What are the types of incontinence?
Stress Incontinence, Urge Incontinence, Overflow Incontinence, Neuropathic Bladder Incontinence
These types are characterized by distinct physiological and anatomical factors.
What are extrinsic causes of incontinence?
- Physical state and co-morbidities
- Reduced mobility
- Confusion (delirium or dementia)
- Drinking too much or at the wrong time
- Medications, e.g. diuretics
- Constipation
- Home and social circumstances
These factors can contribute to the onset or worsening of incontinence.
What are intrinsic causes of incontinence?
- Bladder and outlet either too weak or too strong
- Weak pelvic floor muscles
- Pregnancy and post-pregnancy
These causes are related to the physiological state of the bladder and pelvic support.
What is the anatomy of the bladder and urethra relevant to continence?
- Detrusor muscle (smooth muscle)
- Internal urethral sphincter (smooth muscle)
- External urethral sphincter (striated muscle)
This anatomical structure is crucial for maintaining urinary control.
What is the physiology of urine storage?
Detrusor muscle relaxation with filling (<10cm pressure) to normal volume 400-600ml combined with sphincter contraction
This process allows for the storage of urine without leakage.
What occurs during voluntary voiding?
Voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder
This coordinated activity is essential for the process of urination.
What are the features of stress incontinence?
- Weak bladder outlet
- Urine leak on movement (Coughing, Laughing, Squatting)
- Weak pelvic floor muscles
- Common in women with children
Stress incontinence often occurs during physical activities that increase abdominal pressure.
What are the characteristics of urinary retention with overflow incontinence?
- Bladder outlet is too strong
- Obstructive: Poor urine flow, double voiding, hesitancy, post-micturition dribbling
- Blockage to urethra
- Older men with benign prostatic hyperplasia
This condition can lead to significant discomfort and complications.
What defines urge incontinence?
- Bladder muscle is too strong
- Detrusor contracts at low volumes
- Sudden urge to pass urine immediately
- Can be caused by bladder stones or stroke
Individuals may experience an overwhelming need to urinate with little warning.
What features characterize neuropathic bladder incontinence?
- Underactive bladder secondary to neuro disease (e.g. MS, Stroke) or prolonged catheterisation
- Reduced to no awareness of bladder filling resulting in overflow incontinence
Neuropathic conditions can severely affect bladder function.
What is involved in the assessment of incontinence?
- History (social history, identify extrinsic factors)
- Advise lifestyle, behavioural changes, and stop unnecessary drugs
- Intake chart and urine output diaries
- General examination + vaginal and rectal exam
- Urinalysis and MSSU
- Bladder scan for residual volume
- Consider referral to incontinence clinic for difficult cases
A thorough assessment helps in tailoring appropriate management strategies.
What are the indications for referral of urinary incontinence to specialists?
- Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)
- Vesico-vaginal fistula
- Palpable bladder after micturition or confirmed residual volume of urine after micturition
- Disease of the CNS (e.g. Stroke or Multiple Sclerosis)
- Gyn problems (e.g. fibroids, procidentia, rectocele, cystocele)
- Severe BPH or prostatic carcinoma
- Previous surgery for continence
These indications help ensure patients receive specialized care when necessary.
What are the first-line treatments for stress incontinence?
- Physiotherapy (e.g. Kegel exercises)
- Oestrogen cream
- Duloxetine
Non-surgical approaches can be very effective in managing symptoms.
What surgical options are available for stress incontinence?
- Tension-free vaginal tape
- Culposuspension
Surgical interventions are considered when conservative measures fail.
What treatments are used for urinary retention with overflow incontinence?
- Alpha blocker (e.g. tamsulosin)
- Anti androgen (e.g. finasteride)
- Surgery (TURP)
- Catheterisation (often suprapubic)
These treatments aim to relieve obstruction and improve urinary flow.
What medications are used for urge incontinence?
- Anti-muscarinics (e.g. oxybutinin, tolterodine, solifenacin)
- Bladder re-training
These options help manage symptoms by reducing detrusor activity.
What treatment options exist for neuropathic bladder incontinence?
- Parasympathomimetics may be of use
- Catheterisation is the only effective treatment
Due to the complex nature of neuropathic bladder, management is often challenging.
What are the main drugs for the treatment of incontinence?
- Antimuscarinics for urge incontinence (e.g. oxybutinin, tolterodine, solifenacin, trospium)
- Beta-3 adrenoceptor agonists (e.g. mirabegron)
- Alpha blockers for urinary retention (e.g. tamsulosin, terazosin, indoramin)
- Anti androgen for urinary retention (e.g. finasteride, dutasteride)
- Duloxetine for stress incontinence
These medications target different mechanisms involved in urinary control.
What management options are available if all else fails for incontinence?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheter
- Suprapubic catheter
These options provide support and management for ongoing symptoms.
