Editing Urinary incontinence


Urge incontinence - involuntary leakage, immediately preceded by urgency - often overactive bladder or bladder neuropathy.

Stress incontinence - involuntary leakage which occurs when intra-abdominal pressure rises.

== Incidence ==

* 5% men, 20% of women lifetime incidence
* 40% of women >60yo
* 50% of institutionalised elderly patients

== Aetiology ==

* Children - often a/w
** Infections
** Constipation
** Psychological factors
** Intentional misconduct
** Increased fluid intake
** Overactive bladder
* Problems of social control
** Seen in dementia patients - uninhibited detrusor hyperreflexia and impaired social perception
* Storage problems
** Small bladder capacity owing to fibrosis (TB, RTx, interstitial cystitis)
** Small functional capacity owing to severe detrusor instability, neurogenic dysfunction or infection
* Impairment of emptying
** Small functional bladder capacities with detrusor overactivity causing incontinence, despite having large residual volumes of urine
* Weak sphincter
** Leads to genuine stress incontinence
** Can follow surgical procedures such as radical prostatectomy
* Fistulae

== Aetiology by gender ==

* Men
** Chronic retention with overflow
*** BPH
*** Prostate cancer
*** Urethral stricture
*** Hypertrophy of bladder neck (younger men)
** Post-prostatectomy
*** Injury to external sphincter mechanism
**** Pelvic floor exercises
**** Exclude anastomotic stricture
* Women
** Stress incontinence - usually found in multiparous women with a history of difficult labour
*** Minor symptoms can be controlled by pelvic floor exercises
*** Surgery - colposuspension (sutures are placed between vaginal fascia and iliopubic ligament) or transvaginal tape
* Both genders
** Idiopathic detrusor overactivity
*** Usually results in frequency, urgency, urge incontinence, noturia or enuresis
*** Distinguish from GSI and BOO
*** Exclude infection, TB and cancer
*** Treat with anticholinergics (oxybutynin)
*** Sometimes need enterocystoplasty or botox injections
** Ageing
*** Smooth muscle dysfunction - small functional capacity, detrusor overactivity, impaired bladder emptying, LUTS
** Congenital
*** Ectopic vesicae and severe epispadias
** Trauma
** Infection
** Neoplasia
*** Direct invasion from cervical cancer or prostate cancer to the sphincter

== History ==

* Apart from the obvious
* Constant dribbling coupled with normal micturition could be a ureteric fistula
* Nocturnal enuresis in adolescents - primary vs secondary - vast majority eventually get better once secondary causes have been excluded

== Investigation ==

* Frequency voiding charts
* Urodynamic testing
** Artificially simulate bladder filling and emptying while taking pressure measurements
** Indications:
*** Distinguishing stress incontinence from detrusor instability in women
*** Classification of neurogenic bladder dysfunction
*** Distinguish bladder outflow obstruction from idiopathic detrusor instability in men
*** Low threshold in general for use in investigating incontinence or LUTS
** Overactive bladder
*** Phasic increases in pressure give rise to urgency and urge incontinence
*** Found in patients with neurogenic bladder dysfunction, such as MS or PD, or after a stroke or spinal cord injury
*** 50% of men with BOO have detrusor instability, and in about half of them the problem resolves after prostatectomy
** Genuine stress incontinence
*** Leakage due to increased abdominal pressure, not just increased true detrusor pressure
*** Caused by sphincter weakness
** Chronic urinary retention
*** Incontinence is secondary to overflow, with large residual volume
** Bladder outflow obstruction
*** Increased voiding pressures, often in excess of 90cm H2O, coupled with low urinary flow rates
* Urine MCS
* Creatinine

== Treatment ==

* Conservative - pelvic floor physio, bladder training, lifestyle
* Devices for collection - condom catheter, ISC
* Drugs
** Adrenergic blockers decrease strength of bladder neck
** Inhibit bladder activity - anticholinergics
* Increasing outlet - resistance colposuspension or TVT or slings, periurethral injections of bulking agents, artificial urinary sphincter
* Denervation of bladder - S3 blockade - rarely used nowadays
* Sacral nerve stimulation devices
* Augmentation of bladder
* Urinary diversion - ileal conduit, continent urinary diversion

[[Category:Urology]]