Urinary Incontinence in Women: Evaluation and Management

Urinary incontinence is a common problem among women worldwide, resulting in a substantial economic burden and decreased quality of life. The Women's Preventive Services Initiative is the only major organization that recommends annual screening for urinary incontinence in all women despite low to insufficient evidence regarding effectiveness and accuracy of methods. No other major organization endorses screening. Initial evaluation should include determining whether incontinence is transient or chronic; the subtype of incontinence; and identifying any red flag findings that warrant subspecialist referral such as significant pelvic organ prolapse or suspected fistula. Helpful tools during initial evaluation include incontinence screening questionnaires, a three-day voiding diary, the cough stress test, and measurement of postvoid residual. Urinalysis should be ordered for all patients. A step-wise approach to treatment is directed at the urinary incontinence subtype, starting with conservative management, escalating to physical devices and medications, and ultimately referring for surgical intervention. Pelvic floor strengthening and lifestyle modifications, including appropriate fluid intake, smoking cessation, and weight loss, are first-line recommendations for all urinary incontinence subtypes. No medications are approved by the U.S. Food and Drug Administration for treatment of stress incontinence. Pharmacologic therapy for urge incontinence includes antimuscarinic medications and mirabegron. Patients with refractory symptoms should be referred for more invasive management such as mechanical devices, injections of bulking agents, onabotulinumtoxinA injections, neuromodulation, sling procedures, or urethropexy.