Assessing and Managing Urinary Incontinence in Primary Care

Incontinence generally results from a problem either with the urethra or with the bladder. The urethra can permit urine to leak when it moves incessantly due to poor support or when it closes poorly, as can occur with a neurologic disorder. In the bladder, hyperactivity due to involuntary contractions, or low compliance, can lead to urinary incontinence. A thorough history and physical examination guide management. The history should elicit information that can allow the clinician to assess how severe the problem is (eg, number of pads used per day, frequency of leakage) and factors that may cause or influence the problem, such as medications used, previous surgical and obstetric history, and urologic history including prior therapy for incontinence. Information about when leakage is at its worst is useful. Leakage that worsens in winter is typically associated with detrusor instability. Leakage that worsens at night can indicate a problem with bladder compliance. Incontinence that started after the onset of an antihypertensive or antipsychotic medication may be due to alpha-receptor antagonist effects of drugs such as prazosin or chlorpromazine. Difficulty emptying the bladder may be associated with medications that block cholinergic and calcium-channel activity, such as sedatives, antidepressants, antispasmodics, antiemetics, antipsychotics, antiarrhythmics, and anticonvulsants. Mild incontinence can be managed conservatively in a primary care setting, with pelvic-floor exercise, behavior therapy, or anticholinergic therapy. Patients with severe incontinence or an unclear etiology of incontinence should be referred to a specialist for urodynamic testing.