Urinary incontinence is a syndrome that increases with age and costing alomst $20billion US yearly.
Acute, or transient, incontinence, begins suddenly and is usually reversible.
Chronic incontinence can be thought of as urge, stress, overflow, mixed, and functional.
Stress incontinence is the involuntary loss of urine during increased intra-abdominal pressure (coughing, laughing, sneezing, exercising). It occurs with a weakened pelvic floor and resulting bladder outlet hypermobility.
Functional incontinence is caused by an inability or a lack of motivation to urinate in a toilet.
Urge incontinence is the involuntary loss of urine preceded by a strong urge to void, whether or not bladder is full. It is the most common type.
Mixed incontinence occurs with stress and urge incontinence.
Overflow incontinence results from detrusor muscle weakness or bladder outlet obstruction.
Incontinence is a common reason for non-compliance of diuretics or ACE inhibitors.
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Stress incontinence can be caused by:
Overflow inclontinece: obstruction of the urethra
Fistula: vesicovaginal or ureterovaginal fistulas (obstructed labour)
Functional causes include:
Urination requires somatic and autonomic signals to travel from the full bladder to the spinal cord.
The cerebral cortex is predominantly inhibitory, while the brain stem coordinates sphincter relaxation and detrusor contractor.
As the bladder fills, the SNS closes the bladder neck, relaxes the dome, and inhibits the PNS. Somatic nerves tighten the pelvic floor.
During urination, SNS tone decreases and PNS-related acetylcholine causes bladder contraction.
The normal bladder capacity is 300-500 ml, and the urge to void generally begins at 150-300 ml.
Continence requires intact physiology and functional capacity.
Urge incontinence can combine detrusor overactivity with impaired contractility
Review of systems should include "Do you have trouble with your bladder?" or "Do you lose urine when you do not want to?"
Identify reversible causes
Overflow incontinence results in dribbling, weak stream, intermittency, hesitancy, frequency, and nocturia.
Pain, dysuria, hematuria
General volume status (signs of heart failure)
Abdominal (palpable bladder)
Rectal (sphincter tone, impaction, masses, prostate)
Pelvic (atrophy, vaginitis, prolapse, mass, tenderness)
Measurement of voided volume
A post-void residual (PVR) may be helpful; <50ml is normal; >200ml suggests inadequate emptying
Incontinence is difficult to confuse with other conditions, but the list should include:
Treatment depends on cause and patient preferences.
Urge: antimuscarinics (oxybutynin, darifenacin, solifenacin)
BPH: alpha-adrenergic antagonists (alfuzosin, doxazosin, tamsulosin)
Can be helpful, but also expensive. In/out catheters or indwelling catheters
Incontinence has many consequences. These include:
any good free online resources for further reading.