Urinary
incontinence
Dr. Mohammed Bassil
OBJECTIVES
1. Identify and name the major anatomic and histologic features of the bladder and
urethra in the male and female
2. Define incontinence
3. List the symptoms and signs of the various types of incontinence; stress, urge,
overflow and mixed
4. Describe the epidemiological features of incontinence
5. Describe the natural history and progression of incontinence
6. List the risk factors for incontinence
7. List the important components of the history when interviewing a patient with
incontinence
8. List the important components of the physical exam of a patient with incontinence
9. Summarize the laboratory, radiologic, or urodynamic tests, if any, that should be
ordered in a patient with incontinence
10. List the indications for treatment of incontinence
11. List the nonsurgical treatment options for stress and urge incontinence, describe their
side effects, and outline the mechanisms by which they work.
12. Briefly describe the surgical treatment options for stress and urge incontinence
Definition
Involuntary loss of urine that is a social
or hygienic problem and is objectively
demonstrable.” Urinary incontinence
(UI) is a failure to store urine usually
due to either abnormal bladder smooth
muscle
or
a
deficient
urethral
sphincter. Urine loss may also be
extraurethral, secondary to anatomical
abnormalities such as ectopic ureter or
vesicovaginal fistula.
Prevalence
UI has been reported to affect 12–43% of adult women and
3–11% of adult men. Severe incontinence has a low
prevalence in young women, but rapidly increases at ages
70 through 80. Incontinence in men also increases with
age, but severe incontinence in 70- to 80-year-old men is
about half that in women.
Classification
Stress urinary incontinence (SUI) :is involuntary urinary leakage during effort,
exertion, sneezing, or coughing, due to hypermobility of the
bladder base, pelvic floor,and/or intrinsic urethral sphincter
deficiencies. In females SUI is usually associated with
multiparity. In males, SUI is most commonly the result of
prostatectomy
Classification
Urgency urinary incontinence (UUI):is involuntary urine leakage accompanied or immediately
preceded by a sudden, strong desire to void (urgency).
Mixed urinary incontinence:is urine leakage that has characteristics of both SUI and
UUI.
Overflow incontinence :is leakage of urine when the bladder is abnormally
distended with large post-void residual volumes. Typically,
men present
with chronic urinary retention and dribbling incontinence.
This can lead to hydronephrosis and renal failure in 30% of
patients.
Classification
Nocturnal enuresis:describes any involuntary loss of urine during
sleep.
The prevalence in adults is 0.5%. Approximately
750,000 children over age 7 years will regularly
wet the bed. Childhood enuresis can be further
classified into primary (never been dry for longer
than a 6-month period)
or secondary (re-emergence of bed wetting after a
period of being dry for at least 6–12 months).
Risk factors
Predisposing factors
• Gender (female > males)
• Race (Caucasian > African American/Asian)
• Genetic predisposition
• Neurological disorders (spinal cord injury, stroke, MS, Parkinson
disease)
• Anatomical disorders (vesicovaginal fistula, ectopic ureter, urethral
diverticulum)
• Childbirth
• Anomalies in collagen subtype
• Prostate or pelvic surgery (radical prostatectomy; radical
hysterectomy; TURP) leading to pelvic muscle and nerve injury
• Pelvic radiotherapy
Risk factors
Promoting factors
• Smoking (associated with chronic cough and raised intraabdominal pressure)
• Obesity
• UTI
• Increased fluid intake
• Medications
• Poor nutrition
• Aging
• Cognitive deficits
• Poor mobility
Pathophysiology
Bladder abnormalities
Detrusor overactivity is a urodynamic observation
characterized by involuntary bladder muscle
(detrusor) contractions during the filling phase of
the bladder, which may be spontaneous or
provoked, and can consequently
cause urinary incontinence. The underlying cause
may be neurogenic, where there is a relevant
neurological condition, or idiopathic, where
there is no defined cause
Pathophysiology
Low bladder compliance
is characterized by a decreased volume-topressure relationship during a cystometrogram and
is often associated with upper tract damage. High
bladder pressures occur during filling because of
alterations in the viscoelastic properties of the
bladder wall, or changes in bladder muscle tone
(secondary to myelodysplasia, spinal cord injury,
radical hysterectomy, interstitial or radiation
cystitis).
Pathophysiology
Sphincter abnormalities
Urethral hypermobility is due to a weakness of pelvic floor
support causing a rotational descent of the bladder neck
and proximal urethra during increases in intra-abdominal
pressure. If the urethra opens concomitantly, there will be
urinary leaking.
Intrinsic sphincter deficiency (ISD) describes an intrinsic
malfunction of the sphincter, regardless of its anatomical
position, which is responsible for type III SUI. Causes
include inadequate urethral compression (previous urethral
surgery; aging; menopause; radical pelvic surgery) or
deficient urethral support (pelvic floor weakness; childbirth;
pelvic surgery ; menopause).
Evaluation
History
Inquire about LUTS (storage or voiding
symptoms), triggers for incontinence (cough,
sneezing, exercise, position, urgency), and
frequency and severity of symptoms. Establish risk
factors (abdominal/pelvic surgery; neurological
diseases; obstetric and gynecological history;
medications).
A validated patient-completed questionnaire may
be helpful
Evaluation
Physical examination
Women
Perform a pelvic examination in the supine and standing position with a
speculum while the patient has a full bladder. Ask the patient to cough or strain,
and inspect for vaginal wall prolapse (cystocele, rectocele, enterocele),uterine
or perineal descent, and urinary leakage (stress test). Eighty percent of SUI
patients will leak with a brief squirt during cough in the supine position, while
another 20% will leak only in an inclined or standing position.
Urethral hypermobility is assessed with the Q-tip test. A lubricated cottontipped applicator is introduced through the urethra to bladder neck level.
Hypermobility is defined as a resting or straining angle of >30* from
horizontal.
The Bonney test is used to assess continence with manual repositioning of
the urethra and vesicle neck. Using one or two fingers to elevate the
anterior vaginal wall laterally without compressing the urethra, relief of
incontinence during cough suggests that surgical correction will be
successful.
Evaluation
Both sexes
Examine the abdomen for a palpable bladder
(indicating urinary retention).
A neurological examination should include
assessment of anal tone and reflex, perineal
sensation, and lower limb function.
Inspect the underwear for the status of urinary
collection pads; for men, a standing or squatting
“cough test” gives a good indicator of the presence
and severity of stress incontinence.
Investigation
Bladder diaries
Record the frequency and volume of urine voided,
incontinent episodes, pad usage, fluid intake, and degree
of urgency. Alternatively, pads can be weighed to estimate
urine loss (pad testing).
Urinalysis can exclude UTIs.
Blood tests, X-ray imaging, cystoscopy
These are indicated for persistent or severe symptoms,
bladder pain, and voiding difficulties. Cystoscopy is useful
for evaluating men who have had prostatectomy—it will
show the presence of clips, stones, and strictures that may
develop after surgery that might need to be addressed
concomitantly with anti-incontinence surgery
Investigation
Urodynamic investigations
Valsalva leak point pressure (VLPP) measures the abdominal pressure
at which a half-full bladder leaks during straining—normal individuals
should not leak. VLPP readings <60 cm H2O suggest ISD; VLPP
readings >100 cm H2O suggest hypermobility, while readings of 60–
100 cm are indeterminant.
Detrusor leak point pressure (DLPP) measures the bladder pressure
at which leakage occurs without valsalva—DLPP >40 cm H2O puts the
upper tract at risk.
Videourodynamics can visualize movement of the proximal urethra and
bladder neck, and establish the precise anatomical etiology of UI.
Investigation
urodynamics
Uroflowmetry testing measures the ability of the bladder to
empty; a minimum bladder volume of 150 cc is desired. A
low flow rate indicates bladder outflow obstruction or
reduced bladder contractility. The volume of urine
remaining in the bladder after voiding (post-void residual) is
also important(<50 mL is normal; >200 mL is abnormal;
50–200 mL requires clinical correlation).
Investigation
Sphincter electromyography (EMG)
EMG measures electrical activity from
striated muscles of the urethra or perineal
floor
and
provides
information
on
synchronization between bladder muscle
(detrusor) and external sphincter.
Treatment
Treatment for urinary incontinence depends on the type of
incontinence, its severity and the underlying cause. A
combination of treatments may be needed.
Behavioral techniques
Bladder training, to delay urination after you get the urge to
go. You may start by trying to hold off for 10 minutes every
time you feel an urge to urinate. The goal is to lengthen the
time between trips to the toilet until you're urinating only
every two to four hours.
Double voiding, to help you learn to empty your bladder
more completely to avoid overflow incontinence. Double
voiding means urinating, then waiting a few minutes and
trying again.
Treatment
Time voiding, to urinate every two to four hours rather than
waiting for the need to go.
Fluid and diet management, to regain control of your
bladder. You may need to cut back on or avoid alcohol,
caffeine or acidic foods. Reducing liquid consumption,
losing weight or increasing physical activity also can ease
the problem.
Pelvic floor muscle exercises
It is recommend that you do these exercises frequently to
strengthen the muscles that help control urination. Also
known as Kegel exercises, these techniques are especially
effective for stress incontinence but may also help urge
incontinence.
Treatment
Medications
Anticholinergics. These medications can calm an
overactive bladder and may be helpful for urge
incontinence.
Mirabegron . Used to treat urge incontinence, this
medication relaxes the bladder muscle and can increase
the amount of urine your bladder can hold. It may also
increase the amount you are able to urinate at one time,
helping to empty your bladder more completely.
Alpha blockers. In men with urge or overflow incontinence
due to BPE , these medications relax bladder neck muscles
and muscle fibers in the prostate
Topical estrogen.
Treatment
Interventional therapies
•Bulking material injections. A synthetic material is injected into tissue
surrounding the urethra.
•Botulinum toxin type A (Botox). Injections of Botox into the bladder
muscle may benefit people who have an overactive bladder. Botox is
generally prescribed to people only if other first line medications haven't
been successful.
•Nerve stimulators. A device resembling a pacemaker is implanted
under your skin to deliver painless electrical pulses to the nerves
involved in bladder control (sacral nerves). Stimulating the sacral
nerves can control urge incontinence if other therapies haven't worked.
The device may be implanted under the skin in your buttock and
connected directly to the sacral nerves or may deliver pulses to the
sacral nerve via a nerve in the ankle.
Treatment
Treatment of sphincter weakness
incontinence: injection therapy
The injection of bulking materials into the bladder
neck and periurethral muscles is used to increase
outlet resistance.
Indications
These include stress incontinence secondary to
demonstrable intrinsic sphincter deficiency (ISD),
with normal bladder muscle function. Injection
therapy is used in adults and children.
Treatment
Treatment of sphincter weakness
incontinence: retropubic suspension
Retropubic suspension procedures are used to
treat female stress incontinence caused by
urethral hypermobility. The aim of surgery is to
elevate and fix the bladder neck and proximal
urethra in a retropubic position, to support the
bladder neck, and to regain continence. It is
contraindicated in the presence of significant
intrinsic sphincter deficiency (ISD).
Treatment
Marshall–Marchetti–Krantz (MMK) procedure
Sutures are placed either side of the urethra around the level of the bladder
neck and then tied to the hyaline cartilage of the pubic symphysis.
Burch colposuspension
This requires good vaginal mobility, to allow the vaginal wall to be
elevated and attached to the lateral pelvic wall where the formation of
adhesions over time secures its position. The paravaginal fascia is exposed
and approximated to the iliopectineal (Cooper) ligament of the superior
pubic rami.
Vagino-obturator shelf/paravaginal repair
Sutures are placed by the vaginal wall and paravaginal fascia and then
passed through the obturator fascia to attach to part of the parietal pelvic
fascia below the tendinous arch (arcus tendoneus fascia). Cure rates are
up to 85%.
Treatment
Treatment of sphincter weakness incontinence: pubovaginal
slings
Indications
Sling procedures were developed mainly for female stress incontinence
associated with poor urethral function (type III or ISD) or when previous
surgical procedures have failed. The success of sling procedures,
however, has resulted in expanded applications in women with
hypermobility.
Types of sling
• Autologous—rectus fascia, fascia lata (from the thigh), vaginal wall
slings
• Nonautologous—allograft fascia lata from donated cadaveric tissue
• Synthetic—monofilament “macropore” polypropylene mesh (via
transobturator, transabdominal, or transvaginal needles)
Treatment of sphincter weakness
incontinence
the artificial urinary sphincter
Indications include incontinence secondary to
urethral sphincter deficiency in patients with
normal bladder capacity and compliance. In men, it
is used almost always for sphincter damage due to
prostatectomy (radical prostatectomy for prostate
cancer or TURP). In women it can be used for
neuropathic sphincter weakness (e.g., spinal cord
injury, spina bifida) if the incontinence is not due to
bladder overactivity.
causes of transient incontinence
1)
2)
3)
4)
5)
6)
7)
Drug side effects
Delirium or hypoxia
Impaired mobility
Urinary tract infection
Atrophic vaginitis
psychological problems
Excessive fluid intake
REFERENCES
1-Oxford Handbook of Urology •
2-Smith’s General Urology •
3-CAMPBELL-WALSH Urology •
THE END
THANK YOU
QUIZZZZZ
TRUE OR FALSE
(Genuine stress incontinence)?
A. The bladder neck and proximal urethra is poorly
supported by musculofascial ligamentous
structures
B. which is responsible for type III SUI.
C. Pubovaginal sling procedure is the method of
choice for correction of this condition
D. A large proportion will resolve on its own
E. It is relatively uncommon
TRUE OR FALSE
•
Promoting factors for incontinence
a)Obesity
b) UTI
c)Increased fluid intake
d) Childbirth
e) Anomalies in collagen subtype