Ministry of Higher Education and Scientific Research
University of Kufa
College of Medicine
Department of Urology and Fertility
Urinary Incontinence
Definitions:
Urinary incontinence is a symptom: “the complaint of any involuntary
leakage of urine” as well as a sign: “urine leakage seen during
examination.
In order to serve as a diagnosis; incontinence must be conceptualized
with regard to its underlying pathophysiology.
Classification of incontinence:
Stress urinary incontinence; is the complaint of involuntary leakage on
effort or exertion, sneezing, or coughing.
Urge urinary incontinence; is the complaint of involuntary leakage
accompanied by or immediately preceded by urgency.
Mixed urinary incontinence; is the complaint of involuntary leakage
exertion, effort, sneezing, or .associated with urgency and also with
coughing.
Unconscious (unaware) incontinence; is the complaint of involuntary
loss of urine that is unaccompanied by either urge or stress.
Continuous urinary incontinence; is the complaint of a continuous
leakage.
Nocturnal enuresis; is the complaint of loss of urine occurring during
sleep.
Postmicturition dribble; is the complaint of an involuntary loss of urine
immediately after passing urine.
Overflow incontinence; is not a symptom or condition but rather a term
used to describe leakage of urine associated with urinary retention.
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Dr. Muthanna H. Al- Athari
Senior Lecturer
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Department of Urology and Fertility, College of Medicine, University of Kufa
Email: muth004@yahoo.com
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Extraurethral incontinence; is the observation of urine leakage through
channels other than the urethra (e.g., fistula or ectopic ureter).
EPIDEMOLOGY OF URINARY INCONTINENCE:
Urinary Incontinence in Women;
Bet. 15-30% of women over age 65 yrs have urinary incontinence, &
stress incontinence is the most common type.
Over all age groups, stress incontinence is most common (49%) followed
by mixed incontinence (29%) and pure urge incontinence (21%).
Incontinence during pregnancy has a prevalence of 31% to 60%, but it
resolves in most cases.
Urinary Incontinence in Men:
Half as prevalent, as it is in women.
Stress incontinence in men is rare unless attributable to prostate surgery,
neurologic injury, or trauma.
Risk factors:
For urinary incontinence include:
**female gender, Caucasian race,
**neurologic disease,
**tobacco or alcohol abuse,
**excessive fluid intake,
**pelvic trauma, surgery or radiation,
**parity,
**nutritional deficit, obesity,
**cognitive difficulty
**advanced age, and
Differential diagnosis:
Incontinence may involve fluids other than urine, and egress other than
the urethra;
A. Non-urinary wetness; refers to loss of bodily fluids that
may easily be confused with urine.
Sources of non-urinary wetness include:
-Gastrointestinal tract; -Vagina;
-Infection; -Perspiration;
-Subjective wetness; a complaint of wetness when no wetness is
demonstrated.
B. Non- urethral urinary incontinence:
Involves the leakage of urine via a route other than the urethra:
1- Fistula;
2- Ureteral ectopia;
3- Vaginal reflux of urine;
4- Urinary diversion;
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Etiology and Pathophysiology of Urinary Incontinence:
Urinary incontinence is caused by either an abnormality of the bladder, an
abnormality of the bladder outlet (sphincter), or a combination of both.
Extraurethral incontinence is caused by either urinary fistula or ectopic
ureter.
Causes of Urinary Incontinence:
Bladder dysfunction
Sphincter dysfunction
-Detrusor overactivity
-Intrinsic sphincteric deficiency
-Impaired compliance
-Urethral support defect (hypermobility)
DIAGNOSTIC EVALUATION:
Causes of transient incontinence should be ruled out:
- Drug side effects
- Excessive fluid intake
- Psychological problem
- Urinary tract infection
- Impaired mobility
- Glycosuria
- Delirium or hypoxia
- Atrophic vaginitis
- Recent prostatectomy
- Fecal impaction
EVALUATION: includes:
History; Physical examination; Urinalysis;
Measurement of postvoid residue (PVR).
Micturition Diary;
History:
** Assessing the characteristics and severity of incontinence.
** Impact on quality of life.
** Identifying risk factors and/or transient causes of incontinence.
Physical Examination:
Should focus on detecting anatomic and neurologic abnormalities that
contribute to urinary incontinence, including:
-BCR.
-Cough test.
-The Q-Tip test.
-Vaginal examination.
Urinalysis:
Urinalysis can identify:
acute urinary tract infection, and
diabetes-induced glycosuria.
These conditions are reversible with treatment.
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Residual Urine Measurement (PVR):
It is usually measured by catheterization or ultrasonography. A postvoid
residual (PVR) of less than 50 ml is considered normal (in Stress
Incontinence), and a postvoid residual (PVR) of more than 200 ml is
considered abnormal. Values between 50 and 200 ml require clinical
correlation in interpreting the results.
Micturition Diary:
Micturition diaries and pad tests make it possible to document voiding
patterns in the patient's own environment and during various daily
activities. Micturition diaries vary in duration from 24 hours to 14 days.
The Urodynamics Society recommended the following measurements to
be included in a micturition diary: time of micturition, time and type of
incontinence, and voided volume.
Pad Test:
A semiobjective measurement of urine loss over a given period of time.
There are short-term (1-hour) and long-term (24- to 72-hour) pad tests.
The ICS recommends using one-hour test, during which a series of
standard activities are carried out.
According to the 3rd International Consultation on Incontinence, a pad
weight gain of > 1.3 gm over 24 hours considered ''positive''.
Others have stated that a weight gain of up to 8 g over a 24-hour pad test
is considered normal.
Urodynamic Evaluation:
Imaging studies:
1. The voiding cystourethrogram (VCUG):
2. Magnetic resonance imaging (MRI):
Sphincter Electromyography:
Electromyography is the measurement and display of electrical activity
recruited from the striated muscles of the urethral or anal sphincter or the
perineal floor muscles.
Cystourethroscopy:
Is needed in patients with persistent symptoms of urgency and frequency,
recurrent urinary tract infections, hematuria, or voiding difficulties & to
evaluate voiding dysfunction after anti-incontinence surgery.
Treatment:
A. Non- surgical:
1. Behavioral modification
3. Biofeedback
2. Pelvic floor therapy.
4. Urethral inserts
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5. Pessary
7. Indwelling catheters
9. McGuire urinal
6. Cunningham clamp
8. Condom catheter
10. Absorbent aids:
Pads
Diapers
Absorbent underpants
B. Pharmacologic agents:
In Stress incontinence:
**Adrenergic agonists;
(Phenylpropanolamine, Ephedrine, Pseudoephedrine,
Midodrine, Imipramine and Duloxetin)
**Estrogens:
Oral estrogen
Vaginal estrogen; ( cream, ring, and tablet)
In Detrusor overactivity:
** Antimuscarinic agents:
Oxybutynin chloride (Ditropan)
L-Hyoscyamine
Darifenacin,
Solifenacin,
Propantheline
Tolterodine tartrate (Detrol)
Imipramine
Propiverine,
Trospium,
Behavioral Modification:
Behavioral changes involve:
Decreasing fluids drink,
Regular bowel habits,
Change their activity level.
Urinating more frequently,
Weight loss,
Pelvic Floor Exercises:
Kegel exercises; involves tightening the muscles of the pelvic floor as if
trying to stop urine stream.
Vaginal cone, along with pelvic exercises. The device may be worn for
up to 15 minutes. This procedure should be done two times.
Biofeedback:
Is method that helps a person learn how to control certain involuntary
body responses.
It helps a patient to identify the correct muscle group to work.
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Electrical Stimulation Therapy:
Uses low-voltage electrical current to stimulate and contract the correct
group of muscles.
The current is delivered using:
$$ Anal or vaginal probe
$$ Specially designed electromagnetic chair
Surgical treatment of Stress Incontinence:
Suspensions;
Retropubic, or Transvaginal
Slings,
Periurethral injections,
Sphincter prostheses.
In general, surgical treatment of stress incontinence is far more successful
than nonsurgical treatment.
Surgical treatment of urge incontinence:
1. Augmentation cystoplasty
-Enterocystoplasty Augmentation,
-Autoaugmentation
2. Neuromodulation:
Involves placement of a surgical electrode permanently stimulating S3
afferent or motor nerves.
Types of Surgery in SUI:
If hypermobility exists (anatomic or genuine SUI), treatment is:
Suspention of the bladder neck & proximal urethra, which is either:
-Retropubic Suspensions, or
-Transvaginal suspensions.
If intrinsic sphincteric deficiency (ISD) exists, suspension alone is not
adequate & treatment is:
Pubovaginal sling,
Periurethral injections, or
Sphincter prostheses.
Retropubic Suspension:
Cure (dry) rate beyond 4 years is 84% &include:
The classic Marshall-Marchetti-Krantz (MMK) retropubic suspension;
described in 1949, in which periurethral tissue is attached to the back of
the pubic symphysis.
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Burch colposuspension; in which the anterior vaginal wall is fixed to
Cooper's ligament. It provides the most lasting results.
Transvaginal suspensions:
Cure (dry) rate beyond 4 years is (67%) & include:
Kelly procedure
Pereyra procedure
Pubovaginal sling:
Cure (dry) rate beyond 4 years is 83%. Can be used for virtually any kind
of stress incontinence.
Techniques used include:
--Techniques Using Autologous Tissues:
--Techniques Using Non- autologous Tissues:
--Techniques Using Synthetic Materials:
Such as Monofilament Polypropylene Tape (tension-free vaginal
tape (TVT) procedure).
Periurethral injections:
The main indications for injection therapy include:
$$ high-risk patients for major surgery,
$$ previous surgical failures, or
$$ patient preference.
Injected bulking agents include collagen, autologous fat, silicone
microimplants, polydimethylsiloxane, and Teflon.
Sphincter prostheses:
The most common indication for implantation of an AUS (Artificial
Urinary Sphincter) is incontinence after prostatectomy.
Female patients with neurogenic deficits whose condition responds
poorly to conventional surgery may be better suited for placement of an
AUS.
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