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Urinary Incontinence: Causes, Symptoms, and Treatment Options

Urinary incontinence is the involuntary loss of urine, leading to social and health problems. Learn about its prevalence, anatomy, reversible causes, medications, types, and treatment options in detail.

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Urinary Incontinence: Causes, Symptoms, and Treatment Options

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  1. Urinary Incontinence Dr. Eyad Z. AL-Aqqad Special Urologist

  2. 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

  3. 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

  4. Urinary Incontinence is OftenUnder-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

  5. 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

  6. Anatomy of Micturition • 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

  7. Peripheral Nerves in Micturition • 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

  8. Peripheral Nerves in Micturition

  9. 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 1

  10. Potentially Reversible Causes D - Delirium I - Infection A - Atrophic vaginitis or urethritis P - Pharmaceuticals P - Psychological disorders E - Endocrine disorders R - Restricted mobility S - Stool impaction 2

  11. Medications That May Cause Incontinence • Diuretics • Anticholinergics - antihistamines, antipsychotics, antidepressants • Seditives/hypnotics • Alcohol • Narcotics • α-adrenergic agonists/antagnists • Calcium channel blockers

  12. Categories of Incontinence • Urge incontinence • Stress incontinence • Overflow incontinence • Functional incontinence

  13. Urge Incontinence Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder • 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

  14. 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)

  15. 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

  16. Functional Incontinence • Does not involve lower urinary tract • Result of psychological, cognitive or physical impairment

  17. Physical Examination • Mental status • Mobility • Fluid overload • Abdominal exam • Neurologic exam • Pelvic • Rectal

  18. Diagnostic Tests • Stress test (diagnostic for stress incontinence; specificity >90%) • Post-void residual • Blood Tests (calcium, glucose, BUN, Cr) • Urine Culture • Simple (bedside) Cystometrics

  19. Bladder Pressure-Volume Relationship

  20. Interpretation of Post-Void Residual PVR < 50cc - Adequate bladder emptying PVR > 150cc - Avoid bladder relaxing drugs PVR > 200cc - Refer to Urology PVR > 400cc - Overflow UI likely

  21. Treatment Options • 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) 1

  22. Treatment Options • Bladder training • Patient education • Scheduled voiding • Positive reinforcement • Pelvic floor exercises (Kegel Exercises) • Biofeedback • Caregiver interventions • Scheduled toileting • Habit training • Prompted voiding 2

  23. Pharmacological Interventions • Urge Incontinence • Oxybutynin (Ditropan) • Propantheline (Pro-Banthine) • Imipramine (Tofranil) • Stress Incontinence • Phenylpropanolamine (Ornade) • Pseudo-Ephedrine (Sudafed) • Estrogen (orally, transdermally or transvaginally)

  24. 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

  25. Other Interventions • Pessaries • Periurethral bulking agents (periurethral injection of collagen, fat or silicone) • Diapers or pads • Chronic catheterization • Periurethral or suprapubic • Indwelling or intermittant

  26. Pessaries

  27. Indwelling Catheter

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