Urinary Incontinence

Overview

Urinary incontinence is an important condition because it causes significant distress. Approximately 15% of the general female adult population have a significant problem with urinary incontinence.

Definition

Urinary incontinence: Defined as the condition in which there is invontary loss of urine, which can be objectively demonstrated and which is a social or hygienic problem.
Stress incontinence: Leaking of small amounts of urine during activities that increase pressure inside the abdomen and push down on the bladder
Overflow (Urge) incontinence: Leaking of small amounts of urine associated with an overdistended, hypotonic bladder in the absence of detrusor contractions. This is often associated wtih diabetes melliurs, spinal cord injuries, or lower motot neuropathies. It may also be caused by urethral oedema following pelvic surgery
Midurethral sling procedures: Operations designed to help women with stress incontinence. Mid-urethral sling procedure installs a U-shaped mesh tape under your urethra to give it support

Anatomy and Physiology

Physiology of Micturition

Risk Factors

These risk factors are mainly for stress incontinence

Pregnancy
Prolapse
Menopause
Collagen disorder
Obesity

Clinical Manifestation

The incidence of urinary incontinence increases with age

Frequency
Nocturia
Urgency – overactive bladder
Post-coital continence
Dysuria

Prolapse with coexist with stress incontinenece in over 50% of cases, and an enquiry about symptoms is essential.

Types of Urinary Incontinence

Types of Urinary Incontinence

Stress incontinence (most common cause)
Overactive bladder (Urge Incontinence)
Mix incontinence
Retention with overflow
Fistula

Types of Urinary Incontinence	Feature
Stress incontinence (40%)	Raise in intra-abdominal pressure without detrusor contraction causes urination (i.e coughing, laughing and in severe cases walking)
Overactive bladder (25%)	Urgency is the key differentiating factor between overactive bladder and stress incontinence
Mixed (30%)	Mixed picture of stress incontinence and overactive bladder
Retention with overflow	Often in the eldery caused by neurological problems. The bladder continues to fill until it simply spills over, resulting in leakage
Fistula	Communication between two epithelial surfaces, usually a complication of surgery

Differential Diagnosis

Benign Prostatic Hyperplasia (men)
Prostate tumour (men)
Urinary Tract infections
Faecal impaction
Oestrogen deficiency
Depression
Restricted mobility
Drug induced (diuretics)

Investigations

Diagnosis of urinary incontinence may be based on symptoms or urodynamic studies. All women should have a full story and clinical examination.

Urinalysis – Rule out Urinary tract infections
Mid Stream Urine Sample – Rule out Urinary tract infections
Frequency-volume chart
Ultrasound
Urodynamic studies
Cystoscopy – only for assessment of haematuria or recurrent urinary tract infections

Indication for urodynamic studies

Voiding difficulties

Neurological disease

Failure of conservative management

Prior to surgery

When surgery has failed

Treatment

Lifestyle advice is an essential starting point in the management of incontinence.

Conservation Treatment

Weight loss
Normalise fluid intake
Cut down alcohol and restrict caffeine
Stop smoking
Avoid carbonated drinks
Treat chronic constipation and chronic cough
Bladder retaining
Physiotherapy – pevic floor muscle training

Medical Treatment – Usually for Stress Incontinence

Oestrogen – for postmenopausal women
Anticholinergic – for overactive bladder stress incontinence
Tricyclic antidepressants – for overactive bladder stress incontinence

Pharmacology

Anticholinergics inhibit the parasympathetic nervous system activity. The parasympathetic Nervous system is responsible for the rest and digest response and urination is one of them. Side effect of inhibiting the parasympathetic nervous system include dry mouth, dizziness, nausea and constipation.

Surgical Treatment for stress urinary incontinence