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Urinary Incontinence
Definition
Urinary incontinence is any involuntary leakage of urine.
- Urinary incontinence is extremely common and distressing problem, which may have a profound impact on quality of life.
- 60-80% of patients have never sought medical advice for their condition and 35% view it simply as part of the ageing process
- Incontinence is caused by bladder abnormalities and/or sphincter (valve) weakness
- Stress incontinence is due to sphincter weakness for which the commonest causes are multiple childbirth or prolonged labor
- Urge incontinence is caused by bladder abnormalities for which the commonest cause is an overactive bladder (OAB)
Causes of incontinence
The causes of incontinence are many and depend on the type of incontinence. In some patients, there is more than one cause and different types of incontinence may also co-exist (e.g. combined urge & stress incontinence). Incontinence can be divided broadly into the following types but 90% of patients suffer from stress and/or urge incontinence.
- Stress incontinence - leakage during periods of abdominal pressure (coughing, sneezing, lifting, straining). This is usually the result of sphincter weakness cause by childbirth, loss of hormone support due to the menopause, hysterectomy or increasing age. It is also made worse by obesity
- Urge incontinence - leakage which follows an irresistible urge to pass urine. This is due to bladder muscle overactivity and, in most patients, the underlying cause is unknown; urinary infections, bladder stones, bladder cancer, neurological disease (e.g. stroke, Parkinson's disease) and obstruction (due to prostatic enlargement) can cause secondary urge incontinence
- Mixed incontinence - combined stress & urge incontinence
- Overflow incontinence - inability to empty the bladder with resulting overflow of urine. This is usually due to chronic retention of urine (in men) but may also be caused by a congenital abnormality of the bladder or by spinal cord injury
- Functional incontinence - inability to use the toilet in time due to poor mobility or brain disorders
- Continuous incontinence - constant leakage of urine due to an inherited abnormality or sphincter (valve) injury (often caused by surgery)
- Post-micturition dribble - leakage from the urethra a few minutes after passing urine (not to be confused with terminal dribbling when it is difficult to shut off the stream immediately after passing urine - usually a sign of prostatic obstruction)
- Giggle incontinence - tends only to occur in young girls and normally resolves as the child grows
Diagnosis
- Full urological history to ascertain what type of incontinence the patient has and how this affects day-to-day activities. Past medical and obstetric history, daily fluid intake, medications, bowel function, smoking habits, any other urinary symptoms the patient may be experiencing are important in the discussion.
- Input-output diary
- Structured incontinence questionnaire
- Pad test (leakage following certain, specified exercises is regarded as abnormal)
- Physical examination including measuring blood pressure and body mass index (BMI). Particular attention will be paid to the abdomen (to feel for an enlarged bladder) and to vaginal or rectal examination. A full neurological examination with assessment of reflexes should also be performed.
- Urine tests A routine dipstick test will be performed and a sample will normally be sent to the laboratory to exclude infection.
- Ultrasound scan to check kidneys, to assess bladder emptying and to find out whether there is any problem within or close to the bladder that may be causing symptoms.
- Voiding flow rate (a measure of how fast you pass urine)
- Pressure tests on the bladder (urodynamics) with video screening of the bladder & bladder neck
- Cystoscopy - telescopic examination of the bladder (especially if the patient has recurrent urinary infections, blood in the urine or difficulty passing urine)
Treatment Options
Conservative treatment can be successful in improving most forms of incontinence. Surgery is effective in incontinence, if conservative measures do not work, but there is a late failure rate for all types of surgery
Simple general measures
- reducing caffeine intake
- reducing what you drink
- losing weight
- pelvic floor exercises
- avoid taking drugs which cause more urine to be produced (e.g diuretics)
- stop smoking.
- simple pads to catch the leakage may be sufficient for some patients
If surgery is not appropriate: -
- inserting a catheter into the bladder
- intermittent self catheterization may resolve the incontinence
Non-surgical treatment for Stress incontinence
- Weight loss - may reduce the incontinence to manageable levels without any further treatment
- Physiotherapy - combined with electrical stimulation or the use of vaginal cones can improve many patients with stress incontinence
- Estrogen supplements - may help women with incontinence due to post-menopausal tissue atrophy
- Drugs - some new medications can help women with stress incontinence
Surgical treatment for Stress Incontinence
- Peri-urethral injections - using collagen or artificial materials
- Bladder neck suspension - realigning the bladder neck and urethra
- Sling procedures - using natural or synthetic materials to lift up the bladder neck
- Artificial urinary sphincter - implanting a controllable valve mechanism around the urethra or bladder neck
- Diversion of urine into a conduit will cure incontinence but should be regarded as a last resort when all other measures have failed
Non-surgical treatment of Urge incontinence
- Drugs - designed to inhibit uncontrolled bladder contractions
- Behavioral modification/biofeedback
- Hypnosis
- Acupuncture
Surgery
- Treat the underlying cause - e.g. prostate obstruction, bladder tumor, bladder stone or urethral stricture
- Stretching of the bladder- by overfilling with fluid at the time of telescopic inspection under general anesthetic
- Bladder Botox injections- by injecting into the bladder wall using a telescope under local or general anesthetic
- Sacral neuromodulation - implantation of a stimulator & electrodes into the nerves which supply the bladder
- Augmentation cystoplasty - enlargement of the bladder using a segment of bowel
- Diversion of urine into a conduit should be regarded as a last resort when all other measures have failed.
Treating Overflow incontinence
If the underlying cause of the overflow incontinence can be clearly identified, it should be treated. Men with chronic retention of urine may benefit from TURP but, if surgery is not appropriate, a simple urethral catheter can be inserted into the bladder or self-catheterization started.
Permanent urethral catheterization in women with overflow incontinence can cause significant problems with bladder neck erosion and catheters falling out; intermittent self-catheterization is normally better for women.
Treating Continuous Incontinence
If there is a fistula causing continuous incontinence, this can be repaired surgically but a urethral catheter or intermittent self-catheterization may be preferred if surgery is not appropriate.
Treating Post-micturition dribble
The vast majority of men with post-micturition dribble have no underlying problem apart from a failure of the normal "milk-back" mechanism after passing urine. Simple massaging of the urethra towards the tip of the penis, to expel the last remaining drops of urine, can reduce troublesome dribbling. If an underlying cause is identified on ultrasound scanning (e.g. urethral stricture or diverticulum), telescopic surgery may be advised, although this does not always eliminate the dribbling completely.
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