Makindo Medical Notes

Introduction

Urinary incontinence is defined as the involuntary loss of urine that is sufficiently severe to cause social or hygiene problems. It affects people of all ages but is particularly common among older adults and women. Urinary incontinence can significantly impact the quality of life, leading to embarrassment, social isolation, and decreased physical activity. Understanding the types, causes, and management options is essential for effective treatment.

Always assess whether any medications are contributing to incontinence, as some drugs can worsen symptoms.

Types of Urinary Incontinence

There are several types of urinary incontinence, each with distinct features, underlying causes, and management strategies.

Type	Description	Common Causes	Management
Stress Incontinence	Involuntary leakage of urine during activities that increase intra-abdominal pressure (e.g., coughing, sneezing, laughing, or exercising).	Weakness of pelvic floor muscles Urethral sphincter deficiency Childbirth-related trauma Menopause (reduced estrogen levels) Obesity Prostate surgery in men	Pelvic floor muscle training (Kegel exercises) Weight loss if overweight or obese Behavioral modifications Pessary devices (in women) Surgical options (e.g., mid-urethral sling procedures) Medications (e.g., duloxetine)
Urge Incontinence	Sudden, intense urge to urinate followed by involuntary leakage. Often associated with overactive bladder syndrome.	Detrusor muscle overactivity Neurological conditions (e.g., stroke, Parkinson's disease, multiple sclerosis) Urinary tract infections Bladder irritants (caffeine, alcohol) Bladder outlet obstruction	Bladder training and scheduled voiding Pelvic floor exercises Antimuscarinic medications (e.g., oxybutynin, tolterodine) Beta-3 agonists (e.g., mirabegron) Intravesical botulinum toxin injections Neuromodulation therapy (e.g., sacral nerve stimulation) Avoidance of bladder irritants
Mixed Incontinence	Combination of stress and urge incontinence symptoms.	Factors causing both stress and urge incontinence Pelvic floor weakness with detrusor overactivity	Combination of treatments for stress and urge incontinence Behavioral therapies Medications as appropriate Surgical interventions if necessary
Overflow Incontinence	Continuous or intermittent dribbling of urine due to incomplete bladder emptying.	Bladder outlet obstruction (e.g., benign prostatic hyperplasia in men) Detrusor underactivity Neurological disorders (e.g., diabetic neuropathy) Medications affecting bladder contractility	Address underlying cause (e.g., relieve obstruction) Intermittent self-catheterization Alpha-blockers (e.g., tamsulosin) for bladder outlet obstruction Surgical interventions (e.g., prostatectomy in men)
Functional Incontinence	Incontinence due to physical or cognitive impairments preventing timely toileting.	Mobility limitations (e.g., arthritis, frailty) Cognitive impairments (e.g., dementia) Environmental barriers Psychological factors	Improving accessibility to toilet facilities Timed voiding schedules Assistance with toileting Use of incontinence products Physical therapy for mobility improvement Cognitive interventions

Etiology

Urinary incontinence is often multifactorial, especially in older adults. Factors contributing to incontinence include:

• Physiological Changes: Age-related weakening of the pelvic floor muscles and changes in bladder capacity.
• Medical Conditions: Neurological diseases, diabetes, urinary tract infections, and prostate enlargement.
• Medications: Diuretics, anticholinergics, alpha-blockers, and others can exacerbate incontinence.
• Lifestyle Factors: Obesity, smoking, and high intake of bladder irritants (caffeine, alcohol).
• Obstetric History: Multiple pregnancies, vaginal deliveries, and pelvic surgeries can damage pelvic support structures.

Clinical Assessment

A thorough history and physical examination are essential to identify the type of incontinence and contributing factors.

• History:
  • Onset, frequency, and pattern of symptoms
  • Triggers (e.g., coughing, urgency)
  • Fluid intake and voiding habits
  • Obstetric and gynecological history in women
  • Medication review
  • Impact on quality of life
• Physical Examination:
  • Abdominal examination for bladder distention
  • Pelvic examination in women to assess pelvic organ prolapse or atrophy
  • Digital rectal examination in men for prostate assessment
  • Neurological examination to evaluate sensory and motor function

Investigations

Investigations aim to identify reversible causes and to categorize the type of incontinence.

• Urinalysis: Detects urinary tract infections, hematuria, or glycosuria.
• Bladder Diary: Records fluid intake, voiding times, urine volumes, and incontinence episodes over 3-7 days.
• Post-Void Residual (PVR) Measurement: Assesses incomplete bladder emptying via ultrasound or catheterization.
• Urodynamic Studies: Evaluate bladder function, detrusor activity, and urethral pressures. Indicated if initial treatment fails or before surgery.
• Cystoscopy: Visualizes the bladder and urethra; used if hematuria or bladder pathology is suspected.
• Imaging Studies: Ultrasound, CT scan, or MRI may be indicated in certain cases to assess anatomical abnormalities.

Management of Urinary Incontinence

Management strategies depend on the type of incontinence and underlying causes. A combination of behavioral, pharmacological, and surgical interventions may be employed.

General Measures

• Lifestyle Modifications:
  • Weight loss for overweight individuals
  • Smoking cessation
  • Reduce intake of bladder irritants (caffeine, alcohol, spicy foods)
  • Manage constipation to reduce bladder pressure
• Medication Review:
  • Identify and adjust medications that may worsen incontinence
• Bladder Training:
  • Scheduled voiding and delayed voiding techniques to increase bladder capacity and control
• Pelvic Floor Muscle Training:
  • Strengthen pelvic muscles to improve urethral support
  • Guided by a physiotherapist or continence nurse specialist

Management of Stress Incontinence

• First-Line Treatments:
  • Pelvic floor muscle exercises (Kegel exercises)
  • Behavioral modifications
  • Weight management
• Medications:
  • Duloxetine: A serotonin-norepinephrine reuptake inhibitor (SNRI) that increases urethral sphincter tone. Side effects may include nausea and dizziness.
• Devices:
  • Vaginal Pessaries: Support devices inserted into the vagina to support pelvic organs and reduce leakage.
  • Urethral Inserts: Temporary devices inserted into the urethra to prevent leakage during activities.
• Surgical Options:
  • Mid-Urethral Sling Procedures: Synthetic mesh or autologous tissue used to support the urethra.
  • Bladder Neck Suspension: Elevates and secures the bladder neck and urethra.
  • Urethral Bulking Agents: Injections that increase urethral resistance to flow.
  • Artificial Urinary Sphincter: Implantable device primarily used in men after prostate surgery.

Management of Urge Incontinence

• Behavioral Therapies:
  • Bladder training to increase intervals between voiding
  • Pelvic floor muscle exercises
• Pharmacological Treatments:
  • Antimuscarinics:
    • Oxybutynin, tolterodine, solifenacin
    • Side effects: dry mouth, constipation, blurred vision
  • Beta-3 Agonists:
    • Mirabegron relaxes detrusor muscle
    • Fewer anticholinergic side effects
• Advanced Therapies:
  • Intravesical Botulinum Toxin A Injections: Inhibits detrusor overactivity; effects last 6-9 months.
  • Neuromodulation:
    • Sacral nerve stimulation (implantable device)
    • Posterior tibial nerve stimulation (non-invasive)

Management of Overflow Incontinence

• Address Underlying Causes:
  • Relieve bladder outlet obstruction (e.g., prostate enlargement)
  • Treat neurological conditions
• Bladder Emptying Techniques:
  • Intermittent self-catheterization
  • Indwelling catheterization (short-term)
• Medications:
  • Alpha-Blockers: Tamsulosin, alfuzosin to relax smooth muscle in prostate and bladder neck
  • 5-Alpha Reductase Inhibitors: Finasteride, dutasteride to reduce prostate size
• Surgical Interventions:
  • Transurethral resection of the prostate (TURP) in men
  • Surgical correction of anatomical abnormalities

Management of Functional Incontinence

• Environmental Modifications:
  • Easy access to toilet facilities
  • Use of bedside commodes or urinals
  • Proper lighting and clear pathways
• Assistance and Support:
  • Caregiver assistance with toileting
  • Scheduled toileting regimes
• Mobility Aids:
  • Walkers, canes, or wheelchairs
  • Physical therapy to improve mobility
• Cognitive Interventions:
  • Memory aids and prompts
  • Behavioral therapies for dementia patients

Medications That May Worsen Incontinence

Certain medications can contribute to or exacerbate urinary incontinence. A medication review is essential to identify and adjust these agents.

Medication Class	Examples	Effect on Incontinence
Diuretics	Furosemide, thiazide diuretics	Increase urine production leading to urgency and frequency
Alpha-Blockers	Tamsulosin, doxazosin	Relax urethral sphincter causing stress incontinence in women
Anticholinergics	Antihistamines, tricyclic antidepressants	Cause urinary retention leading to overflow incontinence
Opioids	Morphine, codeine	Impair bladder contractility causing retention and overflow incontinence
ACE Inhibitors	Enalapril, lisinopril	Can cause cough exacerbating stress incontinence
Sedatives/Hypnotics	Benzodiazepines	Reduce awareness and mobility leading to functional incontinence
Caffeine and Alcohol	Coffee, tea, alcoholic beverages	Increase urine production and bladder irritability
Calcium Channel Blockers	Verapamil, diltiazem	Decrease bladder contractility causing retention
Antipsychotics	Haloperidol, risperidone	Impair mobility and bladder function

Conclusion

Urinary incontinence is a common condition with significant impact on individuals' quality of life. A comprehensive assessment and individualized management plan are essential. Combining lifestyle modifications, behavioral therapies, pharmacological treatment, and surgical options can effectively manage symptoms and improve patient outcomes.

References

• National Institute for Health and Care Excellence (NICE). Urinary Incontinence and Pelvic Organ Prolapse in Women: Management. NICE Guideline [NG123]; 2019.
• Abrams P, Andersson KE, Apostolidis A, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse, and Fecal Incontinence. Neurourol Urodyn. 2010;29(1):213-240.
• Wein AJ, Rovner ES. Definition and Epidemiology of Overactive Bladder. Urology. 2002;60(5 Suppl 1):7-12.
• Gormley EA, Lightner DJ, Faraday M, Vasavada SP. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment. J Urol. 2015;193(5):1572-1580.
• Subak LL, Richter HE, Hunskaar S. Obesity and Urinary Incontinence: Epidemiology and Clinical Research Update. J Urol. 2009;182(6 Suppl):S2-S7.
• Lucas MG, Bedretdinova D, Berghmans LC, et al. EAU Guidelines on Urinary Incontinence in Adults. Eur Urol. 2012;62(6):1130-1142.