Urinary Incontinence

Gretchen M. Irwin, MD, MBA

KEYWORDS
 Urinary incontinence  Stress incontinence  Urge incontinence
 Pelvic floor muscle training

KEY POINTS
 Many patients experience urinary incontinence but fail to report symptoms to a physician
unless asked directly.
 Determining the type of urinary incontinence using history and physical examination is crit-
ical to effective treatment.
 The DIAPPERS mnemonic may help physicians recall reversible causes of urinary incon-
tinence that should be ruled out in newly diagnosed individuals.
 Lifestyle modifications are helpful for urge, stress, and mixed incontinence.

INTRODUCTION

Urinary incontinence is a common, although often underreported, condition. Esti-

mates suggest that approximately 20 million women and 6 million men in the United
States experience urinary incontinence during their lives.1 Furthermore, up to 77%
of women in nursing homes may have urinary incontinence.2 Despite such prevalence,
only 25% of individuals affected by incontinence seek or receive treatment.2 Never-
theless, urinary incontinence has significant impacts on quality of life and overall
health for patients. Higher rates of depression and social isolation have been noted
for patients with urinary incontinence.3,4 Also, higher rates of hospitalization, urinary
tract infection, pressure ulcers, and admission to long-term residential care as well
as lower work productivity, general health, and quality of life are noted in populations
with urinary incontinence compared with those without.5–8 Although not often sought
out, a variety of treatment options exist that can significantly improve symptoms. Life-
style modifications, medications, and surgical options improve incontinence episode
frequency and ultimately improve quality of life and general health for those individuals
impacted.

Disclosure: The author has nothing to disclose.

Family Medicine Residency, Department of Family and Community Medicine, Wesley Medical
Center, University of Kansas School of Medicine–Wichita, 1010 North Kansas, Wichita, KS
67214, USA
E-mail address: [email protected]

Prim Care Clin Office Pract - (2019) -–-

https://doi.org/10.1016/j.pop.2019.02.004 primarycare.theclinics.com
0095-4543/19/ª 2019 Elsevier Inc. All rights reserved.
2 Irwin

PATHOPHYSIOLOGY

Urinary incontinence can be defined simply as the loss of bladder control or uninten-
tional voiding. Urinary incontinence can be classified as stress, urge, mixed, overflow,
or functional. Defining the underlying cause of incontinence episodes is critical for
appropriate treatment.
Stress incontinence develops when the urinary sphincter becomes weak and fails to
function appropriately. Clinically, patients will note involuntary loss of urine with
increased abdominal pressure, effort, or physical exertion.9 Laughing, coughing, and ex-
ercise are common triggers of stress incontinence episodes. This type of incontinence is
common in men after prostate surgery.10 It is also common in women, as an estimated
50% of women under age 65 years with urinary incontinence have stress type.11
Urge incontinence results from overactivity of the detrusor muscle.12 As the name
suggests, a common patient complaint is involuntary loss of urine associated with
feelings of extreme urgency to void with limited time to appropriately toilet.9 The diag-
nosis of mixed incontinence should be given to patients who display features of both
stress and urge type. Mixed incontinence is more common than urge type alone, as
only 10% of women have isolated urge incontinence, whereas 30% have mixed
type.11 Although mixed incontinence is less common than stress type, studies have
shown that women with mixed or urge incontinence may have lower quality-of-life
scores than those with stress alone.13
Overflow incontinence results from obstruction or impaired detrusor contractility
that leads to bladder distention, such as seen in men with benign prostatic hyperplasia
leading to obstruction.10,14
Individuals may also suffer from functional incontinence, whereby cognitive or
mobility impairment prevents an individual from appropriately toileting independently
with no underlying bladder or neurologic pathologic condition.14,15

RISK FACTORS

Multiple risk factors for urinary incontinence have been identified. For women, high
parity, history of vaginal deliveries, and menopause are risk factors for the develop-
ment of urinary incontinence.16–18 Similarly, men who have undergone prostate sur-
gery may be higher risk for incontinence. In both cases, damage to neural control of
the bladder or pelvic floor muscles or direct mechanical trauma to the pelvic floor is
thought to underlay the development of urinary incontinence.19 Obesity and increasing
age are risk factors for both genders in the development of urinary incontinence.16–18
After age 80, both genders are equally affected by urinary incontinence.20

DIAGNOSIS

The diagnosis of urinary incontinence can be readily made by a physician simply by

asking if the patient is experiencing episodes of unintended loss of urine. Because
the condition is often embarrassing for patients, individuals may not report inconti-
nence unless directly asked by a physician. Once a diagnosis of urinary incontinence
has been made, however, the physician must perform a more thorough history to
accurately assess the underlying cause or type of incontinence.
An appropriate history for a patient with urinary incontinence should include an assess-
ment of reversible causes. The DIAPPERS mnemonic created by Resnick provides an
easy way to remember the common reversible causes of incontinence, which include:
 D: Delirium
 I: Infection
 Urinary Incontinence 3

 A: Atrophic vaginitis
 P: Pharmaceuticals, such as alpha-adrenergic antagonists, ACE inhibitors, cal-
cium channel blockers, diuretics, COX 2 selective NSAIDS, opioids, skeletal
muscle relaxants, antidepressants, antipsychotics, alcohol, antihistamines, anti-
cholinergics, and thiazolidinediones.21,22
 P: Psychological disorders, such as depression
 E: Excessive urine output secondary to overconsumption of fluids, medications,
or chronic conditions, such as diabetes
 R: Reduced mobility
 S: Stool impaction23
Once reversible causes have been excluded, the physician must determine the
type of urinary incontinence that the patient is experiencing. Eliciting typical symp-
toms and triggers can help to categorize the type of incontinence. Standardized
questionnaires may simplify the process of determining type of incontinence. The
3 Incontinence Questions, for example, has been shown to have a sensitivity of
0.86 for stress incontinence and 0.75 for detecting urge incontinence in middle-
aged and older women.24
A physician should also consider how other medical and surgical history may
contribute to incontinence episodes. For instance, a patient with stress incontinence
and chronic cough secondary to chronic obstructive pulmonary disease (COPD) may
benefit most from treating the COPD to decrease coughing-triggered incontinence.
In addition to a thorough history, a physical examination focused on anatomic ab-
normalities and evidence of contributing causes may be helpful in determining the
type of incontinence the patient is experiencing.21,25 The physical examination should
include a prostate or gynecologic examination to help rule out contributing causes.26 If
a diagnosis of stress incontinence is suspected, the physician should perform the
cough stress test to confirm the diagnosis.14,27,28 While in the dorsal lithotomy position
with a full bladder, a patient is asked to relax his or her pelvic muscles and cough once
during the cough stress test. If no leakage occurs, the test should be repeated with the
patient in a standing position. A positive test, defined as leaking within 5 to 15 seconds
after coughing, confirms the diagnosis of stress incontinence.22,29,30
Laboratory studies are not routinely indicated unless the history or physical exam-
ination suggests a specific cause, such as polyuria secondary to diabetes. Nonethe-
less, many physicians find it helpful to obtain a urinalysis and a serum creatinine test to
rule out urinary retention, infection, and other reversible causes.21
Requesting patient-completed voiding diaries may help a physician to determine
patterns or triggers associated with a particular type of incontinence. For example, pa-
tients with urge incontinence frequently report awakening 2 or more times per night to
void, whereas those with stress incontinence rarely report nighttime symptoms.31,32 A
voiding diary should include a record of all incontinent episodes as well as all continent
voiding episodes over a period of time. Three days of record should be sufficient to aid
with diagnosis and treatment plans.33–35
Although imaging need not be ordered for every patient, if a physician suspects a
patient has overflow incontinence, a postvoid residual may be helpful in confirming
the diagnosis.36 A postvoid residual volume may be calculated after the patient has
emptied his or her bladder using either ultrasound or intermittent bladder catheteriza-
tion to quantify the amount of urine remaining in the bladder.27 A postvoid residual vol-
ume of greater than 200 mL is diagnostic of overflow incontinence, whereas a residual
volume of less than 50 mL rules out overflow incontinence as a contributor to a pa-
tient’s symptoms.21
4 Irwin

TREATMENT

Treatment of urinary incontinence may include lifestyle modifications, medication, or

surgical intervention. Treatment recommendations vary by type of urinary inconti-
nence, yet treatment of all types focuses primarily on improved quality of life for the
patient rather than disease-oriented outcomes. Thus, treatment modalities should
be chosen based on patient preference.2,21 For all patients with urinary incontinence,
psychological intervention should be considered because it may help to improve
coping skills and overall quality of life.37

Urge Incontinence
Patients with urge incontinence often cite urinary frequency, urgency, and nocturia as
the most bothersome symptoms experienced.20 Depending on the most concerning
symptom, patients may use behavioral modifications, medications, devices, or sur-
gery to help alleviate concerns.38
Behavioral or lifestyle modifications have been shown to improve urinary inconti-
nence. Initial interventions should include modification of fluid intake and avoidance
of bladder irritants, such as caffeine, alcohol, and artificial sweeteners.39 Encouraging
timed voiding every 1 to 2 hours can also greatly improve urge incontinence symp-
toms.39 In addition, bladder retraining and pelvic floor muscle strengthening exercises
have been shown to be beneficial for patients.40 When performed properly, pelvic floor
muscle exercises have been shown to be more effective than medications for reducing
urge incontinence episodes.41
Pelvic floor muscle strengthening relies on the repetitive and selective contraction of
specific muscles to improve strength, endurance, and muscle coordination, allowing
the patient to improve voiding control and delay voiding to allow sufficient time to
toilet.42 Patients may seek out specialized physical therapists to aid in teaching effec-
tive muscle strengthening regimens. Furthermore, biofeedback and electrical or mag-
netic stimulation may also be added to training to allow for optimal improvement in
muscle control.42,43 Some studies have even shown benefit in referring at-risk patients
for pelvic floor muscle training in the immediate and late postpartum period to prevent
future incontinence.44
Although medication alone rarely eradicates urge incontinence episodes, pharma-
cologic treatment can be an important component in a comprehensive plan to improve
incontinence.20,45 Anticholinergic medications are the preferred first-line pharmaceu-
tical agents for urge incontinence because they reduce detrusor overactivity by antag-
onizing the M2 and M3 muscarinic receptors in the bladder.46 Common anticholinergic
medications are listed in Table 1. Anticholinergic medications should be used by pa-
tients for 4 to 8 weeks to accurately ascertain the benefit of the therapy.38 Unfortu-
nately, side effects, such as tachycardia, palpitations, nausea, constipation, blurry
vision, confusion, dry mouth, and urinary retention, are common. Physicians should
recommend long-acting anticholinergic medications, such as fesoterodine, oxybuty-
nin, tolterodine, trospium, darifenacin, and solifenacin, to help limit side effects.38 Pa-
tients with narrow angle glaucoma and gastrointestinal obstruction should not use
anticholinergic medications.46 Furthermore, although 60% to 70% of patients in
nursing homes have urinary incontinence, anticholinergic medications should be
used with caution in this population because of worsening confusion and interaction
between anticholinergic medications and cholinesterase inhibitors commonly used
to treat dementia.46
Beta-adrenergic agonist medication, such as mirabegron, that acts on the beta-3
adrenergic receptors of the detrusor muscle to promote relaxation, is also an option
 Urinary Incontinence 5

Table 1
Anticholinergic treatment of urge incontinence

Class Medication Dose (mg) Route Frequency

Nonselective M3 Propantheline (Pro-Banthine) 7.5–30 Oral 3–5 times daily
Tolterodine (Detrol LA) 4 Oral Daily
Trospium (Sanctura) 20 Oral 2 times daily
Solifenacin (VESIcare) 5–10 Oral Daily
Selective M3 Darifenacin (Enablex) 7.5–15 Oral Daily
Smooth muscle Oxybutynin (Ditropan) 2.5–5 Oral 1–3 times daily
relaxant Oxybutynin extended 5–30 Oral Daily
release (Ditropan XL)
Oxybutynin transdermal 4.9 Transdermal Twice per week
(Oxytrol)
Hyoscyamine (Levsin) 0.125–0.375 Oral 2–4 times daily

for pharmacologic treatment.47 When using mirabegron, patients can expect to have 1
to 2 less incontinence episodes per day.48 Commonly reported side effects with use of
mirabegron include nausea, diarrhea, dizziness, headache, and increased blood
pressure.47
When behavioral and oral pharmacologic interventions have proven ineffective,
more invasive treatment modalities may be recommended for urge incontinence.
For example, injection of onabotulinumtoxinA into the detrusor muscle may decrease
incontinence and improve quality of life, as reported by patients on standardized
questionnaires, for 3 to 6 months.49 Similarly, posterior tibial nerve stimulators may
be placed during an in-office procedure and can reduce incontinence in up to 75%
of patients who have failed behavioral modification treatment.38,50 Also, surgery to
implant sacral, paraurethral, or pudendal nerve stimulators may also have a role in
treatment of refractory urge incontinence.51

Stress Incontinence
Whereas urge incontinence results from an overactivity of the detrusor muscle, stress
incontinence is the result of a weakening of the urinary sphincter, allowing leakage of
urine that is exacerbated by increased intra-abdominal pressure. Lifestyle interven-
tions have been shown to be effective for treatment of both types of incontinence.
Weight loss and increased physical activity have been shown to decrease frequency
of incontinence symptoms.39,52 Pilates, yoga, Tai chi, and core training may be partic-
ularly helpful for incontinence symptoms.53 Complementary therapies, such as
acupuncture, hypnotherapy, and reflexology, have also been shown to have some
benefit.54–56 Patients should also be educated on managing fluid intake and coordi-
nating intake with toileting schedule to facilitate fewer incontinence episodes.39 Elim-
ination of contributing factors, such as treatment of constipation and chronic cough,
can also help to decrease stress incontinence episodes.39 Although the mechanism
is not well understood, smoking cessation is effective for improving incontinence of
both the stress and the urge type.39
Although lifestyle changes should be recommended for both urge and stress incon-
tinence patients, no medications are approved for the treatment of stress inconti-
nence. Alpha-adrenergic agonists, such as pseudoephedrine, may have some
benefit, although significant adverse effects limit practical usefulness.57 However,
some patients may benefit from taking an alpha-adrenergic agonist twice daily or
1 hour before exercise.57 Similarly, Cymbalta has been shown to have some benefit
6 Irwin

in reducing stress incontinence episodes, but adverse effects also limit its off-label use
in practice for only stress incontinence as an indication.58
Although few pharmacologic options exist for stress incontinence, mechanical de-
vices may prove quite effective for patients as part of a treatment regimen. Intraure-
thral plugs and extraurethral seals may be fitted that can prevent leakage, whereas
pessaries may be used to support the bladder neck and thereby stop stress inconti-
nence events.59 Pessaries have been shown to be low risk, low cost, and rapidly effec-
tive and to have minimal contraindications for patients.38
Surgical intervention is often viewed as a last resort in treatment of urinary inconti-
nence because of potential complications of an invasive procedure. However, for
stress incontinence, surgery may prove to be quite beneficial and may be a first-line
treatment. Ultimately, 30% of women with stress incontinence will choose to undergo
surgery.60 Surgery can be expected to improve incontinence symptoms for many
women with improvement rates as high as 90% noted in some studies with complica-
tion rates of less than 5%.2
Interestingly, stress incontinence treatments have not often been compared in
head-to-head effectiveness trials, so physicians should use clinical judgment and pa-
tient preference to help guide recommendations for treatment modality to individual
patients.38

Mixed Incontinence
Mixed incontinence should be treated with strategies for stress and urge incontinence
using patient-reported predominant symptoms as a guide for which treatment to use
first. Of note, patients with mixed incontinence who undergo surgical treatment of
stress incontinence often experience improvement in urge symptoms as well.

Overflow Incontinence
Overflow incontinence occurs when the bladder is unable to empty effectively result-
ing in overfilling of the bladder with subsequent spillover incontinence. Treatments
therefore focus on targeting the underlying pathologic condition contributing to
bladder ineffectiveness to facilitate bladder emptying. If medications are causing
bladder ineffectiveness, such as occurs with anticholinergic therapies, then those
medications should be tapered or discontinued.38 If neurologic disease has resulted
in impaired detrusor innervation, then intermittent or indwelling catheter placement
will be the most effective treatment strategy.38

Functional Incontinence
Functional incontinence results not from pathologic condition within the genitourinary
system, but rather from an ailment that results in cognitive or motor difficulty that leads
to the inability for the patient to reach the toilet in a timely appropriate manner. Treat-
ment focuses on assisting with toileting to ensure that the bladder is emptied
regularly.38

Referral
Physicians in primary care should consider referral of patients to a urologist or urogy-
necologist when incontinence symptoms are associated with recurrent symptomatic
urinary tract infections, new-onset neurologic symptoms, marked prostate enlarge-
ment, or pelvic organ prolapse past the introitus. Significant pelvic pain, persistent
hematuria, persistent proteinuria, previous pelvic radiation, a postvoid residual greater
than 200 mL, or uncertain diagnosis should also prompt referral.30,61
 Urinary Incontinence 7

REFERENCES

1. Fantl AJ. Urinary incontinence in adults: acute and chronic management/urinary

incontinence in adults. Guideline panel update. Rockville (MD): U.S. Department
of Health and Human Services; 1996. Agency for Health Care Policy and
Research; Clinical Practice Guideline Number 2: AHCPR publication no. 96-0682.
2. Lukacz ES, Santiago-Lastra Y, Albo ME, et al. Urinary incontinence in women: a
review. JAMA 2017;318(16):1592–604.
3. Melville JL, Fan MY, Rau H, et al. Major depression and urinary incontinence in
women: temporal associations in an epidemiologic sample. Am J Obstet Gynecol
2009;201(490):e1–7.
4. Bogner HR, Gallo JJ, Sammel MD, et al. Urinary incontinence and psychological
distress in community-dwelling older adults. J Am Geriatr Soc 2002;50(3):
489–95.
5. Hunskaar S, Burgio K, Clark A, et al. Epidemiology of urinary and faecal inconti-
nence and pelvic organ prolapse. In: Abrams P, Cardozo L, Khoury R, et al, ed-
itors. Incontinence. 3rd international consultation on incontinence. Plymouth
(United Kingdom): Health Publication Ltd; 2005. p. 255–312.
6. Albertson M. Decreasing urinary incontinence in home healthcare. Home Healthc
Now 2018;36(4):232–7.
7. Lin KY, Siu KC, Lin KH. Impact of lower urinary tract symptoms on work produc-
tivity in female workers: a systematic review and meta-analysis. Neurourol Urodyn
2018;37(8):2323–34.
8. National Institute for Healthcare and Excellence. The management of urinary in-
continence in women. NICE clinical guideline 171 2013.
9. Haylen R, de Ridder D, Freeman R, et al. An International Urogynecological As-
sociation (IUGA)/International Continence Society (ICS) joint report on the termi-
nology of female pelvic floor dysfunction. Neurourol Urodyn 2010;29(1):4–20.
10. DuBeau CE, Kuchel GA, Johnson T II, et al. Fourth international consultation on
incontinence. Incontinence in the frail elderly: report from the 4th international
consultation on incontinence. Neurourol Urodyn 2010;29(1):165–78.
11. Milsom I, Altman D, Cartwright R, et al. Epidemiology of urinary incontinence (UI)
and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP) and
anal incontinence (AI). Incontinence. ICUD-EAU, 2013.
12. Ouslander JG. Management of overactive bladder. N Engl J Med 2004;350(8):
786–99.
13. Schimpf MO, Patel M, O’Sullivan DM, et al. Difference in quality of life in women
with urge urinary incontinence compared to women with stress urinary inconti-
nence. Int Urogynecol J Pelvic Floor Dysfunct 2009;20(7):781–6.
14. Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, et al. What type of urinary incon-
tinence does this woman have? JAMA 2008;299(12):1446–56.
15. Yap P, Tan D. Urinary incontinence in dementia - a practical approach. Aust Fam
Physician 2006;35(4):237–41.
16. MacArthur C, Lewis M, Bick D. Stress incontinence after childbirth. Br J Midwifery
1993;1(5):207–15.
17. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of
urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996;
103(2):154–61.
18. Thom DH, van den Eeden SK, Brown JS. Evaluation of parturition and other repro-
ductive variables as risk factors for urinary incontinence in later life. Obstet Gyne-
col 1997;90(6):983–9.
8 Irwin

19. Glazener CMA, Cooper K. Anterior vaginal repair for urinary incontinence in
women. Cochrane Database Syst Rev 2001;(1):CD001755.
20. Gibbs CF, Johnson TM II, Ouslander JG. Office management of geriatric urinary
incontinence. Am J Med 2007;120(3):211–20.
21. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am
Fam Physician 1998;57(11):2675–84.
22. Imam KA. The role of the primary care physician in the management of bladder
dysfunction. Rev Urol 2004;6(suppl 1):S38–44.
23. Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J
Med 1985;313(13):800–5.
24. Brown JS, Bradley CS, Subak LL, et al, Diagnostic Aspects of Incontinence Study
(DAISy) Research Group. The sensitivity and specificity of a simple test to distin-
guish between urge and stress urinary incontinence. Ann Intern Med 2006;
144(10):715–23.
25. Frank C, Szlanta A. Office management of urinary incontinence among older pa-
tients. Can Fam Physician 2010;56(11):1115–20.
26. Chapple CR, Manassero F. Urinary incontinence in adults. Surgery 2005;23(3):
101–7.
27. Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management.
Am Fam Physician 2000;62(11):2433–44, 2447, 2452.
28. Videla FL, Wall LL. Stress incontinence diagnosed without multichannel urody-
namic studies. Obstet Gynecol 1998;91(6):965–8.
29. Ghoniem G, Stanford E, Kenton K, et al. Evaluation and outcome measures in the
treatment of female urinary stress incontinence: International Urogynecological
Association (IUGA) guidelines for research and clinical practice. Int Urogynecol
J Pelvic Floor Dysfunct 2008;19(1):5–33.
30. Weidner AC, Myers ER, Visco AG, et al. Which women with stress incontinence
require urodynamic evaluation? Am J Obstet Gynecol 2001;184(2):20–7.
31. Moore KN, Saltmarche B, Query A. Urinary incontinence. Non-surgical manage-
ment by family physicians. Can Fam Physician 2003;49:602–10.
32. Wyman JF, Choi SC, Harkins SW, et al. The urinary diary in evaluation of inconti-
nent women: a test-retest analysis. Obstet Gynecol 1988;71(6 pt 1):812–7.
33. Homma Y, Ando T, Yoshida M, et al. Voiding and incontinence frequencies: vari-
ability of diary data and required diary length. Neurourol Urodyn 2002;21(3):
204–9.
34. Nygaard I, Holcomb R. Reproducibility of the seven-day voiding diary in women
with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2000;
11(1):15–7.
35. Yap TL, Cromwell DC, Emberton M. A systematic review of the reliability of
frequency-volume charts in urological research and its implications for the opti-
mum chart duration. BJU Int 2007;99(1):9–16.
36. Dowling-Castronovo A, Specht JK. How to try this: assessment of transient uri-
nary incontinence in older adults. Am J Nurs 2009;109(2):62–71.
37. Shinohara K, Honyashiki M, Imai H, et al. Behavioural therapies versus other psy-
chological therapies for depression. Cochrane Database Syst Rev
2013;(10):CD008696.
38. Hersh L, Salzman B. Clinical management of urinary incontinence in women. Am
Fam Physician 2013;87(9):634–40.
39. Imamura M, Williams K, Wells M, et al. Lifestyle interventions for the treatment of
urinary incontinence in adults. Cochrane Database Syst Rev 2015;(12):CD003505.
 Urinary Incontinence 9

40. Khan IJ, Tariq SH. Urinary incontinence: behavioral modification therapy in older
adult. Clin Geriatr Med 2004;20(3):499–509.
41. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge uri-
nary incontinence in older women: a randomized controlled trial. JAMA 1998;
280(23):1995–2000.
42. Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training
versus no treatment, or inactive control treatments, for urinary incontinence in
women. Cochrane Database Syst Rev 2014;(5):CD005654.
43. McClurg D, Pollock A, Campbell P, et al. Conservative interventions for urinary in-
continence in women: an overview of Cochrane systematic reviews. Cochrane
Database Syst Rev 2016;(9):CD012337.
44. Saboia DM, Bezerra KC, Vasconcelos Neto JA, et al. The effectiveness of post-
partum interventions to prevent urinary incontinence: a systematic review. Rev
Bras Enferm 2018;71(suppl 3):1460–8.
45. Norton P, Brubaker L. Urinary incontinence in women. Lancet 2006;367(9504):
57–67.
46. DeMaagd G. Urinary incontinence: treatment update with a focus on pharmaco-
logical management. US Pharm 2007;32(6):34–44.
47. Mirabegron (Myrbetriq) for overactive bladder. Med Lett Drugs Ther 2013;
55(1409):13–5.
48. Sacco E, Bientinesi R. Mirabegron: a review of recent data and its prospects in
the management of overactive bladder. Ther Adv Urol 2012;4(6):315–24.
49. Duthie JB, Vincent M, Herbison GP, et al. Botulinum toxin injections for adults with
overactive bladder syndrome. Cochrane Database Syst Rev 2011;(12):CD005493.
50. Peters KM, Macdiarmid SA, Wooldridge LS, et al. Randomized trial of percuta-
neous tibial nerve stimulation versus extended-release tolterodine: results from
the overactive bladder innovative therapy trial. J Urol 2009;182(3):1055–61.
51. Bosch JL. Electrical neuromodulatory therapy in female voiding dysfunction. BJU
Int 2006;98(suppl 1):43–8.
52. Wing RR, West DS, Grady D, et al, Program to Reduce Incontinence by Diet and
Exercise Group. Effect of weight loss on urinary incontinence in overweight and
obese women: results at 12 and 18 months. J Urol 2010;184(3):1005–10.
53. Bø K, Herbert R. There is not yet strong evidence that exercise regimens other
than pelvic floor muscle training can reduce stress urinary incontinence in
women: a systematic review. J Physiother 2013;59(3):159–68.
54. Wang Y, Zhishun L, Peng W, et al. Acupuncture for stress urinary incontinence in
adults. Cochrane Database Syst Rev 2013;(7):CD009408.
55. Komesu YM, Sapien RE, Rogers RG, et al. Hypnotherapy for treatment of overac-
tive bladder: a randomized controlled trial pilot study. Female Pelvic Med Re-
constr Surg 2011;17(6):308–13.
56. Yau K, Mak HL, Cheon WC, et al. Effects of foot reflexology on patients with symp-
tomatic idiopathic detrusor overactivity. Int Urogynecol J Pelvic Floor Dysfunct
2006;18(6):653–8.
57. Alhasso A, Glazener CM, Pickard R, et al. Adrenergic drugs for urinary inconti-
nence in adults. Cochrane Database Syst Rev 2005;(3):CD001842.
58. Mariappan P, Ballantyne Z, N’Dow JM, et al. Serotonin and nor-adrenaline reup-
take inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Data-
base Syst Rev 2005;(3):CD004742.
59. Lipp A, Shaw C, Glavind K. Mechanical devices for urinary incontinence in
women. Cochrane Database Syst Rev 2014;(12):CD001756.
10 Irwin

60. Dmochowski RR, Blaivas JM, Gormley EA, et al. Female stress urinary inconti-
nence update panel of the American Urological Association Education and
Research, Inc. Update of AUA guideline on the surgical management of female
stress urinary incontinence. J Urol 2010;183(5):1906–14.
61. Cefalu CA. Urinary incontinence. In: Ham RJ, editor. Primary care geriatrics: a
case-based approach. 5th edition. Philadelphia: Mosby Elsevier; 2007.
p. 306–23.