Urinary incontinence

Question 1

What are the types of urinary incontinence

Answer 1

Stress incontinence: leakage on exertion, sneezing, or coughing

Urge incontinence: leakage accompanied by, or immediately preceded by, a sudden compelling desire to pass urine that is difficult to defer

Mixed incontinence: Both stress and urgency incontinence

Overflow incontinence: Detrusor underactivity or outlet obstruction that results in retention and leakage of urine.

Functional: comorbid condition impairs the patient’s ability to get to a bathroom in time (dementia, sedating meds, injury)

Question 2

What is overactive bladder syndrome

Answer 2

Urinary urgency which is usually associated with increased frequency and nocturia
May be wet (incontinence present) or dry (incontinence is absent)
Symptoms usually occur without a UTI or other obvious pathology

Question 3

What features are important to ascertain from the history for urinary incontinence

Answer 3

Type of incontinence (coughing/sneezing/exertion OR urge)
Other urinary symptoms (dysuria, incomplete voiding, straining, frequency, dribbling, haematuria)
Is leakage competent
Hx UTI, discharge, dyspareunia
Fluid intake, amount, types
Medications
Previous surgeries, esp. pelvic
Occupation

Question 4

What are the signs of urinary incontinence on exam

Answer 4

General: weight, gait (± neuro exam)
Abdo: Palpable bladder, mass
Pelvic:
- Ask patient to cough while observing the urethral meatus
- Assess pelvic muscle tone and contraction during bimanual and assess using the Oxford grading system
- Assess for prolapse
- Assess for masses

Question 5

What are the risk factors for stress incontinence

Answer 5

Increasing age
Pregnancy and vaginal delivery
Obesity
Constipation
Deficiency in supporting tissue from: Prolapse, Hysterectomy, Lack of oestrogen at menopause
Family history
Smoking (chronic cough)
ACEi (cough/worsen cough)

Question 6

What are the causes/risk factors for urge incontinence

Answer 6

Overactive bladder syndrome (involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle)
Idiopathic
Parkinson’s disease
Multiple Sclerosis
Obesity
T2DM
Chronic UTI
Drugs: Parasympathomimetics, antidepressants, hormone replacement, diuretics.

Question 7

What are the causes of overflow incontinence

Answer 7

Bladder outlet obstruction
Detrusor underactivity
Systemic neurological disease
Drugs: ACEi, antidepressants, antihistamines, antimuscarinics, antiparkinsonians, beta-adrenergic, CCBs, opioids, sedatives

Question 8

What investigations should be done for urinary incontinence

Answer 8

1. Bladder diary for min. 3 days
   - Amount, type, timing
   - Frequency
   - Episodes of urgency
   - Activities that precede
   - Pad and clothing changes

Bedside: urine dipstick (UTI, DM), urine MC&S, empty supine stress test, post-void residual measurement, cough stress test
Bloods: U&Es
Other:
- Urodynamics: ?bladder outlet obstruction
- Cystourethroscopy: fistula, foreign body, tumour, cystitis

Question 9

When do you refer for urinary incontinence

Answer 9

2ww referral:
>45 with haematuria without UTI OR haematuria persistent after UTI treatment
>60 with unexplained microscopic haematuria and dysuria

Refer to an appropriate specialist (urologist, urogynaecologist, or nephrologist), using clinical judgement to determine urgency, if there is:
- A bladder that is palpable on abdominal or bimanual examination after voiding.
- Voiding difficulty.
- Persistent bladder or urethral pain (refer urgently if cancer is suspected).
- A pelvic mass that is clinically benign.
- Associated faecal incontinence.
- Suspected neurological disease.
- Hx incontinence surgery, pelvic cancer surgery, or radiation therapy.
- Recurrent urinary tract infection
- Suspected urogenital fistulae

Question 10

What is the management for stress incontinence

Answer 10

1. Exclude and manage any reversible causes/contributing factors
2. Lifestyle advice

First line: pelvic floor muscle training (PFMT)
- minimum 3 months
- Supervised by physiotherapist
- 8 contractions 3x a day

Second line: Refer to urogynae/gynae/urologist
- Duloxetine 2x a day
- Surgery: colposuspension, autologous rectal fascial sling, mesh sling etc.

Question 11

What is the management for urge incontinence

Answer 11

1. Exclude and manage any reversible causes/contributing factors
2. Lifestyle advice

First line: Bladder training
- At least 6 weeks
- Local continence nurse or physiotherapist
- May take at least 4 weeks to work

Second line: Refer to urogynae/gynae/urologist
- oxybutynin (antimuscarinic), tolterodine, darifenacin
- botulinum toxin type A injection
- percutaneous sacral nerve stimulation
- Cystoplasty

Question 12

What are the complications of urinary incontinence

Answer 12

Impaired QOL: employment, leisure
Psychological: depression, anxiety, embarrassment
Social isolation and avoidance
Sexual problems
Loss of sleep
Falls and fractures

Question 13

What is the prognosis for urinary incontinence

Answer 13

A study found that in those with incontinence, not accounting for effect of treatment, after 6 years:
- 50% had no change in symptoms
- A third had decreased incontinence
- 15% had worsened treatment

No treatment is fully curative and combination therapy may be beneficial

Question 14

What is the treatment for the following in women with urge incontinence: elderly, post-menopausal + vaginal atrophy, nocturia

Answer 14

Frail, elderly women: mirabegron
Post-menopausal with vaginal atrophy: intravaginal oestrogen therapy
Nocturia: desmopressin

Question 15

What lifestyle advice should be given to women with urinary incontinence

Answer 15

Reducing caffeine intake
Fluid intake
Weight loss if obese
Smoking