Urinary Incontinence

Urinary incontinence (UI), also known as involuntary urination, is characterised by uncontrolled leakage of urine. It is a prevalent issue, particularly in older adults, and can significantly impact quality of life. Various factors such as pelvic surgery, pregnancy, childbirth, and menopause are associated with increased risk. UI is often under-reported due to stigma and embarrassment.

Anatomy of the lower urinary tract and genital system. The top diagram shows the female urinary system, and the bottom shows the male urinary system.

Signs & Symptoms

UI manifests in different forms based on underlying causes:

• Urge Incontinence: Characterised by a sudden, intense urge to urinate followed by leakage.
• Stress Incontinence: Occurs when physical activities increase abdominal pressure, such as coughing or sneezing, leading to leakage.
• Overflow Incontinence: Involves unexpected leakage due to an overfull bladder.
• Mixed Incontinence: Combines symptoms of more than one type of incontinence.

Causes

Women

In women, stress and urge incontinence are the most common. Stress incontinence is often due to weakened pelvic support structures from pregnancy, childbirth, obesity, and age. Urge incontinence, more common in older women, is due to overactive bladder syndrome.

Pelvic floor muscles in women

Men

In men, urge incontinence is frequently linked to benign prostatic hyperplasia (BPH), while stress incontinence often results from prostate surgery.

The prostate with the urethra passing through it (prostatic urethra)

Both

Both sexes can experience UI due to factors such as age, polyuria, neurogenic disorders, overactive bladder syndrome, smoking, caffeine intake, and depression.

Mechanism

Continence depends on a balance between detrusor muscle activity and urethral closure. Urination involves detrusor muscle contraction and sphincter muscle relaxation. Any disruption to this balance can result in UI. Stress incontinence results from urethral sphincter incompetence, whereas urge incontinence is due to sudden detrusor muscle contractions.

Diagnosis

Diagnosis involves a thorough history and physical examination, focusing on the pattern of voiding, urine leakage, and possible contributory conditions. Diagnostic tests include stress tests, urinalysis, blood tests, ultrasound, cystoscopy, and urodynamics. Patients may be asked to keep a voiding diary to document their symptoms.

Ultrasound of the urinary bladder of an 85-year-old man. It shows a trabeculated wall, which is a sign of urinary retention.

Treatment

Behavioural Therapy and Physical Therapy

Behavioural therapies, such as bladder training, biofeedback, and pelvic floor muscle exercises, are effective for women with UI and have a low risk of adverse effects. Avoiding irritants like caffeine and alcohol, weight loss, and smoking cessation can also help.

Devices

Different types of pessaries. These are inserted inside the vagina for support.

Various devices can help manage UI:

• Collecting Systems: Urisheaths and urine bags for men.
• Absorbent Products: Pads, undergarments, and briefs.
• Intermittent Catheters: Single-use catheters to empty the bladder.
• Indwelling Catheters: Used in severe cases, but risk urinary tract infections.
• Penis Clamp: Used for light or moderate incontinence in men.
• Vaginal Pessaries: Provide support to the urethra in women.

Medications

Medications like fesoterodine, tolterodine, and oxybutynin can relax bladder muscles and are effective for urge incontinence. However, they are not recommended for stress incontinence and have potential side effects.

Surgery

Surgical options are considered for persistent cases. Techniques include slings, tension-free vaginal tape, bladder suspension, and artificial urinary sphincters. The artificial urinary sphincter is particularly effective for men post-prostatectomy.

AMS 800 and ZSI 375 artificial urinary sphincters

Epidemiology

UI affects 30-40% of people over 65, with higher prevalence in women. It is linked to obesity, diabetes, depression, and reduced activity levels. Incontinence is a significant factor in admissions to nursing facilities.

In children, incontinence decreases with age, being most common in those under five years old.

Self-assessment MCQs (single best answer)

Sure, here is the formatted output based on your provided questions:

Which type of urinary incontinence is characterised by a sudden, intense urge to urinate followed by leakage?

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In women, which condition is often due to weakened pelvic support structures from pregnancy, childbirth, obesity, and age?

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Which factor is NOT commonly associated with urinary incontinence in both sexes?

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What diagnostic test involves visual inspection of the bladder and urethra using a scope?

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Which behavioural therapy is commonly used for managing urinary incontinence and involves training the bladder to hold urine for longer periods?

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Which device is used to provide support to the urethra in women with stress incontinence?

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Which medication is commonly used to manage urge incontinence by relaxing bladder muscles?

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What is the most common cause of stress incontinence in men?

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Which of the following is NOT a common symptom of urinary incontinence?

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What surgical option is particularly effective for men post-prostatectomy to treat urinary incontinence?

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