Urinary incontinence

Question 1

What are the different types of urinary incontinence?

Answer 1

STRESS
Leakage due to increased abdominal pressure eg: coughing, lifting
Due to a weak pelvic floor or urinary sphincter damage post surgery

URGE
Strong desire to pass urine, variable urine loss
Often due to OAB

OVERFLOW
Leakage from chronically distended bladder that isn’t emptying fully
Get a reduced sensation of bladder fullness
Often due to BOO (BPH, stricture etc) or neuromuscular bladder dysfunction

FUNCTIONAL
Combination of physical, cognitive and environmental barriers

MIXED
any combination of above

Question 2

Key causes of urinary incontinence in men?

Answer 2

Overactive bladder (OAB)
Chronic urinary retention w overflow
BPH
Treatments for prostate cancer
Other medical conditions
- CCF
- Diabetes
- Dementia
- Stroke
- Parkinsons

Question 3

Key questions to ask on history

Answer 3

what situation urinary incontinence occurs in eg: physical activity, associated with strong desire to urinate
any associated LUTS - voiding or storage symptoms
severity - impact on QoL
onset + duration
associated symptoms (eg: haematuria, recurrent UTIs, constipation)
Medical Hx - neurological conditions, chronic cough, previous pelvic/prostate surgery or RTx
Medications - diuretics, anti-cholinergics

Question 4

What would you look for on exam?

Answer 4

BMI - ?overweight -> more chance of weak pelvic floor
Abdo: palpable bladder? Mass?
Genital: Foreskin ? retractible, meatal stenosis/abnormality
DRE: prostate size, rectal tone, mass
Perineum for sensation
Cardiovascular/neuro exam if indicated

Question 5

What investigations would you do?

Answer 5

urinalysis ?protein ? blood ? glucose
MSU ? UTI/prostatitis
UEC ?renal fx
fasting BSL
PSA
Renal tract USS w PVR
(STI screen if suspect urethritis)

Question 6

What are the general management strategies for all men presenting with urinary incontinence?

Answer 6

If BMI >30 -> weight loss
toileting routine to address physical & cognitive barriers
Good drinking habits - 6-8 cups per day (at least 4 cups of water)
Avoid caffeine
Avoid alcohol
Supervised pelvic floor muscle exercises with pelvic health physio (6 -12 week trial)
Treat any underlying UTI/prostatitis or constipation
Optimise treatment of contributing medical conditions
Review medication

Consider referral to continence service

NB: If mixed symptoms, treat the most predominant symptoms first

Question 7

Specific management of stress incontinence

Answer 7

pelvic floor exercises
Incontinence surgery
- Injectable urethral bulking agents
- Minimally invasive sling surgery
- Artificial urinary sphincter

Question 8

Specific management of urge incontinence

Answer 8

mostly likely due to overactive bladder syndrome (urgency/frequency, nocturia +/- urge incontinence)

Mx
1) Bladder retraining for 6 weeks w continence team or pelvic health specialist

2) if little improvement → medication
anticholinergics - C/I in angle closure glaucoma, myasthenia gravis, dementia

oxybutynin (anti-SLUD side effects, cognitive issues)
solifenacin - less anti-SLUD S/E, private script, can prolong QTc
mirabegron - private script, no anticholinergic S/Es, can cause severe HTN, can prolong QTc, takes 8 weeks to work

3) urology referral for Botox injection to detruser, sacral nerve stimulator

Question 9

Management of overflow incontinence

Answer 9

Determine cause

Determine cause
eg: BPH, prostate Ca, urethral sphincter, bladder or urethral cancer/mass, hypotonic detrusor due to chronic obstruction or neurological damage

if chronic retention due to BPH + large PVR >400ml -> tamsulosin or combo therapy w duodart

if persisting incontinence and PVR >300ml despite medical management + no concerns re: neurological condition -> refer to urology for assessment +/- TURP