29, 95% CI 1.01-1.64) but did not identify coffee as a significant factor. Those with decaffeinated coffee consumption had a lower rate of urgency incontinence than those reporting no caffeine/coffee consumption (OR 0.66, 95% CI 0.49-0.90) [93].

-Alcohol – Very limited available evidence suggests alcohol consumption does not significantly impact urinary incontinence [94,95].

-Artificial sweeteners – In a secondary analysis of data from the United States Women's Health Initiative Observational Study of postmenopausal women, consuming greater than or equal to one serving of artificial sweetener per day was associated with a 10 percent increased risk of mixed urinary incontinence compared with consuming none or less than one serving per week (adjusted OR 1.10, 95% CI 1.02-1.19, n = 80,388 participants) [96]. Significant differences were not found for SUI or urgency urinary incontinence and the study did not differentiate among types of artificial sweeteners.

-Smoking – Smoking has been associated with an increased risk of urinary incontinence in some studies [90,91,97-99]. In a community-based survey of 1720 women, current smokers had a 1.40 relative risk of urgency incontinence. Those with a ≥20 pack-year history of smoking had a 1.25 relative risk compared with nonsmokers [100]. However, NHANES analyses did not identify a significant relationship between smoking and female urinary incontinence [3].

•Urogenital microbiome – Emerging evidence suggests that the urogenital microbiome differs between continent and incontinent women, particularly for urgency urinary incontinence [101-104]. There is conflicting evidence regarding the bacterial diversity in other types of incontinence [104,105]. Additional research is needed to understand the role of the urogenital microbiome in both health and urinary incontinence.

CLASSIFICATION — 

The main types of urinary incontinence are stress, urgency, and overflow incontinence (figure 1). Many women have features of more than one type, which is termed mixed urinary incontinence [106,107]. Identifying the classification of incontinence helps guide therapy. (See "Female urinary incontinence: Treatment".)

Stress urinary incontinence

●Symptoms – Individuals with stress urinary incontinence (SUI) have involuntary leakage of urine that occurs with increases in intra-abdominal pressure (eg, with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction [65,108,109].

●Etiology – SUI is generally thought to be related to the lack of mechanical support of the urethra and/or poor coaptation of the urethral tissues resulting in insufficient resistance to urine outflow during increased abdominal pressures (figure 2). It is the most common type in younger women, with the highest occurrence in women ages 45 to 49 years [51,83,110,111].

Mechanisms of SUI include:

•Urethral hypermobility – Urethral hypermobility is thought to stem from insufficient support of the pelvic floor musculature and vaginal connective tissue to the urethra and bladder neck [112]. This causes the urethra and bladder neck to lose the ability to completely close against the anterior vaginal wall. With increases in intra-abdominal pressure (eg, from coughing or sneezing) the muscular tube of the urethra fails to close, leading to urinary incontinence (like stepping on a hose in sand) (figure 2).

Insufficient urethral support may be related to loss of connective tissue and/or muscular strength due to chronic pressure (ie, high-impact activity, chronic cough, or obesity) or trauma due to childbirth, particularly vaginal deliveries. Childbirth can cause trauma directly to the pelvic muscles and may also damage nerves, leading to pelvic muscle atrophy and dysfunction.

Treatments for hypermobility SUI are aimed at providing a backboard of support for the urethra. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Mechanisms of pelvic floor injury' and "Female urinary incontinence: Treatment".)

•Intrinsic sphincteric deficiency – Intrinsic sphincteric deficiency (ISD) is a form of SUI that results from a loss of intrinsic urethral mucosal and muscular tone that normally keeps the urethra closed (figure 2). There is a lack of standardization of the definition and diagnostic criteria [113]; however, the term ISD has traditionally been a urodynamic diagnosis used to refer to leakage due to neuromuscular damage such as that seen in women who have had multiple pelvic or urinary incontinence surgeries. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Lack of urethral hypermobility and intrinsic sphincter deficiency'.)

Practically, any SUI is associated with underlying ISD as most women exhibiting hypermobility of the urethra remain continent. A longitudinal cohort of primiparous women without pre-existing hypermobility or stress incontinence demonstrated that 48 percent developed de novo hypermobility at six months postpartum yet no increased odds of SUI. Even in those with de novo hypermobility, fewer than half developed SUI after 12 years of follow-up [114]. ISD can occur in the presence or absence of urethral hypermobility and typically results in severe urinary leakage even with minimal increases in abdominal pressure. Treatment is aimed at improving urethral blood flow with vaginal estrogen and increasing urethral coaptation with pelvic muscle exercise or surgery. ISD is challenging to treat and has worse surgical outcomes [115-117]. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Lack of urethral hypermobility and intrinsic sphincter deficiency'.)

Urgency urinary incontinence — Patients with urgency urinary incontinence experience the urge to void immediately preceding or accompanied by involuntary leakage of urine [84,108]. "Overactive bladder" (OAB) is a term that describes a syndrome of urinary urgency with or without incontinence, which is often accompanied by nocturia and urinary frequency [84,108]. The terms "urgency incontinence," "overactive bladder with incontinence," or "OAB wet" are often used interchangeably.

●Symptoms – Patients often complain of frequent, small-volume voids, which may keep them up at night. A strong urge to void may result in leakage before they get to the bathroom. The amount of leakage ranges from a few drops to completely soaked undergarments. Urgency urinary incontinence is more common in older individuals and may be associated with comorbid conditions that occur with age [118,119]. Symptoms may worsen with diuretic use or excessive fluid intake.

●Etiology and comorbid conditions – Urgency urinary incontinence is believed to result from detrusor overactivity, which leads to uninhibited (involuntary) detrusor muscle contractions during bladder filling (figure 1) [84]. This may be secondary to neurologic disorders (eg, spinal cord injury), bladder abnormalities, increased or altered bladder microbiome, or may be idiopathic [84,120-123]. Involuntary detrusor contractions, or detrusor overactivity, have been found in 21 percent of healthy, continent, community-dwelling older adults [124]. (See "Chronic complications of spinal cord injury and disease", section on 'Urinary complications'.)

Mixed urinary incontinence — Mixed urinary incontinence describes patients with symptoms of both stress and urgency urinary incontinence [108,125].

Overflow urinary incontinence

●Symptoms – Patients with overflow urinary incontinence typically present with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying. Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia. When the bladder is very full, stress urinary leakage can occur, or low-amplitude bladder contractions can be triggered, resulting in symptoms similar to stress and/or urgency urinary incontinence.

●Etiology – Overflow urinary incontinence is caused by detrusor underactivity or bladder outlet obstruction (figure 1).

•Detrusor underactivity – Detrusor underactivity may be caused by impaired contractility of the detrusor muscle [119]. Impaired urothelial sensory function may also contribute. Studies suggest that detrusor contractility and efficiency decrease with age [126,127]. Severe detrusor underactivity occurs in approximately 5 to 10 percent of older adults [119,128] and 45 percent of women undergoing urodynamic evaluation for nonneurogenic lower urinary symptoms [129]. Other etiologies of detrusor underactivity include smooth muscle damage from chronic or severe acute sustained overdistention of the bladder, Fowler's syndrome, fibrosis, low estrogen state, peripheral neuropathy (due to diabetes mellitus, vitamin B12 deficiency, alcoholism), and damage to the spinal detrusor efferent nerves by pathologies affecting the spinal cord (eg, multiple sclerosis, spinal stenosis) [130-133]. (See "Chronic urinary retention in females", section on 'Causes of urinary retention' and "Chronic urinary retention in females", section on 'Fowler's syndrome' and "Disorders affecting the spinal cord".)

A subset of women with this condition can have detrusor hyperactivity with impaired contractility (DHIC). With DHIC, the bladder does not effectively contract to empty and also has low-amplitude hyperactivity, resulting in urgency as well as overflow incontinence. DHIC is particularly difficult to treat as most medical therapies for overactivity result in increased urinary retention and overflow incontinence.

•Bladder outlet obstruction – Bladder outlet obstruction in women is rare and generally caused by external compression of the urethra. This can occur with fibroids that obstruct the urethra, advanced pelvic organ prolapse (ie, beyond the hymen), or overcorrection of the urethra from prior pelvic floor surgery. Less common causes include external masses or tumors at the level of the bladder outlet, urethral stricture, or uterine incarceration of a retroverted uterus (which can occur in pregnancy or in the setting of fibroids). An additional yet rare condition, called "Fowler's syndrome," has been described and is characterized by increased urethral sphincter activity during voiding that results in a functional obstruction of the urethra [134]. Functional obstruction from high-tone pelvic floor dysfunction may also contribute to voiding dysfunction. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management" and "Incarcerated gravid uterus" and "Chronic urinary retention in females", section on 'Fowler's syndrome'.)

CONTRIBUTING FACTORS/CONDITIONS — 

Continence depends upon intact micturition physiology (including lower urinary tract, pelvic, and neurologic components (figure 3)), intact pelvic floor muscles and connective tissue support (figure 4 and figure 5), and functional ability to toilet oneself. Interruption of any of these functions can contribute to urinary incontinence symptoms.

●Genitourinary syndrome of menopause/vaginal atrophy – In postmenopausal women, low estrogen levels result in atrophy of the superficial and intermediate layers of the urethral mucosal epithelium. Atrophy results in urethritis, diminished urethral mucosal seal, loss of compliance, and possible irritation, all of which can contribute to incontinence. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis", section on 'Pathophysiology'.)

●Urinary tract infection (UTI) – Lower UTIs can present with symptoms of overactive bladder that exacerbate urinary incontinence symptoms. Not all women with a UTI will experience pain or hematuria. Women with UTI may have more incontinence not only during the episode but also immediately following the UTI [135]. (See "Acute simple cystitis in female adults", section on 'Clinical suspicion and evaluation'.)

●Other urologic/gynecologic disorders – Other less common urologic or gynecologic disorders that can cause urinary incontinence include urogenital fistulas, urethral diverticula, and ectopic ureters. (See "Urogenital tract fistulas in females".)

●Systemic causes – Patients who have underlying medical conditions that contribute to urinary incontinence will also have other characteristic features or relevant history.

•Neurologic disorders – Spinal cord disorders can lead to overflow urinary incontinence as discussed above. Other examples of neurologic disorders that can lead to urinary incontinence include stroke, Parkinson disease, multiple sclerosis, and normal pressure hydrocephalus. (See "Complications of stroke: An overview" and "Clinical manifestations of Parkinson disease" and "Chronic complications of spinal cord injury and disease", section on 'Urinary complications' and "Normal pressure hydrocephalus".)

Overflow urinary incontinence and poor urinary stream can be present in patients with diabetic autonomic neuropathy. (See "Diabetic autonomic neuropathy".)

•Cancer – Less common systemic causes of urinary incontinence include bladder cancer or invasive cervical cancer. (See "Clinical presentation, diagnosis, and staging of bladder cancer" and "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

●Potentially reversible causes – Potentially reversible causes of or contributors to urinary incontinence may include medications (table 1), intoxication, excessive tea and caffeine intake, and constipation/stool impaction [93,136].

●Functional urinary incontinence – Functional urinary incontinence occurs when a patient has intact urinary storage and emptying functions but is physically unable to toilet herself in a timely fashion. This appears to be a common contributor to urinary incontinence for older women. As an example, in one study that included 177 women aged 57 to 85 years with daily urinary incontinence, 62 percent reported at least one functional disability or dependence and 24 percent reported specific difficulty or dependence with using the toilet [137]. Such functional incontinence may be reversible in the setting of modifiable factors (eg, decreased mobility postsurgery, decreased manual dexterity, and change in cognitive or mental status from sedation from medications) [108,138,139].

●Cognitive impairment – The association between cognitive impairment and incontinence is in part mediated by functional impairment and disability [140]. Comorbid conditions and medications also often contribute.

EVALUATION — 

The initial evaluation of urinary incontinence includes characterizing and classifying the type of incontinence that may manifest as urinary incontinence and identifying potentially reversible causes of incontinence [141-143].

The evaluation should start with a thorough history, physical examination, and urinalysis [83,142,144]. Additional evaluation is warranted in the presence of complex medical conditions or concerning findings on history and/or physical examination.

History — Many patients are reluctant to initiate a discussion about their urinary incontinence. Screening questions may be appropriate, especially for older women and those who have comorbid conditions associated with increased risk (eg, prolapse, accidental bowel leakage, diabetes, obesity, neurologic disease) [145,146].

The history further clarifies the patient's urinary symptoms and severity and identifies potential underlying causes that may be treatable or require further evaluation [108]. Classifying the type of incontinence helps direct treatment. (See "Female urinary incontinence: Treatment".)

Urinary symptoms and clinical classification — Symptoms of incontinence and classification can be elicited using short, standardized questionnaires. The three incontinence questionnaire (3IQ) (form 1) can help distinguish between stress, urgency, and mixed urinary incontinence [147]. In a multicenter study of 300 middle-aged women with moderate incontinence, the 3IQ had a sensitivity of 0.75 and specificity of 0.77 for identifying urgency incontinence and a sensitivity of 0.86 and specificity of 0.60 for stress urinary incontinence (SUI) [147].

Relevant urinary symptoms include frequency, volume, severity, hesitancy, precipitating triggers, nocturia, intermittent or slow stream, incomplete emptying, continuous urine leakage, and straining to void [84]. Symptom clusters are associated with specific voiding abnormalities, as discussed above. (See 'Classification' above.)

Systemic symptoms — We evaluate all women with incontinence for urinary tract infection (UTI), asking about symptoms such as fever, dysuria, pelvic pain, and hematuria. (See "Acute simple cystitis in female adults", section on 'Clinical suspicion and evaluation'.)

Symptoms that are concerning for other underlying conditions as the cause of urinary incontinence include lifelong or sudden onset of incontinence, associated abdominal/pelvic pain or gross hematuria without UTI, changes in gait or new lower-extremity weakness, cardiopulmonary or neurologic symptoms (for example, the combination of overflow urinary incontinence, perineal anesthesia, and new accidental bowel leakage suggests cauda equina syndrome), mental status changes, recurrent documented UTIs (three or more per year), advanced pelvic organ prolapse beyond the hymen, elevated PVR (>1/3 total volume), long-term urinary catheterization, or difficulty passing a urinary catheter. Women with these symptoms should have appropriate workup and evaluation for underlying conditions and/or specialist referral if necessary. (See 'Specialist referral' below.)

We also ask about changes in bowel function (eg, constipation and accidental bowel leakage) and symptoms of pelvic organ prolapse (seeing or feeling a lump beyond the opening of the vagina) as these conditions often coexist [56]. (See "Fecal incontinence in adults: Etiology and evaluation" and "Pelvic organ prolapse in women: Diagnostic evaluation".)

In older adults, we typically ask about and assess functional status, mobility, and cognitive status [108,138]. (See "Office-based assessment of the older adult".)

Medications — Some medications (table 1) can contribute to urinary incontinence [139].

Alcohol and caffeine — We routinely elicit alcohol and caffeine intake habits as they have been associated with lower urinary tract symptoms [148]. Caffeine intake has been postulated to exacerbate urinary incontinence due to its smooth muscle stimulant and diuretic effects. Although a small pilot study demonstrated reductions in urinary urgency and frequency with intake of decaffeinated compared with caffeinated drinks, meta-analyses failed to identify significant associations between caffeine and urinary incontinence [92,149,150]. However, excessive tea intake has been identified as a potential contributor to urinary incontinence. (See 'Risk factors' above.)

Impact on quality of life — Clinicians should identify those symptoms that are most bothersome to the patient as this can help guide treatment. The impact of the patient's incontinence on her quality of life can be assessed informally by asking a few targeted questions or by using a validated instrument (eg, International Consultation on Incontinence Questionnaire and Kings Health Questionnaire are available for evaluating impact of incontinence on quality of life) [151]. We use the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire [152]. The Patient Global Impression of Improvement (PGII) and Patient Global Impression of Severity (PGIS) (table 2) are also acceptable measures to assess improvement and satisfaction, respectively [153]. (See "Female urinary incontinence: Treatment".)

Voiding diary — Voiding diaries are helpful in the assessment of urinary incontinence symptoms. One example, of a voiding diary can be found online. While basic diary records of frequency and volume are neither sensitive nor specific for determining the cause of incontinence [106,154], they may be helpful to determine if urinary incontinence is associated with high fluid intake. In addition, they provide a measure of the severity of the problem that can be followed over time. Voiding diaries also identify the maximum bladder capacity and time interval that the woman can reasonably wait between voids, a measure used to guide bladder training (table 3). (See "Female urinary incontinence: Treatment".)

While most clinical studies use a three-day voiding diary to assess outcomes of treatment, we find better compliance with a 24-hour diary. Normal voiding frequency is less than eight times a day and once at night, with total volumes of less than 1800 mL per 24 hours [155,156]. A multicentered study of 237 community-dwelling women reported that 74 percent voided eight or fewer times during the day and 83 percent voided zero to one time per night [157].

Physical examination — Not all women presenting with urinary incontinence need a pelvic examination prior to initiating behavioral or medical therapy as long as the symptoms allow the clinician to differentiate between stress versus urgency urinary incontinence, there is a low suspicion for urinary retention, and there is no systemic or other evidence of pelvic pathology. (See 'History' above.)

Women with atypical symptoms, diagnostic uncertainty, or failure of initial treatment strategies should undergo a pelvic examination with special attention to evaluate for pelvic floor muscle integrity, vaginal atrophy, pelvic masses, urinary retention, and advanced pelvic organ prolapse beyond the hymen.

The components of a detailed pelvic examination are discussed separately. (See "The gynecologic history and pelvic examination", section on 'Components of the examination' and "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis", section on 'Pelvic examination' and "Pelvic organ prolapse in women: Diagnostic evaluation".)

Initial treatment strategies for urinary incontinence are discussed separately. (See "Female urinary incontinence: Treatment", section on 'Initial treatment'.)

A detailed neurologic examination is not necessary in the initial evaluation of all women with incontinence unless patients present with sudden onset of urinary incontinence (especially urgency symptoms) or new onset of neurologic symptoms [141]. If there is concern for neurologic disease, we perform a limited evaluation of lower-extremity strength, reflexes, and perineal sensation. As examples, weakness with hyperreflexia of the lower extremity may suggest an upper motor neuron lesion; absent perineal sensation with decreased rectal tone is concerning for cauda equina syndrome. (See "The detailed neurologic examination in adults".)

Laboratory tests — A urinalysis should be performed for all patients, and urine culture performed if a UTI or hematuria is suggested on screening.

We do not routinely check kidney function unless there is concern for severe urinary retention resulting in hydronephrosis [108]. Other laboratory testing is determined by signs or symptoms elicited on history and physical examination. (See "Clinical presentation, diagnosis, and staging of bladder cancer" and "Evaluation of hematuria in adults", section on 'Risk factors for malignancy' and "Evaluation of hematuria in adults", section on 'Urine cytology and biomarkers'.)

Clinical tests, including urodynamic testing — Only a few clinical tests are necessary for the initial evaluation of a woman with urinary incontinence as conservative treatment can be initiated based on symptoms alone. We do not obtain radiographic imaging for the initial evaluation in patients without complex neurologic conditions or abnormal findings on physical examination.

We check a bladder stress test as part of the initial workup of SUI. Although in our subspecialty practice we routinely evaluate women with a PVR by either catheterization or bladder scan, this is not necessary in the initial evaluation of urinary incontinence by the general practitioner. Urodynamic testing is also not routinely performed initially but may be done prior to considering surgical therapies or when there is diagnostic uncertainty or evidence of urinary retention. (See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Office testing' and "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Urodynamic testing'.)

●Bladder stress test – In patients with suspected SUI or mixed urinary incontinence, we perform the bladder stress test to confirm the diagnosis. This test is performed with the patient in the standing position with a comfortably full bladder. Ideally, the bladder should have at least 300 mL for an adequate assessment; however, leakage at lower volumes is diagnostic. While the examiner visualizes the urethra by separating the labia, the patient is asked to Valsalva and/or cough vigorously. The clinician observes directly whether or not there is leakage from the urethra. This test may be difficult in women with severe obesity, mobility or cognitive impairments; these women may benefit from performing the test in the dorsal lithotomy position.

The positive predictive value of the bladder stress test is 78 to 97 percent [158]. A pooled analysis of three studies demonstrated that a positive bladder stress test helps to confirm stress urinary leakage in women with stress or mixed urinary incontinence [106]. A negative test is less useful because a false negative may result from a small urine volume in the bladder or from patient voluntarily inhibiting leakage. For negative stress testing below 300 mL we either perform a retrograde fill of the bladder to 300 mL, repeat the testing with a premeasurement by bladder scan to ensure 300 mL or more, or conduct urodynamic testing.

●Postvoid residual – Measuring the PVR is not required for initial therapy for stress or urgency urinary incontinence [108]. However, measuring the PVR can be helpful when diagnosis is uncertain, initial therapy is ineffective, or in patients where there is concern for urinary retention and/or overflow urinary incontinence. These patients include those with neurologic disease, recurrent UTIs, history concerning for detrusor underactivity or bladder outlet obstruction, history of urinary retention, severe constipation, pelvic organ prolapse beyond the hymen, new-onset or recurrent incontinence after surgery for incontinence, diabetes mellitus with peripheral neuropathy, or medications that suppress detrusor contractility or increase sphincter tone (table 1) [142,159-161].

Parameters for interpreting the results of PVR testing are neither standardized nor well evaluated. In general, a PVR of less than one-third of total voided volume is considered adequate emptying. We use a PVR of >150 mL or >1/3 total volume as a cutpoint for further evaluation of voiding dysfunction. Analyses of a multicenter study of 296 community-dwelling women who completed uroflowmetry and PVR measurements by ultrasound revealed a mean PVR of 33 mL (standard deviation [SD] 63) after a mean voided volume of 304 mL (SD 192) [162]. Median PVR was 10 mL (SD 36) after 264 mL (SD 209) void. Additional suggested parameters include a PVR under 50 mL as normal and a PVR greater than 200 mL as abnormal [156,163]. (See "Postoperative urinary retention in females", section on 'Spontaneous voiding trial'.)

●Urodynamic testing for selected patients

•No role in initial evaluation – We do not conduct urodynamic testing in the initial evaluation of urinary incontinence in patients whose symptoms are consistent with stress, urgency, or mixed urinary incontinence. Urodynamic testing is invasive and costly and has not been shown to improve clinical outcomes (nonsurgical or surgical) [164-168].

Supporting data include:

-SUI – A systematic review of 99 studies including over 80,000 women found insufficient evidence to support the ability of urodynamic testing to predict the outcomes of nonsurgical treatment for SUI [166]. Additionally, a randomized multicenter trial of preoperative urodynamic testing for uncomplicated SUI demonstrated no improvement in surgical outcomes [167].

-Urgency/OAB – In a multicenter, randomized trial of 1099 female patients with refractory overactive bladder (OAB) or urgency-predominant mixed urinary incontinence, treatment based on the combination of urodynamic studies (UDS) and comprehensive clinical assessment (CCA) produced similar success rates at 15-month follow-up compared with treatment based on CCA alone (UDS + CCA 23.6 percent versus CCA 22.7 percent, adjusted odds ratio 1.12, 95% CI 0.73-1.74) and no difference in adverse events [168]. Success was defined as being "very much improved" or "much improved" on the Patient Global Impression of Improvement assessment. UDS results changed the diagnosis from urgency urinary incontinence to SUI in 13 percent, resulting in more SUI surgeries compared with CCA alone (3.4 versus 1 percent). However, UDS was not cost-effective at the threshold of £20,000 per quality-adjusted life-year gained (34 percent chance of being cost-effective at cost threshold). Notably, this study excluded women with advanced prolapse and neurogenic bladder.

•Preoperative urodynamic testing – Preoperative UDS may assist with surgical counseling and planning in patients considering surgery for SUI. This is discussed in further detail separately. (See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Urodynamic testing'.)

•Urodynamic testing for complicated or mixed symptoms – Urodynamic testing may be useful in the following scenarios:

-Patients with persistent, bothersome symptoms despite first- and second-line treatments

-Patients with mixed incontinence in whom the predominant contributor (ie, SUI or urgency urinary incontinence) is unclear

-Patients with urinary retention and overflow incontinence

-Clinical presentations in which the history and examination findings do not clearly support the diagnosis

Indications for urodynamic testing in the evaluation of incontinence are discussed in further detail separately. (See "Urodynamic evaluation of women with incontinence".)

●Urethral mobility evaluation – Some subspecialists may evaluate for urethral hypermobility. This is discussed separately. (See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Assessing urethral mobility'.)

SPECIALIST REFERRAL — 

In a minority of cases, referral to a specialist is warranted for patients with urinary incontinence. Indications for referral include the presence of:

●Associated abdominal or pelvic pain in the absence of urinary tract infection (UTI)

●Culture-proven recurrent UTIs (three or more per year or two in six months)

●Gross or microscopic hematuria with risk factors for malignancy in the absence of a UTI [169]

•(See "Clinical presentation, diagnosis, and staging of bladder cancer".)

•(See "Evaluation of hematuria in adults", section on 'Urine cytology and biomarkers'.)

•(See "Evaluation of hematuria in adults", section on 'Risk factors for malignancy'.)

●Lifelong incontinence or suspected vesicovaginal fistula or urethral diverticula on vaginal examination (see "Urogenital tract fistulas in females" and "Urethral diverticulum in females")

●Other abnormal physical examination findings (eg, pelvic mass, pelvic organ prolapse beyond the hymen) (see "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management")

●New neurologic symptoms in addition to urinary and/or bowel incontinence

●Uncertainty in diagnosis

●History of pelvic reconstructive surgery or pelvic irradiation

●Persistently elevated PVR volume, after treatment of possible causes (eg, medications, stool impaction)

●Suspected overflow incontinence, particularly in the setting of underlying conditions (eg, neurologic conditions, diabetes)

●Chronic urinary catheterization or difficulty passing a catheter

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary incontinence in adults".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Urinary incontinence in females (The Basics)" and "Patient education: Neurogenic bladder in adults (The Basics)" and "Patient education: Treatments for urgency incontinence in females (The Basics)")

●Beyond the Basics topics (see "Patient education: Urinary incontinence in women (Beyond the Basics)" and "Patient education: Urinary incontinence treatments for women (Beyond the Basics)")

Patients can be referred to incontinence patient advocacy groups. These groups can supply additional information about incontinence and its management, including links to product suppliers. Some useful resources are:

●National Association for Continence: 1-800-BLADDER (252-3337)

●American Urogynecologic Society/Voices for Pelvic Floor Disorders patient education page

SUMMARY AND RECOMMENDATIONS

●Prevalence and risk factors – Female urinary incontinence is common. While the prevalence varies by the population being studied, up to 60 percent of women are affected by urinary incontinence. Major risk factors for urinary incontinence include obesity, vaginal parity, and older age. (See 'Epidemiology' above.)

●Types of female urinary incontinence – The major clinical types of urinary incontinence are stress urinary incontinence (SUI; leakage with maneuvers that increase intra-abdominal pressure), urgency urinary incontinence (sudden urgency followed by leakage), mixed urinary incontinence (symptoms of both stress and urgency), and overflow incontinence (figure 1). "Overactive bladder" is a term that describes a syndrome of urinary urgency, with or without incontinence. (See 'Classification' above.)

Other etiologies for urinary incontinence in women include other less common urologic or gynecologic disorders (eg, urogenital fistulas, cancer), neurologic diseases (eg, multiple sclerosis), and potentially reversible causes [eg, medications (table 1)]. (See 'Contributing factors/conditions' above.)

●Initial evaluation – The initial evaluation of urinary incontinence includes characterizing and classifying the type of incontinence, identifying underlying conditions (eg, neurologic disorder or malignancy) that may manifest as urinary incontinence, and identifying potentially reversible causes of incontinence. This evaluation includes a thorough history, urinalysis, and physical examination when appropriate. (See 'Evaluation' above.)

•History – The history classifies and prioritizes the patient's urinary symptoms, as well as identifies other symptoms that indicate the need to evaluate further for underlying causes of incontinence due to serious conditions or potentially reversible medical or functional conditions. (See 'History' above.)

•Role of pelvic examination – Women presenting with complicated symptoms of urinary incontinence or who fail initial behavioral and medical treatments should have a pelvic examination. Additionally, a patient's history may suggest other components of the physical examination that are important in diagnosis, such as assessing a postvoid residual (PVR). (See 'Physical examination' above.)

•Urinalysis and urine culture – A urinalysis should be performed in all patients. If a urinary tract infection (UTI) is suspected, then a urine culture is obtained. If hematuria is identified, appropriate referral should be initiated to a urologic specialist. (See 'Laboratory tests' above and "Evaluation of hematuria in adults", section on 'Risk factors for malignancy'.)

•Clinical tests – A bladder stress test is used to diagnose SUI. PVR volume and urodynamic testing are not required for initiation of treatment. (See 'Clinical tests, including urodynamic testing' above.)

●Specialist referral – Referral to a specialist is indicated in a minority of cases: incontinence with abdominal/pelvic pain or hematuria in the absence of UTI, suspected vesicovaginal fistula, abnormal physical examination findings (eg, pelvic organ prolapse beyond the hymen), new neurologic symptoms in addition to urinary and/or bowel incontinence or suspected overflow incontinence. Women with three or more culture-proven UTIs in a year or at least two in six months warrant referral to a specialist. (See 'Specialist referral' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Catherine E DuBeau, MD, who contributed to earlier versions of this topic review.