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Urinary incontinence


Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.

Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g. spina bifida & multiple sclerosis) eventually cause inadequate urinary storage or control.

Acute and temporary incontinence are commonly caused by the following:
  • Childbirth
  • Limited mobility
  • Medication side effect
  • Urinary tract infection
  • Chronic incontinence is commonly caused by these factors:
  • Birth defects
  • Bladder muscle weakness
  • Blocked urethra (due to benign prostate hyperplasia, tumour, etc.)
  • Brain or spinal cord injury
  • Nerve disorders
  • Pelvic floor muscle weakness
  • Vaginal prolapse
  • Incidence and Prevalence

    The condition is far more prevalent in women than men. In the general population aged 15 to 64 years old, 10-30% of women versus 1.5-5% of men are affected. At least 50% of nursing home residents are affected. Of that number, 70% are women.

    Types

    Of the several types of urinary incontinence, stress, urge, and mixed incontinence account for more than 90% of cases. Overflow incontinence is more common in people with disorders that affect the nerve supply originating in the upper portion of the spinal cord and older men with benign prostate hyperplasia (BPH). The primary characteristics of these types are as follows:

    Stress - urine loss during physical activity that increases abdominal pressure (e.g., coughing, sneezing, laughing)
    Urge - urine loss with urgent need to void and involuntary bladder contraction (also called detrusor overactivity)
    Mixed - both stress and urge incontinence
    Overflow - constant dribbling of urine; bladder never completely empties.

    Diagnosis

    A complete medical history, which includes a voiding diary and incontinence questionnaire; physical examination; and one or more diagnostic procedures help the physician determine the type of urinary incontinence and an appropriate treatment plan.

    Medical history

    The medical history provides clues about the type of incontinence. Bowel habits, patterns of urination and leakage (when, how often, how severe), and whether there is pain, discomfort, or straining when voiding are important indicators. The patient's history of illnesses, pelvic surgeries, pregnancies, and medications currently used also supply the physician with information relevant to making a diagnosis. In the elderly, a mental status evaluation and assessment of social and environmental factors may be performed.

    Physical examination

    A physical examination includes a neurologic status evaluation and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing indicates a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough indicates urge incontinence.

    The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

    Urinalysis

    Examination of the urine may identify medical conditions associated with urinary incontinence, such as the following:

    Bacteriuria - presence of bacteria in urine; indicates infection.
    Glycosuria - excess glucose in urine; may indicate diabetes.
    Haematuria - blood in urine; may indicate kidney disease.
    Proteinuria - excess protein in urine; may indicate kidney disease, cardiac disease, blood disease.
    Pyuria - presence of pus in urine; indicates infection.

    Specialised Testing

    If incontinence persists after diagnosis and treatment, additional testing may be needed. Urologists perform urodynamic, endoscopic, and imaging tests to obtain a more extensive evaluation of the lower urinary tract to determine a new treatment plan.

    Urodynamic Testing

    Cystometry may be used to measure the anatomic and functional status of the bladder and urethra. The cystometer is an instrument that measures the pressure and capacity of the bladder; thus evaluating the function of the detrusor muscle. Simple cystometry detects abnormal detrusor compliance, but abdominal pressure is not included and the results must be evaluated with caution.

    The multichannel, or subtracted, cystometrogram simultaneously measures intra-abdominal, total bladder, and true detrusor pressures. This allows involuntary detrusor contractions to be distinguished from increased intra-abdominal pressure. The voiding cystometrogram detects outlet obstruction in patients who are able to void.

    Uroflowmetry identifies abnormal voiding patterns. Urethral Pressure Profilometry measures the resting and dynamic

    Treatment Options

    Treatment options for urinary incontinence depend on the type of incontinence as outlined below.

    Stress Incontinence is urine loss during physical activity that increases abdominal pressure (e.g., coughing, sneezing, laughing). Treatment options include:
  • Injectables
  • Medications
  • Surgical treatments
  • Urge Incontinence is urine loss with urgent need to void and involuntary bladder contraction (also called detrusor instability). Treatment options include:
  • Medications
  • Surgical treatments
  • Overflow Incontinence is constant dribbling of urine; bladder never completely empties. Treatment options include:
  • Medications
  • Intermittent Self-Catheterisation
  • Management

    There are several things patients can do to help improve continence:
  • Avoid excessive consumption of diuretics, antidepressants, antihistamines, and cough-cold preparations.
  • Perform Kegel Pelvic floor exercises daily.
  • Practice double voiding (urinate, hold it for a few seconds, urinate again).
  • Eat fruits, vegetables, and whole grains daily to prevent constipation.
  • Retrain the bladder (urinate only every 3 to 6 hours).
  • Stop smoking (nicotine irritates the bladder).