Urinary incontinence

Nocturnal Enuresis, Stress Incontinence, Motor and Sensory Urge Incontinence, Overflow Incontinence

What is Urinary incontinence?

Urinary incontinence is the involuntary loss of urine. It occurs in ten percent of American women on a regular basis. Each delivery of a baby makes it more likely, as does increasing age. The inability to control urine can interfere with a woman's enjoyment of social relationships, work, and sexual life. It can lead to social isolation and disability. Urinary incontinence can be described according to clinical symptoms.

Stress incontinence results in leakage of urine during coughing, sneezing, jumping, or lifting. With this kind of straining, the rise in pressure inside the abdomen forces urine out. This is the most common type of urinary incontinence in women. It is associated with the number of children she has, since this creates stretching and weakness of the muscles at the floor of the pelvis.

Motor urge incontinence, also known as unstable bladder, results from an abnormal contraction of the bladder muscles. A large amount of urine can be lost and under very unpredictable circumstances. It, therefore, has a greater impact on a woman's life than stress incontinence. This condition may coexist with stress incontinence.

Sensory urge incontinence is the loss of urine when an individual senses a strong urge to void, with very little warning before incontinence occurs, and often the individual is unable to reach the toilet. This can occur with a neurologic disease.

Overflow incontinence is seen with a chronically overdistended bladder that never empties, resulting in frequent leakage of urine. This situation may be due to a disorder of the nerves that supply the bladder (as in diabetes), or an obstruction to bladder emptying by urethral narrowing.

Functional incontinence is not related to abnormalities in the urinary tract. Other factors, such as immobility or severe mental impairment, cause the incontinence. One-third of nursing home individuals have urinary incontinence. It can also occur in association with psychological disturbances.

Urinary incontinence may also be from anatomic abnormalities including an abnormal pathway for urine from the bladder (a fistula), an outpouching of the urethra (diverticulum), or an abnormally located ureter (ectopic ureter).

How is it diagnosed?

History: A small amount of urine loss with sneezing, coughing, laughing, bending, lifting weight, and rising from a sitting to standing position indicates stress incontinence. These individuals may also report the sensation of heaviness in the pelvic area.

A large amount of urine loss, frequent voiding, the urge coming too fast to get to the toilet, and the loss of urine at the sound of running water are characteristics of urge incontinence.

A report of dribbling urine without being aware of urine loss and the sensation of incomplete emptying of the bladder indicates overflow incontinence.

Complaints of inability to get to a bathroom on time, the lack of convenient access to a toilet, and the need for assistance in getting on the toilet constitutes functional incontinence.

It is also important to determine how often the individual urinates during the day and the longest amount of time the individual can comfortably stay between urinating. The history should reflect any neurologic conditions affecting the bladder and urinary sphincter such as spinal cord injury, stroke, diabetes, Parkinson's disease, or multiple sclerosis. A history of trauma, vaginal surgery, abdominoperineal resection of rectum, radical hysterectomy, radiation therapy, or previous surgical repair of incontinence should be obtained.

Physical exam should include a general neurologic exam, assessment of anal sphincter tone, perineal sensation and reflexes. Urethrocele, cystocele, and rectocele are looked for, as are redness, vaginal or urethral discharge, and tissue atrophy. The pelvic examination is performed with a full and empty bladder, and during coughing or straining, to check for incontinence, prolapse, and weakness of the pelvic floor. Urethral movement is assessed by the Q-tip test (placing a lubricated applicator in the urethra to measure muscle support).

Tests: Urinalysis is done to look for a urinary infection, with a urine culture for definitive diagnosis. The pad test may be employed to measure urine loss (woman wears a pre-weighed sanitary pad, perform various activities, and pad is re-weighed to determine loss of urine). Urodynamic test should be performed, including cystometry and urethral pressure profile. Visually inspecting in the bladder (cystoscopy and urethroscopy) is also appropriate in many cases.

How is incontinence treated?

Effective treatment requires a correct diagnosis of the cause of incontinence. Any predisposing conditions should be treated first, such as a chronic cough, urinary infection, or estrogen deficiency.

The treatment of stress incontinence may require exercises to strengthen the pelvic floor (Kegel exercises), biofeedback, electrical stimulation of the pelvic floor muscles, drugs, or surgery. Surgical procedures include repair of cystocele, retropubic suspension, and needle suspension to reposition the urethra. The pubovaginal sling (placement of an artificial sphincter) and periurethral bulking injections may be applied to compress the urethra and increase resistance to urine leakage.

In the case of overflow incontinence, the cause of incomplete bladder emptying must be surgically removed or corrected if possible. Alpha-blockers therapy, avoidance of anticholinergic drugs, intermittent draining of the bladder with a catheter, or even permanent bladder drainage (suprapubic catheterization) may be recommended.

The treatment of urge incontinence may include antibiotic therapy, topical estrogen therapy or removal of bladder stones or tumors. If urge incontinence is related to neurological diseases, then bladder and bowel training, techniques to assist bladder emptying, urinating according to a schedule, and improvements to mobility may be employed. In some cases, management of fluid intake, intermittent catheterization or use of external collection devices is appropriate. If urge incontinence is due to unstable bladder muscles, anticholinergic medications may be beneficial.

Treatment of functional incontinence would include a number of different activities. If functional incontinence is related to sleeping pills, diuretics, or alcohol, they should be avoided or rescheduled. Anticholinergic drugs must be avoided. If it is related to sensory deficits, or inability to take off clothing or to access the toilet, then aids such as eyeglasses, hearing aids, easy-to-remove clothing, and convenient toilet facilities should be provided.

Medications

Information Brand Generic Label Rating
Zoloft cost Zoloft Sertraline Off-Label
Strattera Strattera Atomoxetine Off-Label

Luvox (Fluvoxamine), Pamelor (Nortriptyline), Tofranil (Imipramine)

What might complicate it?

Complications may occur as a result of backward flow of urine toward the kidneys (ureteral reflux), enlargement of the urinary drainage system (hydronephrosis), bladder or kidney infection, or chronic kidney failure. Perineal skin damage and infection can result without appropriate preventive skin care.

Complications of medical treatment include those of the medicines themselves or local irritation from mechanical devices. Surgical treatment can occasionally result in damage to the urinary tract and the creation of an abnormal passage for urine (fistula).

Predicted outcome

The great majority of individuals with stress incontinence can be significantly helped. Urge incontinence and overflow incontinence are more likely to recur or become a chronic condition.

Alternatives

Other possibilities include an abnormally high urine production (caused by many disorders, including diabetes), bladder irritation or infection, and bladder scarring from radiation or interstitial cystitis.

Appropriate specialists

Urologist, gynecologist, and neurologist.

Last updated 22 December 2011


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