Urinary incontinence

Urinary incontinence
Involuntary leakage of urine may occur for a variety of reasons
Classification and external resources
ICD-10	N39.3-N39.4, R32
ICD-9	788.3
DiseasesDB	6764
MedlinePlus	003142
eMedicine	med/2781
Patient UK	Urinary incontinence
MeSH	D014549

Urinary incontinence (UI), or involuntary urination, is any leakage of urine. It can be a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners.^[1] Enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis (bed wetting).^[2]

Causes

The most common types of urinary incontinence in women are stress urinary incontinence and urge urinary incontinence. Women with both problems have mixed urinary incontinence. Stress urinary incontinence is caused by loss of support of the urethra which is usually a consequence of damage to pelvic support structures as a result of childbirth. It is characterized by leaking of small amounts of urine with activities which increase abdominal pressure such as coughing, sneezing and lifting. Additionally, frequent exercise in high-impact activities can cause athletic incontinence to develop. Urge urinary incontinence is caused by uninhibited contractions of the detrusor muscle. It is characterized by leaking of large amounts of urine in association with insufficient warning to get to the bathroom in time.

• Polyuria (excessive urine production) of which, in turn, the most frequent causes are: uncontrolled diabetes mellitus, primary polydipsia (excessive fluid drinking), central diabetes insipidus and nephrogenic diabetes insipidus.^[3] Polyuria generally causes urinary urgency and frequency, but doesn't necessarily lead to incontinence.
• Enlarged prostate is the most common cause of incontinence in men after the age of 40; sometimes prostate cancer may also be associated with urinary incontinence. Moreover drugs or radiation used to treat prostate cancer can also cause incontinence.^[4]
• Disorders like multiple sclerosis, spina bifida, Parkinson's disease, strokes and spinal cord injury can all interfere with nerve function of the bladder.

Pathophysiology

Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls and bladder pressure rises.

The body stores urine — water and wastes removed by the kidneys — in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract (detrusor muscle) or muscles surrounding the urethra suddenly relax (sphincter muscles).

Children

Urination, or voiding, is a complex activity. The bladder is a balloonlike muscle that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord and the brain.

The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.

A baby's bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system develops. The child's brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.

Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.

Diagnosis

Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Family physicians and internists see patients for all kinds of complaints, and are well trained to diagnose and treat this common problem. These primary care specialists can refer patients to urology specialists if needed.

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:

• Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
• Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
• Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
• Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
• Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
• Urodynamics – various techniques measure pressure in the bladder and the flow of urine.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

Research projects that assess the efficacy of anti-incontinence therapies often quantify the extent of urinary incontinence. The methods include the 1-h pad test, measuring leakage volume; using a voiding diary, counting the number of incontinence episodes (leakage episodes) per day; and assessing of the strength of pelvic floor muscles, measuring the maximum vaginal squeeze pressure.

Types

• Stress incontinence, also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles to prevent the passage of urine, especially during activities that increase intra-abdominal pressure, such as coughing, sneezing, or bearing down.
• Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
• Overflow incontinence: Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence.
• Mixed incontinence is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.^[5]
• Structural incontinence: Rarely, structural problems can cause incontinence, usually diagnosed in childhood (for example, an ectopic ureter). Fistulas caused by obstetric and gynecologic trauma or injury are commonly known as obstetric fistulas and can lead to incontinence. These types of vaginal fistulas include, most commonly, vesicovaginal fistula and, more rarely, ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.^[6]
• Functional incontinence occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The loss of urine may be large. There are several causes of functional incontinence including confusion, dementia, poor eyesight, mobility or dexterity, unwillingness to toilet because of depression or anxiety or inebriation due to alcohol.^[7] Functional incontinence can also occur in certain circumstances where no biological or medical problem is present. For example a person may recognise the need to urinate but may be in a situation where there is no toilet nearby or access to a toilet is restricted.
• Nocturnal enuresis is episodic UI while asleep. It is normal in young children.
• Transient incontinence is a temporary version of incontinence. It can be triggered by medications, adrenal insufficiency, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.
• Giggle incontinence is an involuntary response to laughter. It usually affects children.
• Double incontinence. There is also a related condition for defecation known as fecal incontinence. Due to involvement of the same muscle group (levator ani) in bladder and bowel continence, patients with urinary incontinence are more likely to have fecal incontinence in addition.^[8] This is sometimes termed "double incontinence".
• Post-void dribbling is the phenomenon where urine remaining in the urethra after voiding the bladder slowly leaks out after urination.
• Coital incontinence (CI) is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or with masturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.^[9]

Treatment

Treatment options range from conservative treatment, behavior management, bladder retraining,^[10] pelvic floor therapy, collecting devices (for men), fixer-occluder devices for incontinence (in men), medications and surgery.^[11] The success of treatment depends on the correct diagnoses.^[12] Weight loss is recommended in those who are obese.^[13]

Exercises

Exercising the muscles of the pelvis such as with Kegel exercises are a first line treatment for women with stress incontinence.^[13] Efforts to increase the time between urination, known as bladder training, is recommended in those with urge incontinence.^[13] Both these may be used in those with mixed incontinence.^[13]

Small vaginal cones of increasing weight may be used to help with exercise.^[14]

Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Time voiding while urinating and bladder training are techniques that use biofeedback. In time voiding, the patient fills in a chart of voiding and leaking. From the patterns that appear in the chart, the patient can plan to empty his or her bladder before he or she would otherwise leak. Biofeedback and muscle conditioning, known as bladder training, can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence

A 2013 randomized controlled trial found no benefit of adding biofeedback to pelvic floor muscle exercise in stress urinary incontinence, but observing improvements in both groups.^[15] In another randomized controlled trial the addition of biofeedback to the training of pelvic floor muscles for the treatment of stress urinary incontinence, improved pelvic floor muscle function, reduced urinary symptoms, and improved of the quality of life.^[16]

Medications

A number of medications exist to treat incontinence including: fesoterodine, tolterodine and oxybutynin.^[17] While a number appear to have a small benefit, the risk of side effects are a concern.^[17] For every ten or so people treated only one will become able to control their urine and all medication are of similar benefit.^[18]

Medications are not recommended for those with stress incontinence and are only recommended in those who have urge incontinence who do not improve with bladder training.^[13]

Surgery

Surgery may be used to alleviate incontinence after other treatments have been tried and found not to be effective. Urodynamic testing seems to confirm that surgical restoration of vault prolapse can cure motor urge incontinence. In those with problems following prostate surgery there is little evidence regarding the use of surgery.^[19]

Slings

The procedure of choice for stress urinary incontinence in females is what is called a sling procedure. A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine or porcine) or the patients own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a backboard of support under the urethra.

Tension-free transvaginal tape

The tension-free transvaginal tape(TVT) sling procedure treats urinary stress incontinence by positioning a polypropylene mesh tape underneath the urethra. The 20-minute outpatient procedure involves two miniature incisions and has an 86-95% cure rate. Complications, such as bladder perforation, can occur in the retropubic space if the procedure is not done correctly. This minimally invasive procedure is a common treatment for stress urinary incontinence.

Rectus fascial sling

The rectus fascial sling procedure treats urinary stress incontinence by providing support under the urethra. This procedure involves taking a strip of the rectus sheath from the patient through a small incision just below the bikini line, and placed under the urethra through an incision in the vagina.^[20]

Transobturator tape

The transobturator tape (TOT) sling procedure aims to eliminate stress urinary incontinence by providing support under the urethra. This minimally invasive procedure eliminates retropubic needle passage and involves inserting a mesh tape under the urethra through three small incisions in the groin area. While the procedure has shown risks during its infancy, recent developments have increased the cure rate to 90%.

Mini-sling

The mini-sling procedure has reported short term cure rates of 67% to 83%.

Needleless sling

The needleless sling is a single incision TOT. It is implanted via one unique incision. The needleless has approximately 136% more surface area than the mini sling, which may better support the pelvic floor and urethra, and no sharp instruments are required to implant the sling besides the scalpel used to make the incision, which may enhance patient comfort.

Readjustable sling

The re-adjustable sling consists of a standard synthetic mesh sling combined with sutures that attach to an implantable tensioning device that resides permanently under the skin in the abdominal wall. Once implanted, this Readjustable Mechanical External (REMEEX) device can be re-accessed under local anesthesia to fine tune the sling should incontinence reappear months or years after the initial surgery.^[21]

Bladder repositioning

Most stress incontinence in women results from the bladder dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament or bone. For severe cases of stress incontinence, the surgeon may secure the bladder with a wide sling. This not only holds up the bladder but also compresses the bottom if the bladder and the top of the urethra, further preventing leakage.

Marshall-Marchetti-Krantz

The Marshall-Marchetti-Krantz (MMK) procedure, also known as retropubic suspension or bladder neck suspension surgery, is performed by a surgeon in a hospital setting. Developed in 1949 by doctors Victor F. Marshall (1913–2001), a urologist, Andrew Anthony Marchetti (1901–1970), an OB/GYN, and Kermit E. Krantz (OB/GYN) is the standard by which new procedures are measured. The patient is placed under general anesthesia, and long, thin, flexible tube (catheter) is inserted into the bladder through the narrow tube (urethra) that drains the body's urine. An incision is made across the abdomen, and the bladder is exposed. The bladder is separated from surrounding tissues. Stitches (sutures) are placed in these tissues near the bladder neck and urethra. The urethra is then lifted, and the sutures are attached to the pubic bone itself, or to tissue (fascia) behind the pubic bone. The sutures support the bladder neck, helping the patient gain control over urine flow. Approximately 85% of women who undergo the Marshall-Marchetti-Krantz procedure are cured of their stress incontinence.

Devices

Individuals who continue to experience urinary incontinence need to find a management solution that matches their individual situation. The use of devices has not been well studied in women as of 2014.^[22]

Collecting systems (for men) – consists of a sheath worn over the penis funneling the urine into a urine bag worn on the leg. These products come in a variety of materials and sizes for individual fit. Studies^[23] show that urisheaths and urine bags are preferred over absorbent products – in particular when it comes to ‘limitations to daily activities’. Solutions exist for all levels of incontinence. Advantages with collecting systems are that they are discreet, the skin stays dry all the time, and they are convenient to use both day and night. Disadvantages are that it is necessary to get measured to ensure proper fit and you need a health care professional to write a prescription for them.

Absorbent products (include shields, undergarments, protective underwear, briefs, diapers, adult diapers and underpants) are the most well know product types to manage incontinence. They are generally easy to get hold of in pharmacies or supermarkets and thus very popular. The advantages of using these are that they barely need any fitting or introduction by a health care specialist. The disadvantages with absorbent products are that they can be bulky, leak, have odors and can cause skin breakdown.

Fixer-occluder devices (for men) are strapped around the penis, softly pressing the urethra and stopping the flow of urine. This management solution is only suitable for light or moderate incontinence.

Indwelling catheters (also known as foleys) are very often used in hospital settings or if the user is not able to handle any of the above solutions himself. The indwelling catheter is typically connected to a urine bag that can be worn on the leg or hang on the side of the bed. Indwelling catheters need to be changed on a regular basis by a health care professional. The advantage of indwelling catheters are, that the urine gets funneled away from the body keeping the skin dry. The disadvantage, however, is that it is very common to get urinary tract infections when using indwelling catheters.^[24]

Intermittent catheters are single use catheters that are inserted into the bladder to empty it, and once the bladder is empty they are removed and discarded. Intermittent catheters are primarily used for retention (inability to empty the bladder) but for some people can be used to reduce / avoid incontinence.

Epidemiology

Globally, up to 35% of the population over the age of 60 years is estimated to be incontinent.^[25] In 2014, urinary leakage affected between 30% and 40% of people over 65 years of age living in their own homes or apartments in the U.S.^[26] Twenty-four percent of older adults in the U.S. have moderate or severe urinary incontinence that should be treated medically.^[26]

Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. Difficulty with bladder control results in higher rates of depression and limited activity levels.^[27]

Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living and nursing care facilities. More than 50% of nursing facility admissions are related to incontinence.^[28]

Children

Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in girls as in boys.

Women

Bladder symptoms affect women of all ages. However, bladder problems are most prevalent among older women.^[29] Women over the age of 60 years are twice as likely as men to experience incontinence; one in three women over the age of 60 years are estimated to have bladder control problems.^[25] One reason why women are more affected is the weakening of pelvic floor muscles by childbirth.^[30]

Men

Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. It is common with prostate cancer treatments. Both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.

While urinary incontinence affects older men more often than younger men, the onset of incontinence can happen at any age. Estimates in the mid-2000s suggested that 17 percent of men over age 60, an estimated 600,000 men, experienced urinary incontinence, with this percentage increasing with age.^[31]

History

The management of urinary incontinence with pads is mentioned in the earliest medical book known, the Ebers Papyrus (1500 BC).^[32]

References

External links

• Urinary incontinence at DMOZ
• Urinary Incontinence Information
• Continence Coach from Ostomy Wound Management

Symptoms and signs: urinary system (R30–R39, 788) Pain Renal colic Costovertebral angle tenderness Dysuria Vesical tenesmus Control Urinary incontinence/Enuresis Diurnal enuresis Giggling Nocturnal enuresis Post-void dribbling Stress Urge Overflow Urinary retention Volume Oliguria/Anuria Polyuria Other urination disorders Lower urinary tract symptoms Nocturia Urinary urgency Urinary frequency Extravasation of urine Extrarenal uremia Urinoma Index of the urinary system Description Anatomy Physiology Development Cells Disease Electrolyte and acid-base Congenital Neoplasms and cancer Other Symptoms and signs eponymous Urine tests findings Blood tests Treatment Procedures Drugs potassium and phosphate Intravenous fluids