Urinary Incontinence

Question 1

What is urinary incontinence (UI)?

Answer 1

Urinary incontinence refers to the loss of control of urination.

Question 2

What are the different types of UI?

Answer 2

1. Urge
2. Stress
3. Mixed
4. Overflow

Question 3

Briefly describe urge incontinence and its features

Answer 3

Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder.

The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.

Patients with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access. This can have a significant impact on their quality of life, and stop them doing work and leisure activities.

Question 4

What causes urge UI?

Answer 4

Detrusor overactivity: age related, idiopathic, UMN lesion and bladder irritation.

Detrusor hyperactivity with impaired contractility: urge incontinence with detrusor underactivity.

Question 5

Briefly describe stress incontinence and its features

Answer 5

Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.

Question 6

What causes stress UI?

Answer 6

Impaired pelvis support and failure of urethreal closure (due to trauma, anti-incontinence surgery, urethral atrophy, prostate procedures and atropic vaginitis).

Question 7

Briefly describe mixed incontinence

Answer 7

Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.

Question 8

Briefly describe overflow incontinence

Answer 8

Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine and the incontinence occurs without the urge to pass urine.

Overflow incontinence presents with high post-void residual, frequency, nocturia, weak urinary stream, hesitancy, straining and small-volume leakage.

It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.

Overflow incontinence is more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management.

Question 9

What causes overflow UI due to bladder outlet obstruction?

Answer 9

Benign prostatic hypertrophy (BPH), urethral stricture, anti-incontinence surgery and severe pelvic organ prolapse.

Question 10

What causes overflow UI due to detrusor underactivity?

Answer 10

Peripheral neuropathy: diabetes mellitus, B12 deficiency and alcoholism.

Damage to spinal detrusor afferent nerves: disc herniation, spinal stenosis, tumour and degenerative neurologic disease.

Fibrosis of detrusor muscle.

Question 11

What are the risk factors for UI?

Answer 11

• Increased age
• Postmenopausal status
• Increase BMI
• Previous pregnancies and vaginal deliveries
• Pelvic organ prolapse
• Pelvic floor surgery
• Neurological conditions such as multiple sclerosis
• Cognitive impairment and dementia
• Diabetes
• Smoking
• Caffeine

Question 12

Briefly describe the history taking of UI

Answer 12

Storage:

• Frequency
• Urgency
• Stress Incontinence
• Urge Incontinence
• Nocturia

Voiding:

• Post micturition dribble
• Hesitancy
• Terminal dribbling
• Incomplete emptying
• Intermittent stream

Ask specifically about:

• Pain, dysuria and haematuria (these symptoms need urgent review)
• Urinary symptoms during childhood e.g. nocturnal enuresis
• Bowel function and frequency
• Systemic symptoms and those symptoms that could be associated with diseases that predispose a patient to urinary incontinence
• Associated co-morbidities (CCF, COPD, DM) and previous surgical procedures, particularly those in or around the pelvis

Obstetric and gynaecological history are also important in female patients.

Medication review is essential as many drugs can exacerbate urinary incontinence.

Question 13

What are the red flag symptoms of UI?

Answer 13

• Sudden onset
• Pelvic pain
• Haematuria
• Dysuria
• Severe straining
• Inability to void

Question 14

What medications may contribute to UI?

Answer 14

• ACE inhibitors
• Anticholinergics
• Antidepressants
• Antipsychotics
• Sedative
• Hypnotics
• Thiazolidinedione
• Calcium channel blockers
• Loop diuretics
• Opioids
• α-adrenergic agonists and α-adrenergic blockers

Question 15

What other conditions may contribute to UI?

Answer 15

• Neurological
  
  • CVD
  • Delirium
  • Dementia
  • Multiple sclerosis
  • Normal pressure hydrocephalus
• Parkinson’s disease
• Spinal stenosis
• Urological and gynaecological
  
  • Surgeries
  • Trauma

Question 16

Briefly describe the physical examination required for UI

Answer 16

• Functional status
• MSK
  
  • Mobility and dexterity
• CVS
  
  • Look for signs of chronic cardiorespiratory disease
• Cognition
  
  • AMT as a screen for cognitive decline
  • Delirium screening if indicated
• Neurology
  
  • Assess gait, peripheral neuropathy and Parkinson’s disease
• Abdomen
  
  • Palpate for masses or enlarged kidneys, palpate and percuss for a distended bladder
• DRE
  
  • Assess anal tone, presence of constipation or rectal mass and to assess prostate size in males
• Pelvic/ vaginal exam
  
  • Assess mucosa, prolapse and volitional squeeze

Note: during the examination, ask the patient to cough and watch for leakage from the urethra

Question 17

Briefly describe the modified Oxford grading system used to assess pelvic muscle strength

Answer 17

The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers. This can be graded using the modified Oxford grading system:

• 0: no contraction
• 1: faint contraction
• 2: weak contraction
• 3: moderate contraction with some resistance
• 4: good contraction with resistance
• 5: strong contraction, a firm squeeze and drawing inwards

Question 18

What initial investigations should be ordered for UI?

Answer 18

• Frequency and volume chart
  
  • Should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days
  • There should be a mix of work and leisure days
• Urinalysis +/- MSU for MC&S
  
  • Note any haematuria and glucosuria
• Blood tests
  
  • FBC, U&E, calcium and glucose
• Post-void bladder scan
  
  • Should be measured using a bladder scan to assess for incomplete emptying

Question 19

Why is it important to assess serum creatinine?

Answer 19

To asess for acute kidney injury.

Question 20

Briefly recap the diagnosis of acute kidney injury

Answer 20

Acute kidney injury (AKI) is defined as an acute drop in kidney function. It is diagnosed by measuring the serum creatinine.

NICE criteria for AKI:

• Rise in creatinine of ≥ 25 micromol/L in 48 hours
• Rise in creatinine of ≥ 50% in 7 days
• Urine output of < 0.5ml/kg/hour for > 6 hours

Question 21

After initial testing, what further investigations can be ordered?

Answer 21

• Cystoscopy
• Urodynamic testing
  
  • Unclear aetiology
  • When empiric treatment has failed and the patient would consider invasive or surgical therapy
• Depression screening

Question 22

Briefly describe urodynamic testing

Answer 22

Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests.

A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken:

• Cystometry measures the detrusor muscle contraction and pressure
• Uroflowmetry measures the flow rate
• Leak point pressure is the point at which the bladder pressure results in leakage of urine
  
  • The patient is asked to cough, move or jump when the bladder is filled to various capacities
  • This assesses for stress incontinence
• Post-void residual bladder volume tests for incomplete emptying of the bladder
• Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied
  
  • Theses are only performed where necessary and not a routine part of urodynamic testing

Question 23

Briefly describe the non-pharmacological management of UI

Answer 23

Minimise contributing factors identified in the history of presenting illness, physical examination and laboratory testing.

Classification and documentation of type and likely aetiology of UI before treatment.

Initially try behavioural therapy, pelvis floor exercises and bladder control strategies.

Question 24

Briefly describe the treatment of stress UI

Answer 24

Management of stress incontinence involves:

• Avoiding caffeine, diuretics and overfilling of the bladder
• Avoid excessive or restricted fluid intake
• Weight loss (if appropriate)
• Supervised pelvic floor exercises for at least three months before considering surgery
• Surgery
• Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Question 25

Briefly describe the use of pelvis floor exercises in managing stress UI

Answer 25

Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowel. Pelvic floor exercises should be supervised by an appropriate professional, such as a specialist nurse or physiotherapist. Women should aim for at least eight contractions, three times daily.

Question 26

What are the surgical management options for stress UI?

Answer 26

Surgical options to treat stress incontinence include:

• Tension-free vaginal tape (TVT)
• Autologous sling procedures
• Colposuspension
• Intramural urethral bulking