Urinary Incontinence
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Introduction
Urinary incontinence is the involuntary loss of urine, well-documented, and causing psychosocial, health, hygenic, or financial concern. It is a syndrome that increases with age, with almost half of women affected yearly, and increasing to almost 3/4 of women in nursing homes.
There are many types of incontinence. 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 is the most common type. It occurs with a weakened pelvic floor and resulting bladder outlet hypermobility.
Urge incontinence is the involuntary loss of urine preceded by a strong urge to void, whether or not bladder is full. It is also known as overactive bladder.
Functional incontinence is caused by an inability or a lack of motivation to urinate in a toilet. This usually follows changes in cognition or in mobility.
Overflow incontinence results from from detrusor muscle weakness or bladder outlet obstruction, with high residual volume or chronic retention, leading to urinary spillage.
Mixed incontinence occurs with stress and urge incontinence.
The Case of Kathy C
Kathy C is a 67 year old woman who comes to you because she has been 'wetting herself' for the past two years. It has been worsening and she now is embarrassed to leave the house.
- how do you approach her problem?
Causes and Risk Factors
General risk factors
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Stress incontinence
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Urge incontinence
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Functional incontinence
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Overflow incontinence
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Fistula: vesicovaginal or ureterovaginal fistulas (obstructed labour)
Total incontinence can be due to a congenital lack of bladder neck and urethra. Ectopic ureters can open into the urethra distal to the spincter or directly into the vagina, causing continuous leakage.
Pathophysiology
Urination requires somatic and autonomic signals to travel from the full bladder to the spinal cord. The normal bladder capacity is 300-500 ml, and the urge to void generally begins at 150-300 ml. As the bladder fills, the sympatethic nervous system (SNS) closes the bladder neck, relaxes the bladder dome, and inhibits the peripheral nervous system (PNS). Somatic nerves tighten the pelvic floor. During urination, SNS tone decreases and PNS-related acetylcholine causes bladder contraction. The cerebral cortex is predominantly inhibitory of urination, while the brain stem coordinates sphincter relaxation and detrusor contractor at the right time.
Stress incontinence can be caused by urethral hypermobility due to lack of pelvic support. This may be due to descent of the urethra below the pelvic floor, or by laxity of the endopelvic fascia, against which the urethra is normally compressed.
Urge incontinence can combine detrusor overactivity with impaired contractility or neuropathy.
Signs and Symptoms
- history
- physical exam
History
Review of systems should include "Do you have trouble with your bladder?" or "Do you lose urine when you do not want to?"
Focus on:
- characteristics of incontinence (bladder records or voiding diaries)
- amount of leakage (ie, number of pads used in 24h)
- most bothersome symptoms
- treatment goals and preferences
Stress incontinence occurs in small amounts, and is unusual at night. Urge incontinence is usually of larger volumes, with increased frequency and nocturia. Overflow incontinence results in dribbling, weak stream, intermittency, hesitancy, frequency, and nocturia. Fistula or ectopic ureter is suggested by continuous leakage. Pain, dysuria, and hematuria suggest infection.
Medical history
- neurological conditions
- radiation to pelvis
- surgeries
- constipation
Medications
- alpha-blockers
- sympathomemetics
- tricyclic antidepressants
- anticholinergics
Physical Exam
General volume status (signs of heart failure)
Neurological exam, including motor, sensation, and bulbocaverous reflex (squeezing of clitoris yielding anal sphincter contraction)
Abdominal (visible scars, extrophy-epispadias, palpable bladder)
Rectal (sphincter tone, impaction, masses, prostate)
Pelvic (atrophy, vaginitis, prolapse, mass, tenderness)
Urethral hypermobility (Q-tip test)
- insert Q-tip until no resistance = in bladder; pull back a bit
- measure resting angle and excursion at rest and with coughing
- a change in over 30 degrees suggests uretheral hypermobility
Cough test
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
urinalysis (including specific gravity, dipstick) and culture to rule out UTI or STI
creatinine
Diagnostic Imaging
A post-void residual (PVR) may be helpful; <50ml is normal; >200ml suggests inadequate emptying. This may be done with bladder ultrasound or in/out catheterization.
cystoscopy/urethroscopy
urodynamics, preferably under fluoroscopy, can test function of the detrusor muscle and sphincter.
Differential Diagnosis
Incontinence is difficult to confuse with other conditions, but it is important to not miss
Treatments
Treatment depends on cause and patient preferences.
Conservative
- pelvic floor (Kegel) exercises, biofeedback, and electrostimulation
- behavioural therapy, bladder drills, with timed voiding
- functional changes: safe lighting, urinal, bedside commode
- reduce diuretics and fluids
- pads or undergarments (can be expensive)
- reduce or eliminate caffeine and nicotine
- pessaries
- accupuncture
- caregiver: regular toileting, prompted voiding
Medications
Stress incontinence: anticholinergics, working to decrease bladder spasms
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Urge inclontinence: anticholinergics, as above, plus tricyclic antidepressants
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BPH: alpha-adrenergic antagonists
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Surgical
- peri-urethral injections of collagen, beads, or hyaluronic acid to bulk up the area
- mid-urethral sling (TVT) or sub-urethral sling
- burch colposuspension (open or laparoscopic)
- botulinium toxin injection
- sacral neuromodulation
Consequences and Course
Incontinence has many consequences. These include:
- skin irritation
- recurrent UTIs
- depression, anxiety, isolation, social withdrawal
- increased weight gain due to concern about leakage while exercising
- avoidance of sexual activity
- sleep disruption
- increased caregiver burden
- costs (pads, diapers, surgery, devices)
However, prognosis is excellent in many cases due to increased capacity in diagnosis and management.
Resources and References
any good free online resources for further reading.
Topic Development
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