Urinary Incontinence Flashcards
What is urinary incontinence (UI)?
Urinary incontinence (UI) is the involuntary leakage of urine.
Who is commonly affected by UI?
It affects around 15% of the general population, most common in the elderly, and is more common in females (male: female 1:3).
What are the various types of UI?
UI can be categorised into various subtypes, all of which have different underlying causes and management options:
- Stress incontinence
- Urge incontinence
- Mixed incontinence
- Overflow incontinence
- Continuous incontinence
Briefly describe stress UI
Stress UI is urine leakage occurring when the intra-abdominal pressure exceeds the urethral pressure, such as coughing, straining, laughing, or lifting. The impaired urethral support is most often due to weakness of the pelvic floor muscle.
It is most commonly seen post-partum, due to the damage occurring to the pelvic floor muscles, weakening the urethral sphincter. Other risk factors include constipation (due to recurrent straining), obesity, post-menopausal, or pelvic surgery (e.g. TURP, resulting in external sphincter damage).
Briefly describe urge UI
Urge UI describes an overactive bladder (detrusor hyperactivity), which leads to uninhibited bladder contraction, leading to a rise in intravesical pressure and subsequent leakage of urine.
Such overactive bladder may be due to neurogenic causes (such as a previous stroke), infection, malignancy, or idiopathic. Medication, such as cholinesterase inhibitors, can also result in urge UI.
Briefly describe mixed UI
Mixed UI is a combination of stress UI and urge UI.
Briefly describe overflow UI
Overflow UI is normally a complication of chronic urinary retention, whereby the progressive stretching of the bladder wall leads to damage to the efferent fibres of the sacral reflex and loss of bladder sensation.
As the bladder fills with urine, it becomes grossly distended however intravesicular pressure builds, leading to a constant dribbling of urine.
The most common cause is from prostatic hyperplasia, however other causes include spinal cord injury or congenital defects.
Briefly describe constant UI
Continuous UI is the constant leakage of urine, meaning the patient is wet all the time. This is typically due to anatomical abnormality (such as ectopic ureter) or bladder fistulae (e.g. vesicovaginal fistula), however may also be due to severe overflow incontinence.
What are the clinical features of urinary incontinence?
A detailed clinical history can allow many cases of UI to be categorised on the first visit. Other symptoms (e.g. dysuria or haematuria), precipitating factors, past medical and surgical history, and drug history will all aid in patient work-up.
Patients should be asked to keep bladder diaries, which can aid in the delineation of the underlying cause. QoL questionnaires (such as ICIQ, BFLUTS, I‑QOL) can aid in quantifying severity of the condition.
Examination can aid in assessment of potential underlying causes, such as an enlarged prostate, prolapse, or any fistula opening.
What investigations should be ordered for urinary incontinence?
All patients should have a midstream urine dipstick performed, assessing for evidence of infection or haematuria. Post-void bladder scans should also be performed routinely, especially in those suspected of overflow UI.
When should urodynamic assessment be performed for urinary incontinence?
For those with unclear aetiology, urodynamic assessment can be a useful adjunct in the assessment of UI cases. Intravesicular and intra-abdominal pressures are measured, allowing detrusor muscle pressure to be calculated; any hyperactivity of the bladder muscle wall may suggest an urge UI.
Briefly describe the conservative management of stress UI
Non-surgical therapy should be attempted initially when managing UI. Lifestyle advice is given to most patients presenting with UI, including weight loss, reducing caffeine intake, avoid drinking either excessive fluid volumes each day, and smoking cessation
For stress UI (or mixed UI), initial management is supervised pelvic floor muscle training (PFMT), which should ideally last for at least 3 months. For those with limited response to PFMT (especially those unsuitable for surgery), often duloxetine (a serotonin–norepinephrine reuptake inhibitor) can be trialled, working to cause stronger urethral contractions.
Briefly describe the conservative management of urge UI
Non-surgical therapy should be attempted initially when managing UI. Lifestyle advice is given to most patients presenting with UI, including weight loss, reducing caffeine intake, avoid drinking either excessive fluid volumes each day, and smoking cessation.
For urge UI, anti-muscarinic drugs can be trialled, such as oxybutynin or tolterodine, acting to inhibit the detrusor contraction. Bladder training should also be offered, ensuring the patient continues this for a minimum of 6 weeks.
Briefly describe the surgical management of stress UI
Options include:
- Tension-free vaginal tape
- Open colposuspension (involving elevation of the bladder neck and urethra through a lower abdominal incision)
- Intramural bulking agents
- Artificial urinary sphincter
Briefly describe the surgical management of urge UI
Options include:
- Botulinum toxin A injections
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty (whereby a detubularised segment of bowel is inserted into the bladder wall to increase bladder capacity)
- Urinary diversion via ileal conduit
