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Urinary Incontinence
Dr. Eyad Z. AL-Aqqad
Special Urologist
Definition
INCONTINENCE:
Involuntary loss of urine or stool in sufficent amount or
frequency to constitute a social and/or health problem.
A heterogeneous condition that ranges in severity from
dribbling small amounts of urine to continuous urinary
incontinence with concomatant fecal incontinence
How Common is Incontinence?
• Prevalence increases with age (but it is not a part of
normal aging)
• 25-30% of community dwelling older women
• 10-15% of community dwelling older men
• 50% of nursing home residents; often associated with
dementia, fecal incontinence, inability to walk and
transfer independently
Urinary Incontinence is Often
Under-Diagnoses and Under-Treated
• Only 32% of primary care physicians routinely ask
about incontinence
• 50-75% of patients never describe symptoms to
physicians
• 80% of urinary incontinence can be cured or
improved
Why is Incontinence Important?
• Social stigmata - leads to restricted activities and
depression
• Medical complications - skin breakdown,
increased urinary tract infections
• Institutionalization - UI is the second leading
cause of nursing home placement
Anatomy of Micturition
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Detrusor muscle
External and Internal sphincter
Normal capacity 300-600cc
First urge to void 150-300cc
CNS control
– Pons - facilitates
– Cerebral cortex - inhibits
• Harmonal effects - estrogen
Peripheral Nerves in Micturition
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Parasympathetic (cholinergic) - Bladder contraction
Sympathetic - Bladder Relaxation
Sympathetic - Bladder Relaxation (β adrenergic)
Sympathetic - Bladder neck and urethral contraction (α
adrenergic)
• Somatic (Pudendal nerve) - contraction pelvic floor
musculature
Peripheral Nerves in Micturition
Taking the History
• Duration, severity, symptoms, previous treatment,
medications, GU surgery
• 3 P’s
– Position of leakage (supine, sitting, standing)
– Protection (pads per day, wetness of pads)
– Problem (quality of life)
• Bladder record or diary
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Potentially Reversible Causes
D
I
A
P
P
E
R
S
- Delirium
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
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Medications That May Cause Incontinence
• Diuretics
• Anticholinergics - antihistamines, antipsychotics,
antidepressants
• Seditives/hypnotics
• Alcohol
• Narcotics
• α-adrenergic agonists/antagnists
• Calcium channel blockers
Categories of Incontinence
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Urge incontinence
Stress incontinence
Overflow incontinence
Functional incontinence
Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder
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Most common cause of UI >75 years of age
Abrupt desire to void cannot be suppressed
Usually idiopathic
Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Parkinson’s Disease,
dementia
Stress Incontinence
• Most common type in women < 75 years old
• Occurs with increase in abdomenal pressure;
cough, sneeze, etc.
• Hypermotility of bladder neck and urethra; associated
with aging, hormonal changes, trauma of childbirth or pelvic
surgery (85% of cases)
• Intrinsic sphinctor problems; due to pelvic/incontinence
surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)
Overflow Incontinence
• Over distention of bladder
• Bladder outlet obstruction; stricture, BPH, cystocele,
fecal impaction
• Non-contractile baldder (hypoactive detrusor
or atonic bladder); diabetes, MS, spinal injury,
medications
Functional Incontinence
• Does not involve lower urinary tract
• Result of psychological, cognitive or physical
impairment
Physical Examination
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Mental status
Mobility
Fluid overload
Abdominal exam
Neurologic exam
Pelvic
Rectal
Diagnostic Tests
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Stress test (diagnostic for stress incontinence; specificity >90%)
Post-void residual
Blood Tests (calcium, glucose, BUN, Cr)
Urine Culture
Simple (bedside) Cystometrics
Bladder Pressure-Volume Relationship
Interpretation of Post-Void Residual
PVR < 50cc
PVR > 150cc
PVR > 200cc
PVR > 400cc
- Adequate bladder emptying
- Avoid bladder relaxing drugs
- Refer to Urology
- Overflow UI likely
Treatment Options
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Reduce amount and timing of fluid intake
Avoid bladder stimulants (caffeine)
Use diuretics judiciously (not before bed)
Reduce physical barriers to toilet (use bedside
commode)
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Treatment Options
• Bladder training
– Patient education
– Scheduled voiding
– Positive reinforcement
• Pelvic floor exercises (Kegel Exercises)
• Biofeedback
• Caregiver interventions
– Scheduled toileting
– Habit training
– Prompted voiding
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Pharmacological Interventions
• Urge Incontinence
– Oxybutynin (Ditropan)
– Propantheline (Pro-Banthine)
– Imipramine (Tofranil)
• Stress Incontinence
– Phenylpropanolamine (Ornade)
– Pseudo-Ephedrine (Sudafed)
– Estrogen (orally, transdermally or transvaginally)
Surgical Interventions
Surgery is reported to “cure” 4 out of 5 cases, but
success rate drops to 50% after 10 years.
• Urethral Hypermotility
– Marshall-Marchetti-Kantz
procedure
– Needle neck suspension
• Intrinsic sphincter deficiency
– Sling procedure
Other Interventions
• Pessaries
• Periurethral bulking agents (periurethral injection
of collagen, fat or silicone)
• Diapers or pads
• Chronic catheterization
– Periurethral or suprapubic
– Indwelling or intermittant
Pessaries
Indwelling Catheter