Virtual Medical Centre

Urinary Incontinence

• What is Urinary Incontinence?
• Who gets Urinary Incontinence?
• Predisposing Factors
• Progression
• Probable Outcomes
• How Will Urinary Incontinence Affect Me?
• Clinical Examination
• How is Urinary Incontinence Diagnosed?
• How is Urinary Incontinence treated?
• Urinary Incontinence References
• Drugs/Products Associated with Urinary Incontinence

What is Urinary Incontinence?

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Bladder Incontinence

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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 populatfion it is a highly important problem.

Who gets 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.

• 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.

• 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.

Predisposing Factors

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.

Therfore, 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

• 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 symtoms which may include incontinence.

• 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

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.