Dr Cherie Yik Wah Chan ( left ) House medical officer at Western Health , Victoria .

Dr Henry Han-I Yao ( centre ) Urological surgeon at Western Health and Eastern Health , Victoria . Senior clinical lecturer , University of Melbourne , Victoria .

Professor Helen O ’ Connell AO ( right ) Urologist , University of Melbourne ; Monash University ; Epworth Healthcare , East Melbourne , Victoria .

First published online on 15 March 2024

BACKGROUND

URINARY incontinence ( UI ), the

involuntary loss of urine , is a very common condition in women . It may have devastating consequences . These include effects on general quality of life ( QOL ), with loss of social activity as people become housebound , as well as loss of confidence and self-esteem , thus reducing effective help-seeking behaviours .

In addition to the mental health effects , physical health impacts include falls when trying to reach the bathroom prompted by urgency , and skin breakdown caused by the use of pads and urine dermatitis .

UI is a significant risk factor for admission to residential aged care , thus incurring an enormous economic cost . 1

This How to Treat reviews normal continence mechanisms and what goes wrong , leading to incontinence in women . It discusses the impact of the condition , including

the gravity in some people , and the high probability of success with appropriate treatment . It aims to outline incontinence based on aetiological factors that permit sub-typing , which can aid appropriate treatment .

EPIDEMIOLOGY

ABOUT 42 % of women are affected by UI , occuring at all ages . 2 The prevalence of UI is about 40 %

in those aged over 30 years , and increases to more than 50 % in those aged 50-59 . 2 Peak incidence occurs between 45 and 70 years of age .

The prevalence for severe incontinence in women is 2.2 %, with 80 % of affected patients requiring assistance with bladder control either sometimes or always . 3

Despite the high prevalence , about 70 % of patients do not seek help because of embarrassment and a lack of understanding of treatment . 1

PHYSIOLOGY OF LOWER URINARY TRACT

THE physiology of the lower urinary

tract ( LUT ) appears in box 1 .

TYPES OF INCONTINENCE

Transient urinary incontinence

INCONTINENCE may be caused by

transient conditions , particularly in the elderly . Treat these conditions first , if present , before proceeding with definitive therapy . Causes of transient incontinence , using the mnemonic DIAPERS , appear in box 2 . 10

Stress urinary incontinence

There are two main subgroups of

stress urinary incontinence ( SUI ). The first is urethral hypermobility , where loss of pelvic support reduces passive or active urethral compression .

The second , intrinsic sphincter deficiency ( ISD ), is due to loss of proximal urethral coaptation and also as a result of lower success rate from mid-urethral sling surgery . ISD is a more severe form of exertion-related leakage associated with failed urethral surgery , denervation related to pelvic surgery , and congenital neurological urogenital conditions such as spina bifida . Although related to exertion , it may manifest as leakage on rising out of a chair and minimal movements , rather than the typical SUI associated with exercise , coughing or sneezing . 11

The risk factors for SUI are listed in box 3 .

Overactive bladder and urge urinary incontinence

Overactive bladder ( OAB ) is a syndrome

in which bladder urine storage is affected ( see figure 1 ). This condition was previously known as an irritable or unstable bladder .