Urinary incontinence is an important physical and social issue that affects over 50% of postmenopausal women, with the number of cases increasing year on year, and it affects twice as many women as men (Kolodyńska et al, 2019). The condition occurs in 20–30% of young women, 30–40% of middle-aged women, and up to 50% of women in older age (Kolodyńska et al, 2019). The aetiology of the problem of incontinence is not completely understood, and the problem affects men and women of all ages and in parallel with many changes in the human body (Kolodyńska et al, 2019). There are five types of urinary incontinence—stress, urge, mixed, overflow, and functional—with different causes and clinical characteristics. This article looks at urge incontinence in postmenopausal women. Kolodyńska et al (2019) stated that incontinence in postmenopausal women occurs more often than other civilization (noncommunicable) diseases, such as diabetes, hypertension and depression.
Urge incontinence can have devastating effects on the patient, and is detrimental to levels of activity and psychosocial state (British Medical Journal (BMJ), 2020). The condition may, therefore, lead to depression and withdrawal from social settings.
Symptoms
Urge incontinence (also known as overactive bladder), is caused by overly active or irritated bladder muscles, and the most common symptom is the frequent and sudden urge to urinate, with occasional leakage of urine. Mixed incontinence occurs when there is muscle weakness and uncontrollable need to void. The BMJ (2020) defined urge incontinence as involuntary, spontaneous urine loss that is associated with an uncontrollable sense of urgency.
When looking at diagnostic factors, some key considerations would be the presence of risk factors, such as older age, white ethnicity and obesity; involuntary urine leakage on effort, exertion, sneezing or coughing; involuntary urine leakage accompanied by or immediately preceded by urgency and the frequency of urination (BMJ, 2020). Other diagnostic factors include presence of nocturia, abnormal bulbocavernosus and wink reflexes, weakened sphincter tone and chronic heart failure (BMJ, 2020).
Causes
The BMJ (2020) stated that urge incontinence may be caused by alterations in anatomical support and/or neuromuscular function of the pelvic floor, or it may be idiopathic. There is a high incidence of stress and urge incontinence where there is chronic lower back pain, and this has been attributed to poor motor control in the local low back and pelvic floor muscles that work in combination to control continence as well as support the spine. Therefore, both problems can often be managed by performing transversus abdominis exercises, known as core-stabilising exercises (Australian Menopause Society (AMS), 2013).
The National Institute for Health and Care Excellence (NICE) (2019a) listed multiple causes for urge incontinence. The condition is often associated with overactive bladder syndrome, the symptoms of which are thought to be caused by involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle. Overactivity of the detrusor muscles causes urgency and frequency of micturition, with or without incontinence. In most women, urge incontinence is idiopathic, and, in some cases, it can be associated with systemic neurological conditions, such as Parkinson's disease and multiple sclerosis, or injury to the pelvic or spinal nerves (NICE, 2019a). There are numerous comorbidities that can increase urgency symptoms, including comorbidities such as obesity, type 2 diabetes and chronic urinary tract infection. Furthermore, the adverse effects of some medications may also cause detrusor overactivity, such as parasympathomimetics, antidepressants and hormone replacement therapy. Diuretics also increase urinary frequency. Additionally, urinary urgency can be increased significantly by caffeinated, acidic or alcoholic drinks.
Management
NICE (2019a) guidelines indicate that treatment of urinary incontinence should start with conservative treatment, and that surgical treatment should only be used when conservative treatment does not yield positive results (Kolodyńska et al, 2019). Conservative treatment would involve pharmacotherapy, physiotherapy, and behavioural therapy.
Where it is a case that does not require referral, and symptoms require managing, the NICE (2019a) clinical knowledge summary states the following:
The NICE (2019a) clinical knowledge summary for the topic of urinary incontinence in women mentions guidelines for when referral is required for those experiencing urge incontinence, for example, in cases of persisting bladder or urethral pain, palpable bladder on bimanual or abdominal examination after voiding, clinically benign pelvic masses, associated faecal incontinence, previous continence surgery and suspected neurological disease.
NICE also published a recent guideline covering the management of urinary incontinence and pelvic organ prolapse in women, which explains, among many things, the non-surgical management of urinary incontinence, which is the most encouraged first point of call when managing the condition (NICE, 2019b). The guidelines (NICE, 2019b) state that recommendations to reduce caffeine intake should be made, advice on fluid take modification should be given (may be too high or too low), and weight loss advice should be given to those whose BMI exceeds 30.
Physical and behavioural therapies explained
One of the primary physical therapies to offer is pelvic floor muscle training. A supervised trial of this intervention should be offered for at least 3 months as a first-line treatment for women who experience stress or missed urinary incontinence, with the pelvic floor training programme consisting of at least eight contractions three times daily (NICE, 2019b). The recommendations by NICE (2019b), however, do go against the use of perineometry or pelvic floor electromyography for biofeedback as a routine part of pelvic floor exercise programmes. If found to be beneficial, the pelvic floor muscle training should be continued.
Another option is electrical stimulation, which should be offered to women who are not physically able to contract their pelvic floor muscles, and should be provided in order to aid motivation and adherence to therapy. This intervention should not be routinely used in the treatment of women with an overactive bladder. It should also not be used routinely in combination with pelvic floor muscle training (NICE, 2019b).
In terms of behavioural therapy, NICE (2019b) recommends bladder training lasting for a minimum of 6 weeks as a first-line treatment for women with urgency or mixed incontinence. Where there is no satisfactory benefit from this, a combination of medication for the overactive bladder in combination with bladder training should be considered where frequency may be a troubling symptom (NICE, 2019b).
Neurostimulation is another physical therapy on offer, although transcutaneous sacral nerve stimulation (TENS) or transcutaneous or posterior tibial nerve stimulation should not be offered for an overactive bladder (NICE, 2019b). Percutaneous posterior tibial nerve stimulation should also not routinely be offered except if there has been a local multidisciplinary team review as well as if it has been ensured that the patient has already tried non-surgical management, including overactive bladder medication, but this has not worked adequately. Additionally, the patient should first also have been offered but has refused botulinum toxin type A or percutaneous sacral nerve stimulation (NICE, 2019b).
Special considerations
The NICE (2019) clinical knowledge summary states that if the patient with urge incontinence is post-menopausal and has vaginal atrophy, intravaginal oestrogen therapy can be considered. This should then be reviewed at least annually to re-assess the need for continued treatment and for the monitoring of symptoms of endometrial hyperplasia or carcinoma in those with a uterus.
If the patient has troublesome nocturia, desmopressin can be considered as an off-label indication, although this should be avoided in women over the age of 65 years with cardiovascular disease or hypertension (NICE, 2019b).
Where conservative treatment options fail, a referral for specialist urological assessment and management should be considered (NICE, 2019b). The treatment options in secondary care include injection of botulinum toxin type A (botox) into the bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty and urinary diversion (NICE, 2019b).
Absorbent containment products and aids
NICE (2019b) makes it clear that any absorbent containment products, hand-held urinals or toileting aids should be offered only as a coping strategy while patients wait for the actual treatment to be initiated or start working. These can be used as an adjunct to ongoing therapy or for long-term management of urinary incontinence but only after treatment options have been looked at properly. Women who do use such products should be reviewed yearly, with a skin assessment also performed, alongside a routine assessment of continence, and an evaluation of the efficacy of the product in meeting the needs of the patient (NICE, 2019b). The skin assessment is particularly important because of the possible occurrence of incontinence-associated dermatitis.
Just Can't Wait toilet access cards
The organisation Bladder and Bowel Community has available for free its ‘Just Can't Wait’ toilet cards. These are universally recognised toilet access cards, with WC signage, meaning there is discrete and clear communication for when someone feels they cannot wait to use the toilet. Those with urge incontinence might find these useful to keep on hand (https://tinyurl.com/ycksqaqt).
Conclusion
Overall, urge incontinence in postmenopausal women remains a complex issue. It may be an embarrassing topic for a patient to discuss, and may be of a neurological or musculoskeletal aetiology. Management of this condition mainly involves non-surgical techniques, including bladder training, medication review, psychosocial approaches such as counselling, and in some cases, continence aids. NICE has a clear and recent guideline for the management of incontinence, and there is further advice in relation to the more specific topic of postmenopausal women experiencing urge incontinence. More research needs to be done on this topic as the evidence base is limited. Certain criteria would indicate referral to specialist services. It is important to approach the topic sensitively and with an open mind to the complexity of the psychosocial issues surrounding this physical condition.