Urinary incontinence - Disorders of the bladder and prostate

Urinary incontinence

Definition

Urinary incontinence is the involuntary loss of urine from the urethra. It has a major physical, psychological and functional impact on the individual.

Incidence/prevalence

Even in young patients it is relatively common (up to 30% of women <65 years but only up to 5% of men <65 years). In older patients the age ratios approach 1–2F:1M. Rates are much higher in certain settings such as care of the elderly institutions (up to 45%) and psychiatric care of the elderly (90%).

Age

Increases with age.

Sex

F > M

Aetiology

Incontinence has been associated with many conditions and risk factors such as chronic cough, depression, dementia, pregnancy, vaginal delivery (particularly with episiotomy, forceps delivery), impaired mobility, drugs and chronic medical conditions such as heart failure, chronic lung disease, stroke, multiple sclerosis and diabetes.

Pathophysiology

Incontinence is multifactorial. To remain continent there must be:

·        The ability to control micturition at the level of the urinary tract as well as neurological control.

·        The ability to recognise the sensation of bladder filling and to be able to respond appropriately and sufficiently quickly to this.

·        The ability to mobilise safely or the manual dexterity to use a container.

·        The motivation to maintain dryness and hygiene.

Clinical features

Symptoms of incontinence may be grouped into those of specific syndromes:

·        Stress incontinence occurs when intra-abdominal pressure is increased, e.g. on coughing, bending over, or running and jumping. The leak may occur at the time or just after. This is due to poor sphincter function.

·        Urge incontinence is when the patient has an over-whelming urge to void leading to leakage. This may be precipitated by the sound of running water, washing hands or even prematurely, e.g. on arriving home. This is mainly due to detrusor instability/over-activity.

·        Mixed stress and urge incontinence is also common.

·        Overflow incontinence is continual or unprecipitated leakage without urge. This may result from either the lack of sensation of a full bladder or sphincter incompetence. Bladder outflow obstruction may lead to overflow incontinence due to bladder decompen-sation. Rare causes include spinal cord compression affecting the sacral segments (S2, 3 and 4) or the conus medullaris. Patients may empty the bladder by strain-ing or manual compression.

A comprehensive examination is important and can avoid the need for specialist tests. It is important to assess fluid balance, mobility, cognitive ability and relevant neurology. Rectal examination for constipation, rectal masses and vaginal speculum examination for atrophy, masses, cystocele or rectocele.

Complications

Increased risk of urinary tract infections (UTI’s) and stones. Hydronephrosis, reflux damage to kidneys.

Investigations

A voiding diary is useful to record the time, volume and relevant events, e.g. beverages, activities, sleeping and medications.

In all patients with persistent incontinence, U&Es, glucose, calcium, vitamin B12 and urinalysis should be performed (with culture if indicated).

Pad test (weighing a pad before and after various exercises).

Post-void bladder volume should be assessed. Urodynamic investigations are rarely required.

Occasionally, depending on the history and examination, other tests include X-rays, ultrasound renal tract and neurological testing for sacral evoked response.

Management

Treatment depends on the class of incontinence and the underlying cause:

Stress incontinence: Initially non-surgical options (e.g. exercises, medication) can be tried, but surgery is the main treatment.

Pelvic floor (Kegel) exercises (with or without weighted cones) may be used but are dependent on the motivation of the patient. Systemic or topical oestrogen therapy may be of benefit. Imipramine (a mixed anticholinergic and α-agonist) has been used. Ring pessaries are useful for those with uterine prolapse.

Surgery is effective but carries a significant morbidity. Using a transabdominal approach (but without entering the peritoneal cavity) stitches are placed through the fascia at the level of the bladder neck or urethra to hitch the urethra and bladder neck up and forwards. These are sutured either to Cooper’s ligament (a Burch colposuspension or urethropexy) or to the periosteum of the pubic bone (a Marshall– Marchetti–Krantz colposuspension). For vaginal cystoceles (where the bladder herniates into the vaginal canal), a transvaginal approach may be used to repair the cystocele but this is generally less effective. Alternatively using both vaginal and transabdominal approaches a sling or sutures are used to lift the bladder neck or midurethra up to the rectus abdominis muscle.

Urge incontinence: unlike stress incontinence, behavioural and medical therapies are the main treatments. Surgery (clam cystoplasty to increase the size of the bladder using bowel) is rarely successful.

·        Behavioural therapy can be more effective than medication. In patients with cognitive awareness of bladder filling and the ability to independently toilet, bladder training is used to learn methods of deliberately suppressing the urge to pass urine. In patients without cognitive awareness or lack of motivation to remain dry, scheduled or prompted voiding reduces the number of episodes of incontinence, as well as the volumes passed when incontinent.

·        Drug therapy: Anticholinergics are the mainstay of drug treatment (e.g. oxybutynin, tolterodine). These tend to cause a dry mouth and may cause constipation and/or urinary retention. Imipramine may also be tried but tends to be avoided in the elderly due to side effects.

Combined stress and urge incontinence may be treated with behavioural therapy with or without medical therapy. Surgical treatment appears to be less effective than in pure stress incontinence. Overflow incontinence: Treatment is aimed at the underlying cause.

·        If there is bladder outlet obstruction, either TURP or incision of the bladder neck (or external sphincter) is used to reduce outlet obstruction.

·        In spinal cord compression emergency decompression is essential. In other neuropathic conditions intermittent selfcatheterisation is the preferred treatment.

·        Patients who are unfit for TURP or are unable to self-catheterise may require a long-term indwelling catheter.

·        Prevention of infection is important both by using sterile catheters and possibly using prophylactic antibiotics.