Urinary incontinence (UI) is defined by The International Continence Society as “the complaint of any involuntary loss of urine”.1 The prevalence of UI has been suggested to be around 3.0% to 60.0% of the population.2 Faecal incontinence (FI) refers to “the involuntary loss of liquid or solid stool that is a social or hygienic problem”.1,3 The reported prevalence of FI in the general population ranges between 2.2% to 20.7%.4 Risk factors for incontinence include patient characteristics (eg, obesity), existing urological or gastrointestinal (GI) conditions, obstetric injury/other injuries to pelvic floor, sequelae from surgical procedures and/or radiotherapy, and neurological disease.3 Treatment-resistant incontinence refer to conditions where symptoms continue despite treatment being provided.5 While treatment-resistant incontinence poses challenges regarding treatment of symptoms, success has been noted for surgical intervention of stress UI (median cure rate of 82.3%), and pharmacological intervention of urgency UI (median cure rates of 49%).6 Despite relatively high prevalence, many patients do not present for management of treatable incontinence, which may need to be specifically enquired about in consultation.7 This may be due to the stigma and embarrassing nature of,4 or the perception that UI is a normal part of aging.7,8 Incontinence negatively impacts many aspects of a sufferer’s life, including physical health, psychological wellbeing and economic, social and functional domains.7,9,10 General practitioners (GPs) are ideally positioned to diagnose, treat and support patients with suspected urinary and faecal incontinence, but must be proactive in assessing for the condition.

Forms and causes of incontinence

There are five forms of incontinence (see Table 1), with all forms sharing the common feature of loss of bladder or bowel control. Clinicians should be mindful of the risk factors which can lead to incontinence and have a low threshold for enquiring about the presence of incontinence. Providing a normalising experience and working on strategies to identify and address incontinence symptoms is essential.

Table 1: Types of urinary and faecal incontinence.

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Urinary incontinence

Causes of urinary incontinence include pregnancy, labour, vaginal delivery, hysterectomy, and menopause, in addition to diabetes, lower urinary tract symptoms (LUTS) and infections (UTI), advancing age, prostatectomy, and neurological disorders and cognitive dysfunction (eg, dementia, Parkinson’s disease, multiple sclerosis, traumatic spinal and/or brain injuries, and cerebrovascular accidents).13 Urethral obstruction is also a cause of overactive bladder, which may occur secondary to sling and pelvic organ prolapse surgery, as well as prostatic or bladder neck obstruction.14,15

Initial assessment of UI symptoms include collection of a medical history, physical examination, laboratory testing and radiographic examination.16 Specific procedures may involve urinalysis and urine cytology, post-void residual measurement, along with urodynamic testing and pelvic ultrasonography.16

Faecal incontinence

Causes of faecal incontinence include sphincter damage, diarrhoea and rapid colonic transit. Overflow incontinence should be considered (hence the importance of the rectal examination with or without abdominal film) as this condition requires specific management (ie, disimpaction). If the stool is watery, the cause of that should be sought, including inflammation, infection, surgery (including cholecystectomy or procedures that shorten the bowel or predispose to bacterial overgrowth), as well as diarrhoea induced by drugs or diet and managed appropriately. If no specific cause can be found, use of a nonspecific antidiarrhoeal and a fibre supplement to bulk and firm the stool up may be effective in treating incontinence, as a loose stool is far more difficult to retain than a formed stool. If symptoms persist referral for pelvic floor assessment is appropriate, and if that is unhelpful, referral for anorectal physiological (eg, manometry) and anatomical (eg, endoanal ultrasound) assessment may be required to determine whether there are any aspects that may benefit from surgical intervention. For information regarding management of incontinence in a residential aged care (RAC) population, see Guinane and Crone.17

Psychopathology and associated psychological mechanisms

Incontinence is distressing as it is associated with poor health perception, sexual dysfunction and reduced quality of life (QoL).3,18 Assessment of the psychological impact of incontinence symptoms should be utilised as part of the medical examination for incontinence (see Table 2 for structured guide).19 In managing these patients, clinicians should also be mindful of associated psychosomatic components of incontinence and the embarrassment and reluctance of patients to seek treatment.8

Table 2: Structured guide for the GP to help explore psychological aspects of urinary and faecal incontinence.

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Note: Psychological treatment questions from the Bladder and Bowel Incontinence Phobia Severity Scale (BBIPSS).23

Psychological factors such as depression, anxiety, embarrassment, fear, shame and living with, management of and attitudes about incontinence symptoms have been associated with incontinence.18,20,21 Literature reviews on the psychosocial impact of UI in women, note that UI is commonly associated with psychological comorbidity.18,20 In particular, women with severe UI have been reported to be 80% more likely to be significantly depressed, while women with mild to moderately severe UI were noted as 40% more likely to have depression.22 Likewise, another study found significantly higher levels of major/other depressive syndromes in men and women with UI, compared to individuals who were continent.21 As for anxiety, a review reported that UI was associated with a 50% increase in risk of anxiety symptoms for both men and women, and a four-fold increase in anxiety prevalence in cases where UI caused functional impairment.23 A review also found psychosocial factors such as how an individual lives with (eg, the impact of incontinence on intimate relationships, physical activity, social and occupational life), manages (eg, planning and constant vigilance of incontinence symptoms, help-seeking behaviours/disclosure) and their attitudes towards incontinence (eg, negative vs positive perceptions) mediate the relationship between UI and mental health status.20 Specifically, incontinence patients can better manage their condition by increasing awareness of the psychosocial issues (eg, reframing their attitudes towards incontinence symptoms) that can influence their incontinence and mental health.20 Conversely, while there are fewer studies which document psychological factors in FI, the depression and anxiety experienced in FI is believed to be greater than that of UI.23 Indeed, according to a review, individuals with FI are four times more likely to be afflicted with anxiety, and five times more likely to be affected by depression, with FI sufferers also being more likely to report anxiety, frustration and shame.23 It is apparent that incontinence has a profound negative impact on QoL, whereby sufferers experience humiliation and stigma over their symptoms.18 Additionally, individuals with incontinence also struggle with anxiety and fear relating to episodes of incontinence in public, and the ensuing consequences.18 As such, the psychological morbidity associated with incontinence likely stems from reduced QoL due to incontinence symptoms.18

During initial examination of incontinence patients, a number of validated measures can be used to assess the nature, severity and impact that incontinence has on QoL. Examples of faecal incontinence measures include the Fecal Incontinence Severity Index (FISI),24 Cleveland Clinic Florida Fecal Incontinence Score (CCFFIS; also known as the Jorge-Wexner incontinence score),25 St. Marks Incontinence Score,26 Comprehensive Fecal Incontinence Questionnaire,27 Revised Fecal Incontinence Scale28 and the International Consultation on Incontinence Questionnaire (ICIQ)-Bowels module.29 As for measures of urinary incontinence severity, examples include the ICIQ-UI Urinary module,29 the Incontinence Severity Index (ISI),30 and the Revised Urinary Incontinence Scale (RUIS).31 Although there are a number of measures available, clinical practice guidelines have recommended commonly used instruments such as the FISI, St. Marks Incontinence Score and CCFFIS.19 It should also be noted that while several of the abovementioned measures include QoL and lifestyle-based items within their scoring, there are incontinence-specific QoL scales such as the Fecal Incontinence Quality of Life (FIQL) scale32 and the Incontinence Quality of Life (I-QOL) instrument33 for UI. Despite the subjective nature of these self-report instruments, the use of QoL-incontinence measures is recommended as they can assist in selecting appropriate therapies (eg, use of more aggressive, interventional therapies for patients with severe symptoms) and gauge treatment efficacy over time.19 Consistent with a cognitive-behavioural framework, incontinence patients have been noted to experience dysfunctional thoughts (eg, thinking they are socially undesirable and physically unattractive) along with avoidance behaviours where they avoid social activities which may lead to incontinence or where incontinence would be particularly distressing (eg, exercising, visiting friends).20 Distress may be significantly increased by of “lack of control or urgency”.20 The relationship between distress and urgency symptoms can be described as a cycle whereby psychological processes perpetuate feelings of incontinence urgency, which lead to development of further psychological symptoms (see Figure 1).34,35 Concerns about incontinence symptoms (eg, feelings of urgency) and potential consequences of incontinence (eg, public humiliation) can lead to increased feelings of anxiety.18 This increased anxiety then produces a physiological (eg, visceral sensations of urgency) or psychosomatic (eg, increased heartbeat) response where the individual focuses on somatic stimuli,36 increasing concerns surrounding incontinence symptoms. Through this cycle, psychological processes exacerbate the physical symptoms of incontinence, which then trigger further anxieties and fears regarding impending incontinence. Accordingly, as well as the physical symptoms of incontinence, associated psychological symptoms should also be monitored.10 Although there is little formal research about pelvic floor overactivity, there is an increasing awareness of this construct and incontinence may be a manifestation of this anxiety driven disorder.37

Figure 1: Cycle of incontinence symptoms and psychological distress.

A notable psychogenic condition that can result from incontinence is bladder and bowel incontinence anxiety. Bladder and bowel incontinence anxiety refers to overwhelming fear of incontinence in a public setting, in the absence of physical illness.34 Primary clinical features include overwhelming fear of incontinence; repeated checking of sensations in the bladder or bowel; reoccurring, intense visceral sensations of urgency; avoidance of anxiety-provoking situations (eg, travelling long distances without access to a restroom); and compulsive urination or defecation.34,38–40 While prevalence rates for incontinence have been reported, the prevalence of bladder and bowel incontinence anxiety has yet to be clearly identified. The recently developed Bowel Incontinence Phobia Severity Scale (BBIPSS)41 will help better assess fear relating to bowel and bladder incontinence and help to explore the prevalence and severity of psychopathology surrounding incontinence anxiety.

Management recommendations

A systematic review by Forte and colleagues42 on FI treatment reported low-strength evidence for certain non-surgical treatment (eg, psyllium supplementation), while also noting insufficient evidence on all available surgical treatment. The review concluded that surgical treatment was associated with greater complications and adverse effects compared to non-surgical management, and that limited evidence was present to support treatment beyond three to six months.42 Conversely, a recent systematic review on UI cure rates noted that surgical intervention was effective for stress UI, with open colposuspension displaying a median cure rate of 32%, and other surgical techniques displaying a cure rate of 82.3%.6 For urgency UI, pharmacological intervention had a median cure rate of 45.8%.6 Supervised pelvic floor muscle therapy (PFMT) interventions were noted to display a cure rate of 35% at 12 months.6 For mixed UI, the median cure rate of surgical intervention in women was 82.3%, with supervised PFMT intervention eliciting a cure rate of 47% in men and 28% in women at six months.6 While physical characteristics of incontinence are routinely explored in consultations, psychosocial aspects of incontinence tend to be overlooked.20 Factors such as attitudes towards, living with and management of incontinence have been reported to contribute towards the relationship between incontinence and mental health.20 Given the significant bi-directional links between distress and incontinence (eg, incontinence causing distress and distress affecting coping behaviours in people with incontinence), evidence-based psychological interventions such as Cognitive Behavioural Therapy (CBT)43 should be considered in the psychological management of incontinence, especially when symptoms are associated with treatment-resistant incontinence.

Summary

Urinary and faecal incontinence significantly impact the physical health and mental wellbeing of those afflicted. While the prevalence of urinary and faecal incontinence has reported to range between 3.0% to 60.0% and 2.2% to 20.7% respectively, due to the stigma and embarrassing nature of symptoms, patients hesitate to raise incontinence issues during consultations, and these may need to be specifically enquired about. Clinicians should be mindful of risk factors associated with incontinence along with the psychosocial impact of incontinence on mental health and QoL. Treatment interventions should be tailored to the pattern of symptoms, underlying causes/contributors, individual needs and circumstances of each patient. Where appropriate, psychological interventions should be utilised to facilitate patient management of symptoms, especially in cases involving psychological distress and/or treatment-resistant incontinence.

Key points

• There are several forms of urinary and faecal incontinence.
• Due to the stigma and embarrassing nature surrounding incontinence, patients may be reluctant to disclose their symptoms.
• General practitioners should provide a normalising experience for the patient and proactively identify and address incontinence symptoms.
• Urinary and faecal incontinence are often associated with significant psychological symptoms, which may in turn lead to an increase in physical symptoms and reduction in quality of life.

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