.png){kind=small}
.png){kind=small}
BackTable / OBGYN / Article
Stress, Urgency, Mixed or Overflow? Diagnosing the Different Types of Urinary Incontinence in Females
Faith Taylor • Updated Jan 12, 2025 • 38 hits
Urinary incontinence is a common yet underreported condition among women, often shrouded in stigma and shame. Despite its significant impact on quality of life—affecting mental health, body image, and relationships—it frequently receives less attention than more life-threatening conditions.
In this article, urogynecologist Dr. Sarah Boyles sheds light on how healthcare professionals can better address female urinary incontinence by acknowledging its prevalence, educating patients about its various presentations, and employing effective diagnostic strategies. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• Urinary incontinence affects roughly 60% of women, with 30% experiencing regular leakage, but it remains underreported due to stigma and perceived normalcy.
• Urinary incontinence disproportionately affects older women, with data linking urgency incontinence to increased falls and fractures.
• The main types of incontinence include stress, urgency, mixed, and overflow, each with different causes and underlying physiological mechanisms.
• Mixed incontinence is a combination of both stress and urgency incontinence. This presentation can be particularly difficult to treat, as addressing one form of leakage may not resolve the other, necessitating clear patient education and treatment planning.
• Urinalysis and post-void residual (PVR) measurements are utilized to diagnose urinary incontinence, identify the cause of leakage, and rule out underlying conditions such as infection or bladder dysfunction.
• Pelvic exams are critical for diagnosing prolapse, tissue quality, and pelvic floor strength, which can directly affect urinary function.
• Women who are breastfeeding, using contraceptives, or experiencing menopause may develop urinary incontinence due to decreased estrogen levels, which can often be identified through an examination of vaginal tissue.
Table of Contents
(1) Female Urinary Incontinence: A Highly Prevalent Problem
(2) Educating Patients on the Different Types of Urinary Incontinence
(3) Diagnosing Female Urinary Incontinence: A Comprehensive Approach
Female Urinary Incontinence: A Highly Prevalent Problem
Female urinary incontinence is both highly prevalent and significantly underreported due to stigma and misconceptions about its normalcy. Recent studies reveal that 60% of women experience leakage at some point, with 30% reporting it as a regular issue.
Despite its non-life-threatening nature, urinary incontinence profoundly impacts quality of life, influencing body image, mental health, and relationships while limiting physical activity and social engagement. Urinary incontinence disproportionately affects older women, with troubling data linking urgency incontinence to increased falls and fractures, underscoring its broader health implications.
[Dr. Suzette Sutherland]
Why don't we just jump in on female urinary incontinence? How big of a problem do you really think this is in the general population?
[Dr. Sarah Boyles]
It's a huge problem. There have been some recent studies that have queried the American population and about 60% of women leak at some point. 30% of women leak regularly, but it's not something that we talk about because there's so much shame associated with it. So many women think that it is normal. While it is common, I would say it's not normal. It's a big problem.
It is definitely a bigger problem in older populations. It becomes more common as we age. There are lots of young women who suffer from incontinence as well. About 10% of the population will leak their entire lives. It's a big problem that we're not addressing and talking about.
[Dr. Suzette Sutherland]
Since it's not cancer or life-threatening, oftentimes it does get ignored. We see that all the time. Patients come in and you're just flabbergasted that they've been dealing with this for 20 years already. You think, "Gosh, why hadn't you come in sooner? We could have allowed you to jump on the trampoline with your kids when they were young. Now your knees hurt so you can't jump on that trampoline." There are a lot of statistics too in the older patients that look at the number of falls and fractures at night with how many times people get up to go to the bathroom at night. We know that it really definitely can be threatening to people's quality of life for sure.
[Dr. Sarah Boyles]
I think just like you said, medically, it is not considered to be as important of a problem as cancer or heart disease. That's definitely true. It has such a negative impact on quality of life. It impacts body image. It impacts self-esteem. It impacts mental health, sexual relationships, personal relationships. I think in order to age gracefully, we need to be active and social. This is something that prohibits that. It's a very important thing to address. The data on falls with urgency incontinence is pretty alarming and pretty dramatic.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Educating Patients on the Different Types of Urinary Incontinence
Urinary incontinence is often categorized into four main types, each with distinct causes and treatment pathways. Stress urinary incontinence occurs when physical activities, such as coughing or sneezing, exert pressure on the bladder, resulting in leakage. Urgency urinary incontinence is characterized by a sudden, strong urge to urinate, often accompanied by involuntary leakage, and may include nocturia. Overflow incontinence, though rarer, occurs when the bladder fails to empty completely, leading to constant dribbling of urine. Mixed urinary incontinence is a combination of stress and urgency incontinence.
Dr. Sarah Boyles advocates for clinicians to educate patients about the various types of incontinence to help set realistic expectations and prevent misunderstandings about treatment outcomes. This is especially important for mixed urinary incontinence, which often requires multiple treatment approaches due to the presence of different incontinence types with distinct underlying causes. By understanding that treatment may focus on one type of incontinence at a time, patients are less likely to assume treatment has failed if they continue to experience leakage from another type of incontinence.
[Dr. Suzette Sutherland]
It is a quality of life issue. That's how I talk to patients as well. Then we really emphasize what quality of life do you want? This is impacting it. Well said. When we talk about trying to evaluate a woman for urinary incontinence, we know there are a number of reasons why women leak. Not one woman's incontinence is the same as another woman's incontinence.
The reason they leak, then that totally dictates what the right treatment options are. Can you tell us a little bit more about what are the main types that we need to be thinking about so we can diagnose the woman correctly?
[Dr. Sarah Boyles]
When patients come to the office, they're just upset that they're leaking. They're not thinking about why they're leaking or the pathophysiology behind it. It's really up to us to figure that out. In women, there are four main types of leaking. There's stress urinary incontinence, which is leaking with a Valsalva maneuver. Coughing, sneezing, exercise will do it. Laughing. I will frequently tell my patients they should stop laughing, but no one ever takes me up on that. It should be a discrete leak. That leak should only happen while you're coughing or while you're running. It shouldn't be a big leak that continues afterwards.
There's urgency urinary incontinence, which is part of the overactive bladder spectrum. That's when women are going to the bathroom frequently. They have a strong urge to get there. They're worried that they can't get there on time. There can be associated leaking with that as well. Sometimes that does include nocturia, going to the bathroom frequently at night. There's mixed urinary incontinence, which is both. You can leak for two reasons. Mixed urinary incontinence is actually the second most common type of leaking.
Urgency urinary incontinence is the third. Then the last is overflow incontinence, where you're not emptying well. There are a couple of other more rare reasons why women will leak like fistulas, but they're pretty uncommon. Then there's usually other cues in the history that would make you think of a fistula. Pretty rare.
[Dr. Suzette Sutherland]
I'm sure you feel the same. One of the most difficult things is when a woman really has mixed incontinence. A combination of both stress and urge because they have two reasons why they're leaking that are very different reasons that require different thought processes about how to fix those and educating the woman about that is really important.
[Dr. Sarah Boyles]
I definitely agree with that. I think that expectation setting is so important because a patient only cares that they're leaking and they want to stop leaking. If you fix half the leaking, so the stress incontinence and not the urgency incontinence, that's frequently perceived as a failure because they see it as continuing to leak. Really discussing why they're leaking, making sure people understand that becomes really important. They're part of the treatment process and they understand the successes that they're having and they're not disappointed. They understand that you're going to need two different treatments. We're going to start with one and then we'll get to the second one after that.
[Dr. Suzette Sutherland]
That is such an important point. I see women all the time who come in and had a well-placed midurethral sling. It's working for their stress incontinence. They're still leaking because they have OAB urgency incontinence and they say the sling never worked. That's their perception. Educating them about what type of treatment works for what type of problem. You have to educate them in order to be able to assess the true efficacy of your interventions.
[Dr. Sarah Boyles]
I definitely agree with that. That is such a common thing to see where someone comes in and they say, "Oh, the sling failed. It never worked," and it's working beautifully. We just have to focus on something else. Those are important conversations to have with people. It's always important when you go into surgery to know what you're going to get and what you might not get and what additional work we have to do afterwards.
[Dr. Suzette Sutherland]
Absolutely. What's left over so that you can talk to the patient about that and say, "Remember, you're still going to have X, Y, and Z, and we're going to work on that, but that's not what this intervention is meant to do."
[Dr. Sarah Boyles]
I'm sure you do the same thing. I think it's always really important to under-promise and over-deliver. You want to tell people they're going to leak a little bit and then if they don't leak at all, they're pleasantly surprised. If you have more work to do, they're on board with it.
Diagnosing Female Urinary Incontinence: A Comprehensive Approach
A comprehensive diagnostic approach is essential for accurate identification of urinary incontinence types and effective treatment planning. Dr. Sarah Boyles highly recommends that the diagnostic evaluation of urinary incontinence begin with a detailed patient history to identify symptoms and exclude neurologic or other underlying causes. Boyles also advises her peers to utilize urinalysis and post-void residual (PVR) measurement. Urinalysis is used to rule out infection and hematuria, which can mimic symptoms of overactive bladder. PVR measurements assess proper bladder function, as incomplete emptying may contribute to incontinence.
A comprehensive physical exam offers valuable diagnostic insight into factors contributing to urinary incontinence, such as prolapse, urethral mobility, and pelvic floor muscle strength. In women who are breastfeeding, using contraceptives, or experiencing menopause, a physical examination can reveal signs of genitourinary syndrome. This condition, if left untreated, leads to estrogen deficiency in the vaginal tissues, which may worsen urinary incontinence. Together, these evaluations ensure an accurate diagnosis, guide treatment decisions, and facilitate appropriate referrals when necessary.
[Dr. Suzette Sutherland]
Along the same lines about trying to determine what's going on and overall with their voiding pattern and so on and so forth, what are the minimum diagnostic things that one should do to work up a woman with incontinence? I think most of the time we're really able to talk to the woman. If you ask the right questions in the right way, you pretty much can figure out what's going on, but there are a few key diagnostic things that everyone should do before initiating intervention. Let's talk about those.
[Dr. Sarah Boyles]
Like all things in medicine, I think the most important thing is the history. Incontinence is usually a very benign problem. You want to make sure that the patient doesn't have any neurologic symptoms, that there isn't anything else going on that might point you in a different direction. I think certain patients who have had extensive pelvic surgeries or who have failed incontinence procedures or who have had pelvic radiation, those patients fall into a special category and deserve more attention and a more in-depth workup.
In general, you're assessing the history, you're getting their symptoms, you're figuring out why they leak, and then you do your physical exam. The additional diagnostic things that you really want to get is you always want to get a urinalysis and you can definitely assess urinary incontinence on a virtual visit, but even if you do a virtual visit, you have to get the UA. What you're really looking for is you're looking for infection and you're looking for blood. Those are the big things because hematuria is not something that we want to miss and there is an overlap in overactive bladder symptoms and then symptoms that might be related to something with more pathology.
[Dr. Suzette Sutherland]
Yes, absolutely. If there's anything abnormal in the bladder, it's going to irritate the bladder and make the woman feel like she has to pee all the time. What's that? That's OAB. It's not OAB if there's an organic cause for it such as a bladder tumor that's sitting in the bladder. Ruling that out is super important and getting an inkling if there might be any a problem with the UA is great, so I love that point. What else should we be doing?
[Dr. Sarah Boyles]
The other thing is making sure that that patient is emptying correctly. We frequently do that in the office with an ultrasound machine, with a bladder scanner. You can cath the patient. Patients don't particularly like it, but it is more accurate. Bladder scanners can definitely be a little bit flaky so you have to make sure your scanner is reading correctly, but it is really important to make sure that someone is emptying correctly.
People that are neurologically intact will usually know if they are emptying correctly, but there are a lot of people out there who don't and that impacts how we treat things. It may push them into the overflow category, but any treatment that we do for leaking always makes it a little bit harder to empty so you really want to know how that patient is emptying at baseline. That is a very important thing to check.
[Dr. Suzette Sutherland]
Or also are they going to the bathroom all the time because they're never emptying well and when we say that we mean they're leaving a substantial amount behind. The tank is half full all the time and it doesn't take long before it fills up again and they feel the need to go to the bathroom again. We're not talking about leaving an ounce or two behind. That's not pathological so to speak, but if they're leaving over 100, 150, 200 behind, of course, it's going to influence their urinary frequency and that's the main reason why rather than saying that they have true overactive bladder.
[Dr. Sarah Boyles]
Checking a PVR, a post-void residual is so important because it absolutely has changed my diagnosis in the past. I've had patients who've come in with stress incontinence stories. "I leak playing tennis. That is the only time that I leak. No other symptoms." I think I even talked to this patient about a sling before I examined her and checked the PVR and then had to redo everything and redo the plan, but had a post-void residual of 500 cc's which is clearly abnormal. She's leaking because she's so full and that is really what needs to be treated. It's a very important part of the workup that should not be forgotten.
[Dr. Suzette Sutherland]
Yes, exactly. Then I would say to the general GYNs or general urologists that are out there that don't want to do work in this area, you find that as a problem, and then you send them on to somebody who specializes in this area or maybe some neuro urology or something that can identify a little bit more what's going on and what to do. You don't have to manage that just because you found it, but finding it is super important.
[Dr. Sarah Boyles]
Yes, I agree with that. I think those patients should frequently be referred on because there are more things that can be going on with them. It's not your typical incontinence patient.
[Dr. Suzette Sutherland]
Absolutely. I think you hit the two things on the head there, getting a UA and then a post-void residual. Those are two really basic and easy things to do that really are going to help you to differentiate what's really happening with this woman. I would say if we use a lot of bladder scan in our office as well, but if the bladder scan isn't adding up, it's not really making sense, then we're both in clinics where we have the utensils available to do a cath PVR, and I think that it's really important to get an accurate PVR. If it's not making sense, then check it because the bladder scan sometimes can have a certain amount of error.
[Dr. Sarah Boyles]
This is a little bit of an OBGYN aside. The bladder scanners are really looking at fluid. I've also had patients who've had big ovarian cysts and the bladder scanner is reading the cyst. Then it becomes really important to figure that out because you're pretty sure your bladder scanner is reading and there's something that's fluid-filled there, but it's not the bladder. When you check a straight cath, there's nothing there. That's an important thing to follow up further.
[Dr. Suzette Sutherland]
I think a woman who comes in with complaints of urinary incontinence, I think if you're going to do a pelvic exam, what kinds of things are you looking for to rule out or rule in to help you with your diagnosis?
[Dr. Sarah Boyles]
I think it's always important to look at the patient's skin. You want to be looking at that external skin, seeing if there's any irritation, anything that needs to be addressed there. You want to be looking for prolapse because prolapse can definitely impact how the urinary tract system works. I would tell you when you're looking for prolapse, I would have you look for prolapse before you put a speculum in. Just spread the labia, have someone bear down or cough. I usually have patients cough because I find it's hard. People don't like to bear down when I'm looking at them because everyone's afraid they're going to pass gas and coughing feels a little bit easier.
If you put a speculum in, you're pushing everything back up so you can't see the prolapse. You just want to look and see if they have prolapse. You want to look at the urethra, see if there's anything abnormal there, see if there's a diverticulum that's there, make sure that all looks correct. You want to assess for genitourinary syndrome of menopause. Do those tissues look like they are lacking estrogen?
Postmenopausal patients or patients who are on contraceptives or are on a medication that decreases your estrogen level can absolutely have these issues. Breastfeeding can definitely cause those issues. You just want to look at those tissues carefully because vaginal estrogen has been shown to help with urinary incontinence. That is a very easy treatment, so you don't want to miss that.
When we're looking at the urethra, we look at the urethra to see if it's hypermobile, to check the mobility. I don't always do a Q-tip test anymore where you're putting a Q-tip into the urethra, but you want to look at that and assess it. I think it's important to do a good pelvic exam and feel and make sure that there aren't any masses there. I've definitely seen patients in the past who have had a cancer or who have ascites, and that is what is causing their incontinence, that increased abdominal pressure.
Then the last thing is pelvic floor muscle strength. You want to have that patient contract their muscles, ask them to squeeze like they're trying to hold in their urine. You want to grade their strength from 0-5, see if there's any tenderness there. Then the big thing is make sure that they can do that contraction correctly because so many people can't.
Podcast Contributors
Dr. Sarah Boyles
Dr. Sarah Boyle is a urogynecologic surgeon at the Oregon Clinic in Portland, Oregon.
Dr. Suzette Sutherland
Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 6). Ep. 61 – Evaluating Female Urinary Incontinence: Essential Steps for the Generalist [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Female Urinary Incontinence Treatment: Physical Therapy, Weight Management & Intravaginal Device Options