Urinary incontinence

urinary incontinence
definition
the involuntary leakage of urine sufficiently severe to cause social or hygiene problems
• continence is dependent on:
? compliant reservoir (detrusor m. + involuntary smooth muscle of bladder neck)
? sphincteric efficiency (voluntary striated muscle of external sphincter intact mucosa, intact pelvic floor supports)
epidemiology
_ affects all ages
_ more frequent in elderly.
_ f:m = 2:1
classification
i. stress: urine loss with sudden increase in intra-abdominal pressure
(e.g. coughing or sneezing) ––> usually only lose a few dropings of urine
• weakness of pelvic floor musculature (child bearing, previous abdominal/pelvic surgery)
• damage/weakness of urethra or sphincter (eg. hypoestrogen of menopause, child bearing)
• dx by stress test
• degrees: mild: sneezing, coughing moderate: leaks when walking
severe: leaks when standing up
ii. urge: urine loss preceded by strong, unexpected urge to void
• local bladder irritation (e.g. cystitis, stone, tumour, infection)
• associated with inflammatory or neurogenic disorder
• urodynamics findings
1.uninhibited contractions if unstable bladder (detrusor hyperreflexia/instability)
2.small bladder capacity if irritable bladder
iii. overflow: urine loss when intravesical pressure exceeds urethral pressure (due to retention and overdistension)
• obstructive (e.g. bph, stricture)
• hypotonic bladder (e.g. dm, autonomic neuropathy, anticholinergic meds)
• urodynamics findings: large bladder capacity
iv. total: constant or periodic loss of urine without warning
• loss of sphincteric efficiency (previous surgery, nerve damage, cancerous infiltration)
• abnormal connection between urinary tract and skin thereby bypassing sphincter
(bladder exstrophy, epispadias, vesico-vaginal fistulae, ectopic ureteral orifices)
v. functional: urine loss caused by inability to reach toilet in time
• physical immobility



assessment
_ history +/– voiding diary
_ physical exam: gu, dre, neurologic
_ labs: urinalysis, urine c+s, renal profile
_ other investigations:
• catheterization with post-void residuals
• u/s
• cystoscopy
• vcug
• urodynamic studies – cystometrogram (cmg), uroflowmetry
bladder . . . cont.
management
? goals
• improvement or cure
• improvement in quality of life
• low pressure system with minimal tubes and devices

? treatment according to the type of inc.
i. stress
• kegel’s exercises
• topical estrogen cream
• injectable agents
• surgery (cystourethropexy slings)
ii. urge
• antispasmodics (oxybutinin)
• anticholinergics (propanthaline, tolterodine)
• tricyclic antidepressants (imipramine)
iii. overflow
• catheterization
• further treatment directed at underlying cause of urinary retention
iv. total
• usually surgical correction of underlying etiology or urinary diversion
v. other treatments
• pads
• bladder training (timed voiding patterns)
• self-stimulated voiding
• condom drainage
• penile clamp