Urinary Incontinence

Background/Classifications

Involuntary leakage of urine

    • Functional incontinence: e.g. due to poor mobility (unable to reach the toilet)
    • Stress incontinence: involuntary leakage on effort/exertion e.g. sneezing/coughing.  Most commonly in women due to weakness of the pelvic floor muscles
    • Urge incontinence: involuntary leakage immediately preceded by urgency, usually due to bladder dysfunction
    • Overflow incontinence: usually due to chronic bladder outflow obstruction (e.g. prostatic disease in men) and can be accompanied by urinary retention
  • Much more common in women than in men and the elderly (46% of women >80 and 34% of men >80)

Risk factors

  • Women
    • Parity (more pregnancies and vaginal deliveries- more risk) – particularly of stress incontinence
    • BMI
    • Menopause

History

  • Determine type of incontinence (stress, urge, mixed)
    • NB if mixed focus mainly on the predominant symptoms
  • Ask about other urinary symptoms
    • Frequency, nocturia, dribbling/incomplete emptying, dysuria
    • Also ask about any sexual dysfunction, bowel habit
  • Ask about previous medical history and current/past medications
    • In women, this should a full PMHx for Obs/Gynae (particularly parity, deliveries, surgery etc)
    • Ask about any neurological conditions (personal or family history)
  • Ask about social circumstances, including functionality/mobility
    • e.g. access to the bathroom, family support
    • Also ask about caffeine, alcohol and diet/fluids
  • Patients may also be asked to fill out a symptom scoring checklist to estimate the severity/impact of symptoms

Examination

  • Women
    • Perform a full gynaecological examination including testing the tone of the pelvic floor
      • Assess also any prolapse
  • Men
    • DRE: prostate examination
  • Also examine the abdomen, pelvis and nervous system

Investigations

  • Urinalysis/MSSU
    • Important to exclude treatable cause like UTI
  • Residual volume scan (USS) or catheterisation
  • Urinary (voiding) diaries
  • NB Urodynamic testing is not often used first line but can be used in
    • patients with symptoms of over-active bladder/detrusor overactivity
    • symptoms suggestive of voiding dysfunction e.g. poor flow
    • patients who have had previous surgery for stress incontinence

Management

  • 1st line
    • Lifestyle
      • Reduce caffeine intake
      • Consider altering fluid intake
      • Weight loss
    • Physiotherapy
      • pelvic floor muscle training for stress incontinence
      • bladder re-training for urge incontinence
  • 2nd line
    • Drug treatment
      • Oxybutynin or tolterodine can be offered for urge incontinence
        • Review in 4 weeks (benefit) and 6 months (review)
      • The use of drugs in treating stress incontinence is limited although duloxetine may be used in conjunction with pelvic floor exercises (SIGN not NICE)
  • 3rd line
    • Surgery/Invasive
      • Consider retropubic mid-urethral tape procedure with synthetic tape
      • Other procedures include open colposuspension and autologous rectus fascial sling procedures
    • Intramural bulking agents (rare)
  • Others
    • Catheterisation can be considered (first line for relief in obstructive incontinence)

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