Guidelines for preventive activities in general practice

Miscellaneous

Urinary incontinence

Guidelines for preventive activities in general practice
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Miscellaneous | Urinary incontinence

Urinary incontinence is defined as the involuntary loss of urine. It can have a considerable impact on health and the overall quality of life.1 Urinary incontinence is more common in women than in men.1 The Continence Foundation of Australia estimates that 80% of those with urinary incontinence in the community are women.2

Although bedwetting (enuresis) is common in children, the prevalence and severity of urinary incontinence tends to increase with age. It is estimated that severe urinary incontinence affects approximately 5% of people aged 65–84 years, and this increases by more than fivefold for those aged ≥85 years (28%).3,4 However, these numbers are likely to be underestimated, because urinary incontinence tends to be under-reported and undertreated.3

Screening

Recommended as of: 28/06/2024
Recommendation Grade How often References
Routine urinary incontinence screening in the general population has insufficient evidence.  Practice point N/A 5

Case finding

Recommended as of: 28/06/2024
Recommendation Grade How often References

Ask about the occurrence of urinary incontinence in women and people who are at higher risk (see Specific populations).

The 3 Incontinence Questions (3IQ)

  1. During the last three months, have you leaked urine (even a small amount)?
☐ Yes
☐ No – questionnaire completed
 
  1. During the last three months, did you leak urine (check all that apply):
☐ a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
☐ b. When you had the urge or feeling that you needed to empty your bladder, but you could not get the toilet fast enough?
☐ c. Without physical activity and without a sense of urgency?
 
  1. During the last three months, did you leak urine most often (check only one):
☐ a. When you are performing some physical activities, such as coughing, sneezing, lifting, or exercise?
☐ b. When you had the urge or feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?
☐ c. Without physical activity or a sense of urgency?
☐ d. About as equally as often with physical activities as with a sense of urgency? 
 

Definitions of the type of urinary incontinence are based on responses to Question 3:

Response to Question 3

Type of incontinence
  1. Most often with physical activity.

Stress only or stress predominant.
  1.  Most often with the urge to empty the bladder.

Urge only or urge predominant.
  1.  Without physical activity or sense of urgency.

Other cause only or other cause predominant.
  1.  About equally with physical activity and sense of urgency.

Mixed.
Conditionally recommended Opportunistically 6

Types of urinary incontinence

There are four common types of urinary incontinence. When diagnosing a patient with incontinence, it is important to distinguish between urge incontinence and stress incontinence because treatment and management differ.7

  • Stress incontinence is the leaking of urine that may occur during exercise, coughing, sneezing, laughing, walking, lifting or playing sport. This is more common in women, although it also occurs in men, especially after prostate surgery. Pregnancy, childbirth and menopause are the main contributors to stress incontinence.
  • Urge incontinence is a sudden and strong need to urinate. It is often associated with frequency and nocturia, and is often due to having an overactive or unstable bladder, neurological condition, constipation, enlarged prostate or a history of poor bladder habits.
  • Mixed incontinence is a combination of stress and urge incontinence and is most common in older women.
  • Overflow incontinence results from bladder outflow obstruction or injury. Its symptoms may be confused with those of stress incontinence.

Case finding

Although there is no evidence to screen for urinary incontinence in the general, asymptomatic population, GPs should take a proactive approach by asking about urinary symptoms in at-risk groups during routine appointments. This is because many patients can be embarrassed by urinary incontinence and not raise the issue with their GP.1 Some patients may also see it as a ‘normal part of ageing’ and not realise that treatments are available.1

A list of people who may be at risk of urinary incontinence is given in Specific populations.

It is important to approach the topic with sensitivity. Consider probing statements, such as ‘Other people with [state conditions of higher risk here] have had problems with their waterworks [bladder control]…’

Prevention of urinary incontinence

Changes that patients can make in order to prevent urinary incontinence can include:8

  • losing weight
  • quitting smoking
  • reducing caffeine and alcohol intake
  • addressing constipation by eating plenty of fibre, fruits and vegetables
  • exercising for 30 minutes most days
  • practising good toilet habits.

It is important that people at risk drink plenty of water, because reducing water intake can worsen bladder control issues.

There is some evidence to suggest that pelvic floor exercises may reduce the prevalence of urinary incontinence in antenatal women in late pregnancy and postpartum.10 However, the evidence is insufficient to determine whether pelvic floor exercises are an effective preventive activity to prevent urinary incontinence more than one year after birth.9

People with urinary incontinence can be at risk of falls,3,10 mental health3,4 and skin conditions.11

There are no additional recommendations for this specific population.

 

People at higher risk of urinary incontinence include:3,4,6

  • Women, in particular, women who:
    • are prenatal and postnatal,
    • have had children vaginally, had an assisted delivery or delivered a large baby
    • are overweight or obese
    • have had a hysterectomy
    • report constipation
  • Men who have had prostate surgery
  • Those with respiratory conditions, diabetes, stroke, heart conditions, recent surgery, neurological disorders, disability and multimorbidity
  • Those on polypharmacy and on medications that may aggravate urinary incontinence
  • Frail elderly people or long-term residents of care facilities.

Evidence is limited about the prevalence of incontinence among culturally and linguistically diverse and sex and gender diverse communities.4

Guidance about urinary incontinence in the setting of supported accommodation:
Urinary incontinence, RACGP aged care clinical guide (Silver Book) – Part A 

GP resource about pelvic floor muscle training for women with stress, urge or mixed urinary incontinence:
Pelvic floor muscle training: urinary incontinence, Handbook of non-drug interventions (HANDI) | RACGP

  1. Pizzol D, Demurtas J, Celotto S, et al. Urinary incontinence and quality of life: A systematic review and meta-analysis. Aging Clin Exp Res. 2021;33(1):25-35. doi: 10.1007/s40520-020-01712-y.
  2. Deloitte Access Economics. The economic impact of incontinence in Australia. Continence Foundation of Australia; 2011 [Accessed 2 February 2024].
  3. The Royal Australian College of General Practitioners (RACGP). RACGP aged care clinical guide (Silver Book). 5th edn. RACGP, 2019 [Accessed 2 February 2024].
  4. Australian Institute of Health and Welfare (AIHW). Incontinence in Australia. AIHW; 2013 [Accessed 2 February 2024].
  5. Nelson HD, Cantor A, Pappas M, Miller L. Screening for urinary incontinence in women: A systematic review for the Women's Preventive Services Initiative. Ann Intern Med 2018;169(5):311–19. doi: 10.7326/M18-0225.
  6. Brown JS, Bradley CS, Subak LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006 May 16;144(10):715–23. doi: 10.7326/0003-4819-144-10-200605160-00005.
  7. National Institute for Health and Care Excellence (NICE). Urinary incontinence and pelvic organ prolapse in women: Management. NICE guideline [NG123]. NICE, 2019 [Accessed 2 February 2024].
  8. Continence Foundation of Australia. About continence: Prevention. Continence Foundation of Australia, 2021 [Accessed 27 April 2023].
  9. Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay‐Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2017;12(12):CD007471. doi: 10.1002/14651858.CD007471.pub3.
  10. Moon S, Chung HS, Kim YJ, et al. The impact of urinary incontinence on falls: A systematic review and meta-analysis. PLoS One 2021;16(5):e0251711. doi: 10.1371/0251711.
  11. Bliss DZ, Mathiason MA, Gurvich O, et al. Incidence and predictors of incontinence-associated skin damage in nursing home residents with new-onset incontinence. J Wound Ostomy Continence Nurs 2017;44(2):165–71. doi: 10.1097/WON.0000000000000313.
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