Clinical Consult

Each month, questions with a common theme will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

This Month's Question:

How can I easily differentiate between symptoms of stress urinary incontinence and urge urinary incontinence?

Response by Diane K. Newman, MSN, RNC, CRNP, and Jean F. Wyman, PhD, APRN-BC, GNP, FAAN, posted 07/26/2004:

Stress urinary incontinence (SUI) is defined by the International Continence Society as "the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing."¹ Urge urinary incontinence (UUI) is "the complaint of involuntary leakage accompanied by or immediately preceded by urgency."¹ UUI is also one of the main symptoms of the complex of overactive bladder (OAB).^2,3 When symptoms of SUI and UUI appear together, this is called mixed urinary incontinence (mixed UI). UUI and mixed UI are most often seen in the elderly, whereas SUI is more often found in younger and perimenopausal women.^4-7

A diagnosis of urinary incontinence can be psychologically upsetting to a younger woman because it is associated with loss of control and aging populations, and is often viewed (inappropriately) as a hygiene issue. Once the topic is brought up, many women feel a sense of relief because they realize that they are not alone. Definition and explanation of SUI by a clinician are especially important because the "stress" in SUI does not connote emotional stress. Therefore, open communication between the patient and the clinician about urinary incontinence may lessen the stigma associated with this condition.⁸

To identify SUI, the key question is: "Do you ever lose urine when you cough, laugh, sneeze, or exercise?" A clinician may be able to observe the incontinence if a patient is asked to cough during the pelvic/perineal examination.⁹ The most common risk factors associated with SUI in women are age, pregnancy (especially vaginal delivery), obesity (elevated body mass index [BMI]), previous pelvic surgery, high-impact physical activity, menopause, medication side effects, and occupational risks (eg, repeated heavy lifting ).^8,10-14 Another risk factor for any urinary incontinence is a history of hysterectomy for women over 60 years of age.¹⁵

To identify UUI, a clinician can ask, "Do you ever experience strong sudden urges to urinate, with or without leakage?"¹⁶ UUI can occur whether or not the bladder is full. Symptoms to look for include urgency, followed by involuntary leakage, daytime frequency, painful urination, nocturia, or bedwetting.⁸

Once a patient recognizes that her leakage is a treatable medical problem, a clinician can make an assessment to determine which type of urinary incontinence is the problem. A bladder diary (one is available at www.StressUI.org ) is an important tool that provides the clinician with information regarding the patient's daytime and nighttime voiding patterns and episodes of urine leakage, as well as fluid and caffeine intake. It is useful in documenting leakage associated with urinary incontinence and activities that increase the abdominal pressure associated with SUI; a diary provides the clinician with key information to diagnose the type of incontinence present.¹⁷

SUI and UUI are often unrecognized and unreported. Clinicians can effectively diagnose and differentiate between the types of urinary incontinence by asking the appropriate questions, recognizing the risk factors, and encouraging patients to document their experiences in a bladder diary. This is the first step in improving the quality of life for hundreds of thousands of women.

References:

1. Abrams P, Cardozo L, Fall M, et al; Standardization Sub-committee of the International Continence Society. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167-178.
   


2. Newman DK, Giovannini D. The overactive bladder: a nursing perspective. Am J Nurs. 2002;102:36-45.
   
   
3. Ouslander JG. Management of overactive bladder. N Engl J Med. 2004; 19;350:786-799.
   
   
4. Sampselle CM. Behavioral interventions in young and middle-age women: simple interventions to combat a complex problem. Am J Nurs. 2003;(suppl):9-19.
   
   
5. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S; Norwegian EPINCONT Study. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol. 2000;53:1150-1157.
   
   
6. Hagglund D, Olsson H, Leppert J. Urinary incontinence: an unexpected large problem among young females. Results from a population-based study. Fam Pract. 1999;16:506-509.
   
   
7. Brown JS, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet Gynecol. 1999;94:66-70.
   
   
8. Newman DK, Wyman JF, et al; Collaborative to Support Urinary Incontinence and Women's Health (CSUIWH). SUI in Women: A Clinical Guide. Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc; 2003.
   
   
9. Newman DK. Stress urinary incontinence in women. Am J Nurs. 2003;103:46-55.
   
   
10. Hunskaar S, Burgio K, Diokno A, Herzog AR, Hjalmas K, Lapitan MC. Epidemiology and natural history of urinary incontinence in women. Urology. 2003;62(4 suppl 1):16-23.
    
    
11. Meyer S, Hohlfeld P, Achtari C, De Grandi P. Pelvic floor education after vaginal delivery. Obstet Gynecol. 2001;97(5 pt 1):673-677.
    
    
12. Moller LA, Lose G, Jorgensen T. Risk factors for lower urinary tract symptoms in women 40 to 60 years of age. Obstet Gynecol. 2000;96:446-451.
    
    
13. Chiarelli P, Brown WJ. Leaking urine in Australian women: prevalence and associated conditions. Women Health. 1999;21:1-13.
    
    
14. Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I. Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstet Gynecol. 2002;100:1230-1238.
    
    
15. Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and urinary incontinence: a systematic review. Lancet. 2000;356:535-539.
    
    
16. Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2000;62:2433-2444, 2447, 2452.
    
    
17. Locher JL, Goode PS, Roth DL, Worrell RL, Burgio KL. Reliability assessment of the bladder diary for urinary incontinence in older women. J Gerontol A Biol Sci Med Sci. 2001;56:M32-M35.