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Urinary Incontinence

Urinary incontinence is involuntary loss of urine, caused by acute or chronic factors.


Presentation

There are three types of urinary incontinence:

  1. The symptom of loss of urination may be associated with some stressful activities like it can be experienced during excessive coughing, or sneezing, straining while moving bowels, lifting weights, or any other strenuous physical activity. This is known as stress incontinence [5].
  2. The involuntary loss of urine may sometimes follow a strong urge to void urine which is known as the urge incontinence.
  3. There can be a continuous leakage of urine which is known as true incontinence.

Individuals with both stress as well as urge incontinence are said to have mixed incontinence [6]. Stress incontinence occurs as a result of loss of structure of urethra which occurs as a result of damage of pelvic structures during the childbirth. Urge incontinence occurs as a result of uninhibited contractions of detrussor muscle.

History taking in such patients forms the most essential pillar in urinary incontinence. One has to enquire about the triggering factors which provoke the complaint and has to differentiate between constant and intermittent urinary incontinence which may differ when there is a change in the abdominal pressure or change in position of micturition. Severity and duration of the urge to urinate frequently and loss of control over the initiation of urination confirms the diagnosis.

Overflow Incontinence
  • Overflow incontinence was completely resolved after septum resection in two patients.[ncbi.nlm.nih.gov]
  • We report a case of overflow incontinence due to bladder stones in a 40-year-old widow (para 2) who presented with a 5-month history of involuntary loss of urine aggravated by postural change, and associated with recurrent painful ineffectual urge to[ncbi.nlm.nih.gov]
  • Our experience suggests that radiologic determination of stent location may be helpful in patients who present with new-onset stress or overflow incontinence.[ncbi.nlm.nih.gov]
  • Overflow Incontinence Overflow incontinence is treated by emptying the bladder. If the cause of overflow is obstruction, then relieving the obstruction should lead to improved emptying.[auanet.org]
  • Overflow incontinence One can have overflow incontinence where the bladder fills, doesn’t empty, and reaches its capacity and then the patient leaks urine more or less on a continuous basis.[uihc.org]
Urinary Stress Incontinence
  • Major types of incontinence include urinary urge incontinence and urinary stress incontinence Urinary incontinence is loss of bladder control. Symptoms can range from mild leaking to uncontrollable wetting.[icd9data.com]
  • In some ways, Impressa is a variation on devices known as pessaries that doctors may offer to women for urinary stress incontinence. Like pessaries, Impressa is inserted into the vagina to support the bladder.[foxnews.com]
  • The objective of this review is to determine the effectiveness of vaginal cones in the management of female urinary stress incontinence (SUI).We wished to test the following comparisons in the management of stress incontinence: 1. vaginal cones versus[ncbi.nlm.nih.gov]
  • Aksac B, Aki S, Karan A, Yalcin O, Isikoglu M, Eskiyurt N (2003) Biofeedback and pelvic floor exercises for the rehabilitation of urinary stress incontinence. Gynecol Obstet Investig 56:23–27 CrossRef Google Scholar 10.[doi.org]
  • Major types of incontinence include URINARY URGE INCONTINENCE and URINARY STRESS INCONTINENCE.[fpnotebook.com]

Workup

A careful history taking is a very essential point as regards identifying the pattern of voiding the urine and the type of leakage as it suggests the type of incontinence occuring. The physical examination will focus on careful examination of the tract, whether there is any tumor obstructing the urinary pathway, stool impaction or poor reflexes which may suggest a nerve related cause. A test that is performed is measurement of the bladder capacity and the residual volume of urine to know about the poor functioning of the muscles [7].

  • Stress test: Here, the patient relaxes and then coughs and to measure the amount of urine that leaks. 
  • Urine analysis: Analysis of a urine sample is done to check for urinary infection, urinary calculus, or other contributing causes.
  • Ultrasound: It is used to visualize the kidneys, the ureters, the bladder and the urethra to identify any anatomical cause of urinary incontinence like a tumor, calculus, etc.
  • Blood test: A blood sample is ordered to look out for any contributing factors like infection.
  • Cystoscopy: A thin tube with a camera is introduced to visualize the bladder and the urethra to look for anatomical causes of incontinence directly when other tests are inconclusive.
  • Urodynamics: This test involves measurement of the pressure in the bladder and dynamics of the flow of urine.

Treatment

The treatment options range from conservative treatment, behavioral management, bladder retraining, pelvic floor therapy and medications to surgery.

  • Medications like anti-cholinergics are advised which help to calm down an overactive bladder. Other medications like alpha blockers help in relaxing the detrussor and prevent voiding of urine. 
  • Exercises to strengthen the pelvic floor muscles are extremely important as they will reduce the symptoms dramatically in more than half the number of patients [8]. Teaching the technique of double voiding is a must as it helps empty the entire bladder. This technique involves voiding once followed by voiding again after a few minutes. The success of treatment depends on correct diagnosis. 
  • Physiotherapy if continued for a long term will help the patients and save them from surgery [9]. Conservative management is the mainstay in urinary incontinence. 
  • Weight loss is recommended in those who are obese. Controlling diabetes and treatment of other causes as a result of which the condition has occurred is essential to treat the symptom. Training pelvic floor muscles is the first line of treatment which is generally given to females of stress incontinence. Efforts for holding urine in the bladder which is known as bladder training is recommended in patients with urge incontinence.
  • Surgery will involve correcting the leak by increasing the bulk of tissues around the sphincter [10]. Sling procedure is most commonly used. Some surgeons may also involve use of botulinum toxin injections which help in maintaining the tone of the muscles and improve complaints.

Prognosis

The prognosis of a patient with urinary incontinence is excellent with present health care facilities. With improvement in information and technology, advances in medical knowledge and well trained medical staff, patients do not experience the morbidity they use to experience in the past. Though ultimate well being of the patient depends on the precipitating cause, with adequate knowledge and proper training it can me managed through the hands of a health care professional.

Etiology

Genuine stress incontinence exists when the pressure of the bladder exceeds the pressure of the urethra in the absence of detrussor contraction. It is generally due to anatomical changes in the urinary tract. Older menopausal women are likely to develop genuine stress incontinence as a result of loss of muscle tone due to estrogen deficiency. Multiparous women after repeated child birth are more prone to loss of tone of the pelvic floor muscles [2]. Besides these, obesity, prolapse, smoking and constipation can be other reasons.

During pregnancy, stress incontinence may occur as a result of pressure of the gravid uterus on the urethra. This is commonly experienced in the later months of pregnancy. During puerperium, stress incontinence occurs as a result of descent of the bladder and loss of urethrovesical angle.

Enlarged prostate in men, especially after the age of 40, is a common cause of incontinence. Sometimes prostate cancer can also cause urinary incontinence. Urge incontinence is commonly due to detrussor muscle overactivity [3]. Individuals with both stress as well as urge incontinence are said to suffer from mixed incontinence.

Polyuria occurring due to uncontrolled diabetes mellitus, diabetes insipidus, primary polydipsia (excessive fluid intake) may cause urge to urinate; however it is not necessarily followed by incontinence. Disorders like spina bifida, multiple sclerosis, Parkinson disease, stroke and spinal cord injury can all interfere with the nerve function of the bladder leading to incontinence.

Epidemiology

Urinary incontinence is commonly an undiagnosed and underreported condition. As many as 50-70% of females fail to seek a medical opinion as a fear of social stigma. People with incontinence often live with this condition for 5 to 9 years before they actually visit a physician. It has been estimated that urinary incontinence affects about 10 to 13 million people in the United States and around 200 million people worldwide.

Age is the single largest risk factor for urinary incontinence, although no age is exempt. It is two times more common in females than in males and may affect 7% of children less than 5 years of age, 10 to 35% of adults, and 50 to 84% of the elderly people [4]. Studies have shown that stress incontinence is more common in women below 65 years of age, while urge and mixed incontinence are more common in the age group above 65 years of age.

Athletes may also experience stress incontinence while doing strenuous exercises. Bladder control problem has also been found to be associated with other health problems such as diabetes and obesity. Incontinence in turn has seen to be affecting activities of the patient and also been a cause of depression.

Sex distribution
Age distribution

Pathophysiology

Urination or voiding is a complex activity. The bladder is a balloon like muscle which lies in the lower part of the abdomen. The bladder stores urine and then releases it to the urethra. Controlling this activity involves nerves, muscles, the spinal cord and the brain. Continence and micturition is a balanced activity between urethral closure and detrussor muscle activity. Urethral pressure normally exceeds bladder pressure, due to which urine remains inside the bladder.

The proximal urethra and bladder lie within the pelvis. Activities like coughing, sneezing, etc. increase the intraabdominal pressure, which is transmitted to the bladder as well as the urethra. Sometimes, the abdominal pressure might increase the intra-bladder pressure enough to overcome the urethral pressure, leading to stress incontinence.

Urge incontinence occurs when the involuntary and/or voluntary sphincter of the urethra has lost it tone leading to inability to hold the urine back till a suitable place for voiding urine can be reached.

During urination, the detrussor muscle contracts, resulting in the transmission of the urine from the bladder into the urethra. At the same time the sphincter muscles surrounding the urethra relax, letting the urine pass out of the body. Incontinence will occur if the detrussor muscles suddenly contract, or the muscles surrounding the sphincter of urethra suddenly relax.

Prevention

The only way to prevent urinary incontinence is my regularly doing pelvic floor exercises and keeping up the muscle tone.

Summary

Urinary incontinence can be a symptom, a sign or it can be a condition. The sign is the objective loss of the urine, and the condition is the underlying pathophysiologic mechanism which is responsible for the urine leak [1]. Urinary incontinence is also called as ‘leaky bladder’ and is the inability to hold urine and leading to involuntary voiding of urine.

Patient Information

Urinary incontinence is the loss of control on the act of urination. This happens when there is loss of control over the tissues which guard the urinary tract opening i.e. urethra. Urination is a voluntary act but in this condition it becomes involuntary. The causative factors are many like injury of the spinal cord and the nerves that supply the bladder and sphincter, repeated pregnancies or post operative injury. The patient tends to pass urine without realizing and in some cases there is loss of urine during coughing or sneezing.

Diagnosis is done by various tests like physical examination, ultrasonography and urodynamics. Pelvic floor and bladder training exercises are the best form of conservative treatment which increase the tone of muscles of the pelvic floor. Maintaining adequate local hygiene and avoiding high water intake when one moves out of the house are essential to keep the symptom under control. Surgery will also help correct the cause if necessary.

References

Article

  1. Yonguc T, Bozkurt IH, Arslan B, Kozacioglu Z, et al. Outcomes of two different incision techniques for surgical treatment of stress urinary incontinence with concomitant anterior vaginal wall prolapse. World J Urol. 2014 Aug 31.
  2. Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C. EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Arch Gynecol Obstet. 2005 Dec;273(2):93-7. 
  3. Simoncini T..Prevalence of urinary incontinence according to hysterectomy status in the WHI observational study. Climacteric. 2014 Dec;17(6):725-6.
  4. de Groat WC, Griffiths D, Yoshimura N. Neural control of the lower urinary tract. Compr Physiol. 2015 Jan 1;5(1):327-96. 
  5. Yonguc T, Aydogdu O, Bozkurt IH, Degirmenci T, et al. Long-term outcomes of transobturator tape procedure in women with stress and mixed urinary incontinence: 5-year follow-up. Minerva Urol Nefrol. 2015 Jan 13.
  6. Thom DH, Brown JS. Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiologic literature. J Am Geriatr Soc. 1998 Nov;46(11):1411-7.
  7. Parkkinen A, Karjalainen E, Vartiainen M, Penttinen J. Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5-year follow-up study. Neurourol Urodyn. 2004;23(7):643-8.
  8. Weinberger MW, Goodman BM, Carnes M. Long-term efficacy of nonsurgical urinary incontinence treatment in elderly women. J Gerontol A Biol Sci Med Sci. 1999 Mar;54(3):M117-21.
  9. John A et al. Summaries for patients. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Sep 16;161(6):I-34. 
  10. Qaseem A, Dallas P, Forciea MA, Starkey M, et al. Clinical Guidelines Committee of the American College of Physicians Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Sep 16;161(6):429-40.

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Last updated: 2019-06-28 11:10