Urinary incontinence

• What is urinary incontinence?
• Statistics
• Risk factors
• Progression
• Symptoms
• Clinical examination
• How is it diagnosed?
• Prognosis
• Treatment
• References

What is urinary incontinence?

Urinary incontinence is the involuntary leakage of urine.
There are many causes of urinary incontinence and incontinence is usually due to multiple factors. Urinary incontinence, if uncontrolled and poorly treated, has significant physical, functional and psychological consequences in affected individuals. Urinary incontinence occurs in all walks of life; the young, the old, males and females. Due to its universal distribution within the population it is a highly important problem.

Statistics of urinary incontinence

Incontinence is relatively common and disabling condition for Australian patients, particularly in the elderly where it can affect around 27% of the population over 60 years and up to half of nursing home residents. The exact incidence in Australia is not known due to the lack of quantitative studies, however extrapolation of overseas studies suggests that over one million Australians suffer from urinary incontinence, costing Australians more than one billion dollars each year for continence pads.

Women

• Studies state that 25-45% of women would have suffered from incontinence at least once in the past year.
• The incidence of incontinence increases with age: 20 – 30% in young adults, 30 – 40% in the middle aged, and as high as 50% in the elderly.
• 1 in 3 women who have had a baby experience some loss of bladder control.

Men

• 17% of men over the age of 60 have incontinence.
• 42% of that 17% have incontinence on a daily basis.
• Men experience one third the rate of incontinence compared to females.

Children

• Staying dry overnight occurs at a median age of 34.1 months in girls and 35.8 months in boys.
• Around 3% of the population aged 7-12 years experience regular urinary incontinence that disrupts their lives.

Risk factors of urinary incontinence

Normal continence depends on several factors:

• Intact micturition pathway- The nerves and muscles controlling the bladder and sphincters need to be working.
• Intact functional ability to toilet oneself which requires.
• Readily available toilet facilities.
• Mobility and dexterity to carry out the act.
• Cognitive ability to recognise and react to sensations of a full bladder.

Therefore, numerous factors and medical conditions can increase the rates of urinary incontinence in the population. For example, obesity can be associated with incontinence so losing weight may be part of the overall treatment strategy to promote continence. Listed below are various factors which may be associated with urinary incontinence:

Women

• Childbearing related: Lots of children, vaginal deliveries and episiotomies (tears in the perineum) are associated with increased rates of urinary incontinence.
• Obesity.
• Other urinary symptoms.
• Urogenital atrophy- Low estrogen levels after menopause causes atrophy (destruction) of the superficial and middle layers of the urethral mucosa making older women more prone to stress (small leaks during exercise, coughing etc) and urge incontinence (associated with sudden urges to urinate and possibly flooding).
• Heart failure.
• Chronic obstructive pulmonary disease– Chronic cough can lead to leakage of urine.
• Diabetes– Polyuria (high urine flow) is an associated feature of this disorder.
• Stroke/TIA
• Constipation- The full bowel creates pressure on the bladder causing irritation.
• Certain medications

Men

• Lower urinary symptoms.
• Functional and cognitive impairment.
• Neurological- Conditions where the nerves controlling the bladder are affected can cause incontinence.
• Medical conditions such as diabetes, obesity, constipation and chronic cough.
• Prostatectomy. Benign Prostatic Hyperplasia in older men is associated with numerous urinary symptoms which may include incontinence.

Children

• UTI.
• Psychological stress.
• Night time voiding- Due to failure of the child to wake when the bladder is full. This may be associated with low bladder capacity and a reduced arousal response to a full bladder.
• Diabetes Mellitus.
• Diabetes insipidus.
• Dysfunctional voiding.
• Other rarer causes are acquired neurogenic bladder, seizure disorder, heart block, hyperthyroidism.

Elderly

The increase in incontinence rates in older individuals can be attributed to several age related changes that take place in the body. These include:

• Increased involuntary (uninhibited) detrusor contractions i.e. uncontrolled contraction of the bladder muscle.
• Reduced ability to postpone a void in conjunction with reduced bladder capacity.
• Reduced urinary flow rate in both elderly males and females.
• Increase in the residual volume (urine left in the bladder after emptying).

Progression of urinary incontinence

Leakage of urine can present with a variety of symptoms, each of with may point to a specific cause of the incontinence.

Urge incontinence

Urgency is the development of an overpowering need to pass urine. Urgency can be associated with a leakage of urine ranging from a few drops to a complete soaking. The feeling of urgency can be precipitated by various factors, some of which include:

• Running water
• Washing of hands;
• Being in the cold etc.

The time which a person can hold on to their urine for is a good indicator of the severity of the incontinence, and provides a rough idea of the person’s ability to urinate. Urgency is often accompanied by increased urinary frequency and nocturia (urination during the night).
The underlying cause of urge incontinence in older individuals is usually a result of overactivity of the bladder muscle with uninhibited bladder contractions. However this is commonly found in healthy elderly individuals.
Younger females can have a form of urinary incontinence associated with interstitial cystitis (inflammation of the bladder). The main features of this form of incontinence are that there is an urge usually with small amounts of urine as well as associated dysuria.

Stress incontinence

This occurs when there is an episode of incontinence with exertion, coughing or sneezing. The underlying mechanism behind this form of incontinence is mainly due to increased pressures in the abdomen.

Women

This is the most common cause of incontinence in younger women, and is the second most common in elderly females. In women, this form of incontinence most commonly occurs due to weakness of the pelvic floor muscles, for example following vaginal childbirth. Less commonly this form of incontinence occurs in women post-menopausally.

Men

In males stress incontinence usually occurs in the older age groups, especially following surgery to the regions surrounding the urethra. This results in intrinsic sphincter deficiency where there is complete failure of closure of the urethral sphincter (a tight ring around the opening of the bladder).

Mixed incontinence

This is a combination of both stress and urge incontinence. However the cause of this problem is still under investigation.

Overflow incontinence

This usually occurs due to obstruction to the flow of urine or reduced bladder emptying. The features of overflow incontinence are that there is an elevation of the post void urinary volume, with a poor urinary stream, hesitancy in initiating the stream, dribbling, intermittency as well as nocturia. There may be associated stress leakage.

Women

Incontinence of this type is relatively uncommon in females. However it may occur in women who have had previous surgery for incontinence. It also occurs in women who have lost their control of urination because of spinal or nervous problems.

Men

Overflow incontinence is the second most common form of incontinence found in elderly men. Outflow obstruction can occur due to diseases of the prostate gland as well as conditions that narrow the urethra. Dribbling after urinating is a common symptom in these men.

Detrusor underactivity

This form of incontinence is extremely uncommon in younger individuals and only occurs in 5 – 10% of older people. Causes of this form of incontinence include the following:

• Fibrosis of the detrusor muscle secondary to chronic outflow obstruction (i.e. the bladder muscle becomes scarred due to prolonged damage).
• Peripheral neuropathy (eg. due to diabetes mellitus, vitamin B12 deficiency etc.)
• Damage to the spinal efferent nerves supplying the detrusor muscle.

Reversible incontinence

There are many important factors that play a role in ensuring voluntary control of urination. Cognition, mobility, dexterity, environmental and medical factors all determine whether a person will develop incontinence or not. In these cases the incontinence is more a functional disorder rather than due to an abnormality in the urinary tract.

Symptoms of urinary incontinence

Adult males and females

Your doctor should discuss problems regarding continence openly and non-judgementally with you so that you can feel comfortable about discussing your problem. Many diagnoses are missed and therefore not treated as people can be too embarrasses to voluntarily admit they have a problem with incontinence. Your doctor will ask you a series of questions regarding your incontinence symptoms including:

• When did the problem occur?
• Did it happen suddenly or gradually?
• How frequently does the problem occur?
• When exactly does the problem occur?
• What is the volume of urine that is expelled when the problem occurs? E.g. with stress manoeuvres such as coughing and sneezing.
• Are there any associated symptoms? E.g. urgency, frequency, nocturia (urinating at night), hesitancy, interrupted voiding, incomplete emptying, straining to empty, sense of warning before the problem occurs.
• Are there any precipitants such as medications, beverages, alcohol, physical activity, cough, laughing etc.
• Bowel and sexual function.
• Other medical conditions.
• Previous pregnancies and their details.
• Medications.
• Social history to ascertain the social implications of the incontinence.

Children

There are a limited number of tests that a doctor can perform to investigate bed wetting, therefore the doctor will need to take a thorough history to illicit the cause. This will include the following questions, in addition to the questions used for adults:

• Has the child ever had dry nights before?
• How long was each spell of dry nights?
• Does the child suffer any psychosocial problems?
• Has there been any changes in the child’s living arrangements recently? Including whether there has been a new child in the family or the death of a relative.
• Family history of bed wetting as well as diabetes, kidney disease, neurological disease etc.

Following the history the doctor may ask you to start a bladder diary, recording episodes of incontinence. This can help establish a baseline level of function so that progress with therapy can be monitored.

Clinical examination of urinary incontinence

Adult males and females

A thorough physical examination should be performed on all patients with suspected urinary incontinence. The physical examination should include the following:

• An assessment of the patient’s level of consciousness and functional assessment.
• Evidence of low blood pressure
• Examination of the neck
• Examination of the back
• Cardiovascular examination
• Abdominal examination
• Mobility and functional assessment of the limbs
• Neurological examination
• Examination of the genitalia in both males and females.

Children

A thorough physical examination is needed, with the same examinations performed on children as is in adults.

How is urinary incontinence diagnosed?

There are a series of tests that a doctor will perform in order to try and determine the cause for incontinence. These include:

• Blood tests
• Urine tests
• Urodynamic testing: A series of special tests only used in certain types of incontinence. Important whan considering suitability for surgery.

Prognosis of urinary incontinence

Urinary incontinence is not generally a great threat to life, it is more often an everyday annoyance and because of this can lead to emotional distress. However if incontinence is left untreated, complications can occur including:

• Candida infection (commonly referred to as thrush).
• Skin infections
• Pressure sores
• Urinary tract infection
• Blood poisoning with bacteria
• Falls and fractures
• Sleep deprivation due to urination at night

Psychologically the detrimental effects of incontinence can be reduction in self esteem, and associated depression, social withdrawal and sexual dysfunction.

Treatment of urinary incontinence

There are numerous different modes of treatment for incontinence. Normally lifestyle and behavioural modifications will be trialed first and if there is not enough improvement, medical and then surgical treatment will be used. In most cases you will be referred to a continence advisory nurse who can teach you conservative methods to treat your incontinence. Physiotherapists are also useful to teach pelvic floor exercises to build up the musculature. An overview of treatment options is provided below.

Lifestyle modifications

The lifestyle modifications that can be used to treat this condition include:

• Ensuring adequate but not excessive consumption of fluids
• Avoidance of caffeine and alcohol, as well as cessation of smoking
• If nocturia is a concern, limit consumption of fluid at night
• Treatment of constipation
• Treatment of chronic cough if this is a precipitant.

Behavioural modification

Modification of behaviour using bladder training is effective. It is important for you to develop a routine of regular urination to ensure that bladder volume is kept to a minimum. Pelvic muscle exercises are another useful behavioural strategy that can be employed before medical or surgical treatment. If you are motivated and supervised appropriately, these are extremely effective treatment methods.

Medical therapy

Medical therapy is not useful for all forms of incontinence, and is not useful in pure stress incontinence. There are many agents currently available which you may be prescribed depending on how well it is thought you will tolerate the medication, other co-existing medical conditions you have, as well as the cost of the medication. In many cases a combination of low dose drugs will be used as this is generally more effective and better than large doses of a single drug. Oxybutynin is probably the most widely used medication for incontinence.

Surgical therapy

The choice of surgery depends of the underlying cause of the incontinence. Stress incontinence has the greatest success rates with surgery.
The use of spinal cord stimulation is currently being investigated for treatment of urinary incontinence.

Other useful therapies

Pads and protective measures

In women the use of menstrual pads are usually not sufficient for larger volumes and specific pads need to be purchased. In men urethral sheaths may be preferred if dribbling is the main problem.

Catheters

These are generally reserved for the severely ill patients where other treatment options are not recommended or possible. Care must be taken with catheters due to the high risk of infections as well as kidney stones.  

Female specific therapies

• Continence pressaries: Pressaries are an implant used in the vaginal cavity which basically holds the vaginal walls in place to treat prolapse. These are a very good option in women who are reluctant or unfit for surgical therapy. These devices are inserted in specialist clinics or by trained general practitioners.

Male specific therapies

• Incontinence after removal of the prostate gland: This is difficult to treat. The mainstay of initial therapy is usually with bulking injections as well as pelvic floor exercises. If the incontinence is severe, pads as well as the use of urinary catheters may prove to be useful.

Therapies for children

Much like the therapeutic measures used in adults a stepwise approach should be adopted when treating children suffering from enuresis. The therapeutic measures include:

• Education: Doctors will educate both the child and the parents, and explain to them that the child should not be punished for their bed wetting problem.
• Alarms: Bed wetting alarms have shown to be one of the most effective treatment methods. These alarms are ineffective if they are insufficient to wake the child from sleep
• Medications
• Behavioural strategies: these include bladder training, reward strategies, and parental or self awakening.

References

1. DuBeau CE ‘Uptodate – Clinical Presentation and Diagnosis of Urinary Incontinence’ [online], Web MD, 2006
2. DuBeau CE ‘Uptodate – Epidemiology, risk factors, & pathogenesis of urinary incontinence’ [online], Web MD 2006.
3. DuBeau CE ‘Uptodate – Treatment of urinary incontinence’ [online], Web MD 2006.
4. Hoebeke PB & Vande Walle J, The pharmacology of paediatric incontinence’, BJU International 2000, vol. 86, pp. 581 – 589.
5. Millard R, Moore K, Urinary incontinence: the Cinderella subject, The general practitioner can do much to manage incontinence and to promote continence, MJA 1996; 165: 124-125.
6. Nield LS & Kamat D, 2004, Eneuresis: How to Evaluate and treat, Clinical Paediatrics, vol. 43, pp.409 – 415.
7. Victorian Continence Resource Centre, Continence Foundation of Australia, 2006, Available [online] at URL: http://www.continencevictoria.org.au