Urinary incontinence

Dr. Mohammed Bassil

OBJECTIVES
1. Identify and name the major anatomic and histologic features of the bladder and
urethra in the male and female
2. Define incontinence
3. List the symptoms and signs of the various types of incontinence; stress, urge,
overflow and mixed
4. Describe the epidemiological features of incontinence
5. Describe the natural history and progression of incontinence
6. List the risk factors for incontinence
7. List the important components of the history when interviewing a patient with
incontinence
8. List the important components of the physical exam of a patient with incontinence
9. Summarize the laboratory, radiologic, or urodynamic tests, if any, that should be
ordered in a patient with incontinence
10. List the indications for treatment of incontinence
11. List the nonsurgical treatment options for stress and urge incontinence, describe
their side effects, and outline the mechanisms by which they work.
12. Briefly describe the surgical treatment options for stress and urge incontinence
Definition
Involuntary loss of urine that is a social or hygienic problem and is objectively
demonstrable.” Urinary incontinence (UI) is a failure to store urine usually due to either
abnormal bladder smooth muscle or a deficient urethral sphincter. Urine loss may also
be extraurethral, secondary to anatomical abnormalities such as ectopic ureter or
vesicovaginal fistula.
Prevalence
UI has been reported to affect 12–43% of adult women and 3–11% of adult men. Severe
incontinence has a low prevalence in young women, but rapidly increases at ages 70
through 80. Incontinence in men also increases with age, but severe incontinence in 70-
to 80-year-old men is about half that in women.

Classification
Stress urinary incontinence (SUI) :-
is involuntary urinary leakage during effort,exertion, sneezing, or coughing, due to
hypermobility of the bladder base, pelvic floor,and/or intrinsic urethral sphincter
deficiencies. In females SUI is usually associated with multiparity. In males, SUI is
most commonly the result of prostatectomy
Urgency urinary incontinence (UUI):-
is involuntary urine leakage accompanied or immediately preceded by a sudden, strong
desire to void (urgency).

Mixed urinary incontinence:-

is urine leakage that has characteristics of both SUI and UUI.
Overflow incontinence :-
is leakage of urine when the bladder is abnormally distended with large post-void
residual volumes. Typically, men present with chronic urinary retention and dribbling
incontinence. This can lead to hydronephrosis and renal failure in 30% of patients.
Nocturnal enuresis:-
describes any involuntary loss of urine during sleep.The prevalence in adults is 0.5%.
Approximately 750,000 children over age 7 years will regularly wet the bed. Childhood
enuresis can be further classified into primary (never been dry for longer than a 6-month
period)or secondary (re-emergence of bed wetting after a period of being dry for at least
6–12 months).
Risk factors
Predisposing factors
• Gender (female > males)
• Race (Caucasian > African American/Asian)
• Genetic predisposition
• Neurological disorders (spinal cord injury, stroke, MS, Parkinson
disease)
• Anatomical disorders (vesicovaginal fistula, ectopic ureter, urethral
diverticulum)
• Childbirth
• Anomalies in collagen subtype
• Prostate or pelvic surgery (radical prostatectomy; radical
hysterectomy; TURP) leading to pelvic muscle and nerve injury
• Pelvic radiotherapy
Promoting factors
• Smoking (associated with chronic cough and raised intra-abdominal pressure)
• Obesity
• UTI
• Increased fluid intake
• Medications
• Poor nutrition
• Aging
• Cognitive deficits
• Poor mobility
Pathophysiology
Bladder abnormalities
Detrusor overactivity is a urodynamic observation characterized by involuntary bladder
muscle (detrusor) contractions during the filling phase of the bladder, which may be
spontaneous or provoked, and can consequently cause urinary incontinence. The
underlying cause may be neurogenic, where there is a relevant neurological condition,
or idiopathic, where there is no defined cause
Sphincter abnormalities
Urethral hypermobility is due to a weakness of pelvic floor support causing a rotational
descent of the bladder neck and proximal urethra during increases in intra-abdominal
pressure. If the urethra opens concomitantly, there will be urinary leaking.
Intrinsic sphincter deficiency (ISD) describes an intrinsic malfunction of the sphincter,
regardless of its anatomical position, which is responsible for type III SUI. Causes
include inadequate urethral compression (previous urethral surgery; aging; menopause;
radical pelvic surgery) or deficient urethral support (pelvic floor weakness; childbirth;
pelvic surgery ; menopause).
Evaluation
History
Inquire about LUTS (storage or voiding symptoms), triggers for incontinence (cough,
sneezing, exercise, position, urgency), and frequency and severity of symptoms.
Establish risk factors (abdominal/pelvic surgery; neurological diseases; obstetric and
gynecological history; medications).
A validated patient-completed questionnaire may be helpful
Physical examination
Women
Perform a pelvic examination in the supine and standing position with a
speculum while the patient has a full bladder. Ask the patient to cough or strain, and
inspect for vaginal wall prolapse (cystocele, rectocele, enterocele),uterine or perineal
descent, and urinary leakage (stress test). Eighty percent of SUI patients will leak with
a brief squirt during cough in the supine position, while another 20% will leak only in
an inclined or standing position.
Urethral hypermobility is assessed with the Q-tip test. A lubricated cotton-tipped
applicator is introduced through the urethra to bladder neck level. Hypermobility is
defined as a resting or straining angle of >30* from horizontal.
The Bonney test is used to assess continence with manual repositioning of the urethra
and vesicle neck. Using one or two fingers to elevate the anterior vaginal wall laterally
without compressing the urethra, relief of incontinence during cough suggests that
surgical correction will be successful.
Both sexes
Examine the abdomen for a palpable bladder (indicating urinary retention).
A neurological examination should include assessment of anal tone and reflex, perineal
sensation, and lower limb function.
Inspect the underwear for the status of urinary collection pads; for men, a standing or
squatting “cough test” gives a good indicator of the presence
and severity of stress incontinence.
Investigation
Bladder diaries
Record the frequency and volume of urine voided, incontinent episodes, pad usage,
fluid intake, and degree of urgency. Alternatively, pads can be weighed to estimate
urine loss (pad testing).
Urinalysis can exclude UTIs.
Blood tests, X-ray imaging, cystoscopy
These are indicated for persistent or severe symptoms, bladder pain, and voiding
difficulties. Cystoscopy is useful for evaluating men who have had prostatectomy—it
will show the presence of clips, stones, and strictures that may develop after surgery
that might need to be addressed concomitantly with anti-incontinence surgery
Urodynamic investigations
Valsalva leak point pressure (VLPP) measures the abdominal pressure
at which a half-full bladder leaks during straining—normal individuals
should not leak. VLPP readings <60 cm H2O suggest ISD; VLPP readings >100 cm
H2O suggest hypermobility, while readings of 60–100 cm are indeterminant.
Detrusor leak point pressure (DLPP) measures the bladder pressure
at which leakage occurs without valsalva—DLPP >40 cm H2O puts the
upper tract at risk.
Videourodynamics can visualize movement of the proximal urethra and
bladder neck, and establish the precise anatomical etiology of UI.
urodynamics
Uroflowmetry testing measures the ability of the bladder to empty; a minimum bladder
volume of 150 cc is desired. A low flow rate indicates bladder outflow obstruction or
reduced bladder contractility. The volume of urine remaining in the bladder after
voiding (post-void residual) is also important(<50 mL is normal; >200 mL is abnormal;
50–200 mL requires clinical correlation).

Sphincter electromyography (EMG)

EMG measures electrical activity from striated muscles of the urethra or perineal floor
and provides information on synchronization between bladder muscle (detrusor) and
external sphincter.
Treatment
Treatment for urinary incontinence depends on the type of incontinence, its severity
and the underlying cause. A combination of treatments may be needed.
Behavioral techniques
Bladder training, to delay urination after you get the urge to go. You may start by trying
to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen
the time between trips to the toilet until you're urinating only every two to four hours.
Double voiding, to help you learn to empty your bladder more completely to avoid
overflow incontinence. Double voiding means urinating, then waiting a few minutes
and trying again.
Time voiding, to urinate every two to four hours rather than waiting for the need to go.
Fluid and diet management, to regain control of your bladder. You may need to cut
back on or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing
weight or increasing physical activity also can ease the problem.
Pelvic floor muscle exercises sphincter‫هذا يفيدني لل‬
It is recommend that you do these exercises frequently to strengthen the muscles that
help control urination. Also known as Kegel exercises, these techniques are especially
effective for stress incontinence but may also help urge incontinence.
Medications
Anticholinergics. These medications can calm an overactive bladder and may be helpful
for urge incontinence.
Mirabegron . Used to treat urge incontinence, this medication relaxes the bladder
muscle and can increase the amount of urine your bladder can hold. It may also increase
the amount you are able to urinate at one time, helping to empty your bladder more
completely.
Alpha blockers. In men with urge or overflow incontinence, these medications relax
bladder neck muscles and muscle fibers in the prostate
Topical estrogen.
Interventional therapies
•Bulking material injections. A synthetic material is injected into tissue surrounding the
urethra.
•Botulinum toxin type A (Botox). Injections of Botox into the bladder muscle may
benefit people who have an overactive bladder. Botox is generally prescribed to people
only if other first line medications haven't been successful.
•Nerve stimulators. A device resembling a pacemaker is implanted under your skin to
deliver painless electrical pulses to the nerves involved in bladder control (sacral
nerves). Stimulating the sacral nerves can control urge incontinence if other therapies
haven't worked. The device may be implanted under the skin in your buttock and
connected directly to the sacral nerves or may deliver pulses to the sacral nerve via a
nerve in the ankle.
 Treatment of sphincter weakness

incontinence: injection therapy

The injection of bulking materials into the bladder neck and periurethral muscles is
used to increase outlet resistance.
Indications
These include stress incontinence secondary to demonstrable intrinsic sphincter
deficiency (ISD), with normal bladder muscle function. Injection therapy is used in
adults and children.
Treatment of sphincter weakness
incontinence: retropubic suspension
Retropubic suspension procedures are used to treat female stress incontinence caused
by urethral hypermobility. The aim of surgery is to elevate and fix the bladder neck
and proximal urethra in a retropubic position, to support the bladder neck, and to
regain continence. It is contraindicated in the presence of significant intrinsic
sphincter deficiency (ISD).
Marshall–Marchetti–Krantz (MMK) procedure
Sutures are placed either side of the urethra around the level of the bladder
neck and then tied to the hyaline cartilage of the pubic symphysis.
Burch colposuspension
This requires good vaginal mobility, to allow the vaginal wall to be
elevated and attached to the lateral pelvic wall where the formation of
adhesions over time secures its position. The paravaginal fascia is exposed
and approximated to the iliopectineal (Cooper) ligament of the superior
pubic rami.
Vagino-obturator shelf/paravaginal repair
Sutures are placed by the vaginal wall and paravaginal fascia and then
passed through the obturator fascia to attach to part of the parietal pelvic
fascia below the tendinous arch (arcus tendoneus fascia). Cure rates are
up to 85%.
Treatment of sphincter weakness incontinence: pubovaginal slings
Indications
Sling procedures were developed mainly for female stress incontinence
associated with poor urethral function (type III or ISD) or when previous
surgical procedures have failed. The success of sling procedures, however, has
resulted in expanded applications in women with hypermobility.
Types of sling
• Autologous—rectus fascia, fascia lata (from the thigh), vaginal wall slings
• Nonautologous—allograft fascia lata from donated cadaveric tissue
• Synthetic—monofilament “macropore” polypropylene mesh (via
transobturator, transabdominal, or transvaginal needles)
Treatment of sphincter weakness
incontinence
the artificial urinary sphincter
Indications include incontinence secondary to urethral sphincter deficiency in patients
with normal bladder capacity and compliance. In men, it
is used almost always for sphincter damage due to prostatectomy (radical prostatectomy
for prostate cancer or TURP). In women it can be used for neuropathic sphincter
weakness (e.g., spinal cord injury, spina bifida) if the incontinence is not due to bladder
overactivity.
causes of transient incontinence
1) Drug side effects
2) Delirium or hypoxia
3) Impaired mobility
4) Urinary tract infection
5) Atrophic vaginitis
6) psychological problems
7) Excessive fluid intake

REFERENCES
1-Oxford Handbook of Urology
2-Smith’s General Urology
3-CAMPBELL-WALSH Urology