Urinary Incontinence

Urinary Incontinence Definition Involuntary passage of urine that is distressing and socially debilitating symptoms Epidemiology More common in elderly More common in females Causes Category Loss of cortical control (suprapontine injury) Pathophysiology Causes Loss of inhibitory control of voiding reflex Dementia Results in low pressure “safe bladder” Multiple sclerosis Stroke Spinal cord injuries above the sacral level Disrupt the brain to bladder communication Suprasacral cord conditions Lead to neurogenic bladder Detrusor muscle overactivity SCI Spina bifida Disc prolapse Leads to unsafe high-pressure bladder with risks to the upper tracts Low SCI Sacral reflex arc is damage on either afferent or efferent sides Disorders of the sacral reflex control of detrusor and sphincter Reflex contraction of the detrusor and function by sacral cord or relaxation of the sphincter are loss peripheral nerve damage Causes low pressure/safe bladder Cauda equina Diabetic nephropathy Pelvic organ surgery Invasive pelvic tumours Age -> overactive bladder Idiopathic bladder overactivity and urge incontinence Most common Urinary frequency Intreated bladder infection Urgency Excessive sensory irritation Urine leak before reaching toilet Features similar to overactive bladder Uninhibitory contractions of the Weak bladder or pelvic floor detrusor muscle during the muscles filling/storage phase of micturition when the bladder is not at full capacity Most common Coughing, sneezing or laughter Transurethral resection of prostate or radical proctectomy Damage to sphincter in men Urethral diverticulum Stress incontinence The most common condition in this category Structural abnormalities of bladder or sphincter Pelvic organ prolapse Bladder outlet obstruction E.g. from enlarged prostate Combination of weak sphincter gland or benign prostatic combined with a degree of bladder neck hyperplasia, large bladder and ureteral hypermobility in women diverticula More common in parous women Urethral hypermotility Sphincter trauma Stricture Atrophic vaginitis/urethritis Others Alcohol, caffeine, carbonated drinks and artificial sweeteners Irritates the bladder Spicy and sugary foods Excessive weight Pressure on the bladder Medications Diuretics Sedatives Muscle relaxants Some anti-depressants Classification Type Description Causes Weakness of pelvic floor muscles Most common Most commonly seen post-partum Intra-abdominal pressure exceeds ureteral pressure Stress UI Coughing, straining, laughing or lifting Urethral sphincter mechanism due to inability to withstand the sudden rise in bladder pressure Weakening of the pelvic floor muscles and urethral sphincter Other RF: Constipation Obesity -> increases abdominal pressire Post-menopause Pelvic surgery Neurogenic MS Parkison disease Spinal injury Urge UI Involutory leakage of urine Stroke Associated with increased urgency Local bladder irritation Associated with an overactive bladder Bladder stones Detrusor hyperactivity Infection Due to an inhibited bladder contraction, rise in intravesical pressure -> urine leak Malignancy Outflow obstruction BPG Urethral stricture Medications Cholinesterase inhibitors Mixed Combination of stress UI and urge UI Usually a complication of chronic urinary retention Overflow UI Progressive bladder stretching -> low of bladder sensation Prostatic hyperplasia SCI Congenital defects Usually due to anatomical abnormality Continuous Constant urine leakage UI E.g. ectopic ureter Bladder fistulae E.g. vesicovaginal fistula Investigations Bladder diaries Quality of life questionnaires Can help quantifying severity of the condition Midstream urine dipstick Look for infection or haematuria Post-void bladder scans For patients suspected of having an overflow UI Urodynamic assessment Usually not done before starting conservative management Cystoscopy IV urogram Vaginal speculum exam MRI imaging Management Lifestyle Weight loss Reducing caffeine intake Avoid drinking either excessive fluid Smoking cessation Conservative management Pelvic floor muscle training Should ideally last at least 3 to 4 months Should be done with three sets of 8 to 12 slow maximal contractions sustained for 6 to 8 seconds and repeated 3 to 4 times a week. Bladder training Pharmacology If response not enough for the above Duloxetine (SSRI) Causes stronger urethral contractions Anti-muscarinic drugs Reduces involuntary detrusor contractions medicated by Ach Oxybutynin or tolterodine First line Inhibit detrusor contraction Most commonly used anticholinergic Used for urge incontinence TCA May reduce detrusor activity Surgical Surgical methods vary based on initial diagnosis For urge UI Botulinum toxin A injections Sacral nerve stimulation Augmentation cystoplasty Detublarised segment of the bowel is inserted into the bladder wall to increased bladder capacity Urinary diversion via ileal conduit For stress UI Tension free-vaginal tape Colposuspension Peri-urethral intramural bulking agents Artificial urinary sphincter Pubovaginal sling with rectus fascia or mid urethral tapes More invasive methods Detrusor myomectomy Bladder augmentation Complications Skin issues Rashes Infections Sores Frequent UTIs Psychological impact Anxiety Depression Social isolation Reduced quality of life