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
- Perform a full gynaecological examination including testing the tone of the pelvic floor
- 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
- Lifestyle
- 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)
- Oxybutynin or tolterodine can be offered for urge incontinence
- Drug treatment
- 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)
- Surgery/Invasive
- Others
- Catheterisation can be considered (first line for relief in obstructive incontinence)