Urinary Incontinence

Contents
• Definition
• Epidemiology
• Physiology of micturition
• Causes of urinary incontinence
• Risk factors
• Types of UI
• Diagnostic test
• Prevention
• Conclusion
• References
 Definition

INCONTINENCE:
Involuntary loss of urine or stool in sufficient amount
or frequency to constitute a social and/or health problem.
A heterogeneous condition that ranges in severity
from dribbling small amounts of urine to continuous urinary
incontinence with concomitant fecal incontinence
 How Common is Incontinence?
• Prevalence of UI in a community is 30%
• Increases with age (but it is not a part of normal aging)
• 25-30% of community older women
• 10-15% of community older men
• 50% of hospital patients have urinary incontinence;
often associated with dementia, fecal incontinence,
inability to walk and transfer independently
 Urinary Incontinence is Often
Under-Diagnosed and Under-Treated

• Only 32% of primary care physicians

routinely ask about incontinence.
• 50-75% of patients never describe
symptoms to physicians.
• 80% of urinary incontinence can be cured or
improved
 Why is Incontinence Important?

• Social stigma- leads to restricted activities and

depression
• Medical complications - skin breakdown,
increased urinary tract infections.
• Institutionalization - UI is the second leading
cause of nursing home placement.
 Anatomy of Micturtion
• Normal capacity 300-600ml
• First urge to void 150-300ml
• Detrusor muscle
• External and Internal sphincter
• CNS control
-Pons ,Cerebral cortex
• ANS
• Somatic Nervous system
• Hormonal effects - estrogen
 Peripheral Nervous system
• Parasympathetic (cholinergic) :- Bladder
contraction
• Sympathetic :-
β adrenergic - Bladder Relaxation
α adrenergic -Bladder neck and urethral
contraction
• Somatic (Pudendal nerve) - contraction pelvic of
floor musculature
 Peripheral Nervous system
Bladder Relaxation Bladder neck and
β adrenergic urethral contraction
α adrenergic

Parasympathetic -
Bladder contraction
Contraction of pelvic floor musculature
PHYSIOLOGY OF MICTURITION

• Impulse travel from

the bladder wall to
the sacral region of
the spinal cord
Parasympathetic
neurons are activated
and this will cause
smooth muscle on
bladder wall to
contract
Sensory signals to
the sacral region of
the spinal cord also
stimulate ascending
pathway to the pons
and cerebrum which
results in conscious
desire to urinate
If urination is not
convenient at the time
the brain sends
impulses down the
spinal cord to inhibit
the micturtion reflex
somatic nerve keep the
urinary sphincter
contracted
 Causes of urinary incontinence

• Temporary urinary incontinence

-Alcohol -UTI
-Caffeine -Constipation
-Over-hydration
-Dehydration
-Bladder irritation
-Medication
Persistent Urinary incontinence

-Pregnancy and childbirth

-Aging
-Hysterectomy
-Painful bladder syndrome
-Enlarged prostate
-Obstruction
-Neurological disorder
 Risk factors
• Sex
• Age
• Obesity
• Smoking
• Vascular disease
• High impact sports
• Other disease
 Types of UI
• Acute incontinence
-sudden onset, transitory episode due to acute
illness eg:- infection, delirium, epilepsy
• Persistent incontinence
-Urge incontinence
-Stress incontinence
-Overflow incontinence
-Functional incontinence
-Gross total incontinence
 Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder, over active
bladder
• Most common cause of UI >75 years of age
• Sudden ,intense urge to urinate, followed by an
involuntary loss of urine
• Abrupt desire to void cannot be suppressed
• Detrusor instability or detrusor hyperreflexia
• Causes: infection, tumor, atrophic vaginitis or
urethritis, stroke, Parkinson’s Disease, dementia
 Stress Incontinence
• Most common type in women < 75 years old
• Loss of urine when exert pressure or stress to the
bladder by coughing , sneezing, exercising,etc.
• Due weakness of sphincter muscle
• Causes:- aging, hormonal changes, trauma of
childbirth or pelvic surgery
• In man stress incontinence is due to prostatectomy
 Overflow Incontinence
• Characterized by hesitancy, dribbling, poor urinary
stream, leakage of small amount urine
• Common in man with outflow tract obstruction due
to prostatic hypertrophy
• Non-contractile bladder (hypoactive detrusor or
atonic bladder):- diabetes, spinal injury,
medications
• In women it associated with cystocoele
 Functional Incontinence
• Inability of an old person to reach toilet in
time
• Result of psychological, cognitive or
physical impairment
• Does not involve lower urinary tract
• Disease associated with this:-Arthritis, AD,
Dementia
 Gross total incontinence
• Continuous leakage of urine
• Bladder has no storage capacity
• Due anatomical defect, spinal cord injury,
injury to urinary system
• Fistula
 Diagnostic approach
Taking the History
• Duration, severity, symptoms, previous
treatment, medications, GU surgery
• 3 P’s
– Position of leakage (supine, sitting, standing)
– Protection (pads per day, wetness of pads)
– Problem (quality of life)
• Bladder record or diary
 Diagnostic test
• Urine microscopy
• Routine blood test
• Postvoid residual urine (PVR):-to measure how
much urine remains in the bladder after urination
• Urodynamic studies:-tests to measure pressure and
urine flow
• Multi-channel cystometric studies (inspect inside
of the bladder)
• Prostate specific antigen
 Treatment
• Noninvasive Treatments
Behavioral Modifications
Medications
• Minimally Invasive Treatments
Bulking agents
Botulinum toxin
Devices
• Surgical Treatment
Pubovaginal Fascial Slings
Suburethral Slings
Sacral Nerve Stimulation
Enlarging the Bladder
Laparoscopic Surgery
 Behavioral Modifications
• Pelvic floor muscle exercises (Kegel exercises)
• Proper performance of Kegel exercises should be
confirmed by digital vaginal examination or biofeedback.
• Bladder training
• Modifying the diet, fluid management , eliminating or
adding medications, Avoiding Physical and Occupational
Stress
• Do not have side effects and are often very effective
• Stress incontinence, detrusor instability, and urge
incontinence
 Medication
• Drugs can change the autonomic function of the bladder
by affecting the cholinergic and adrenergic nerves
Anticholinergic drugs
Propantheline bromide
Emperonium bromide
Musculotrophic drugs
Oxybutinine
Dicyclomine
Flavoxate
Tricyclic antidepressants
Imipramine
Doxypin
• Beta (β) - adrenoceptor agonists
Terbutaline
Salbutamol
Isoprenaline
• Alpha (α) - adrenoceptor antagonists
Phenoxybenzamine
Prazosine
• Prostaglandin synthetase inhibitors
Flurbiprofen
Indomethacin
 Bulking agents

• Treat stress incontinence in men and women

• Bulking materials can be injected into the
tissue around the urethra to add bulk and
keep the sphincter muscles closed to stop
urine from leaking
• Collagen,
Carbon particle beads
Synthetic sugar
 Botulinum Toxin
• Is a neurotoxin protein produced by the
bacterium C. botulinum
• Injected into the muscles of the bladder to
treat incontinence
• Blocks the release of chemicals which cause
muscle spasms
• Is effective for nine months to a year
 Devices
• Pessary- a special device inserted in the vagina to
hold up the bladder and prevent leakage
• Bladder neck support device -inserted in the vagina
to elevate the bladder neck and restore the normal anatomic
relationship between the bladder and urethra

• Urethral insert- A small plug that is inserted into the

urethra, and removed for urination
• Urine seal -a small disposable foam pad that is placed
over the urethra opening
• Artificial urinary sphincter -A tiny, doughnut-shaped
device is inserted under the skin of the penis to close the
urethra
 Surgical Treatment
Pubovaginal Fascial Slings
• Attaches a piece of fascia around the bladder neck to keep urine in
• Fascia taken from the patient's body
• Success rate of over 90 percent
Suburethral Slings
• This is an outpatient, minimally invasive form of sling surgery with
a high success rate
• Suburethral slings are made of a synthetic mesh
Sacral Nerve Stimulation
• FDA-approved electronic stimulation therapy which can be
effective in reducing urge incontinence
• Small electrode tip is surgically placed near the sacral nerve
act as a bladder pacemaker
Enlarging the Bladder
Using a segment of intestine to enlarge the size of
the bladder, this surgery can cure incontinence.
However, in up to 30 percent of cases, patients may
need a catheter.
Laparoscopic Surgery
These procedures are used to surgically remove
urinary tract obstructions, such as kidney stones and
enlarged prostate glands
 Prevention
• Maintain a healthy weight
• Don’t smoke
• Practice Kegel exercises
• Avoid bladder irritant
• Eat more fiber
 Conclusion
Management of UI needs very comprehensive
planned approach after an accurate assessment
and diagnostic evaluation. The majority of the
patient are treatable, often curable.
Appropriate treatment almost always resolves
or improves the problem
 References
• Management of urinary incontinence ;P K Sarkar and
A E S Ritch: Jr of Clin Pharm and Therap:(2000)25,251-263
• Pathophysiology of Overactive Bladder and Urge Urinary
Incontinence; William D Steers, MD, FACS Rev Urol. 2002; 4
(Suppl 4): S7–S18
• The Pathophysiology of Stress Urinary Incontinence: A Historical
Perspective; Geoffrey W Cundiff, MD Rev Urol. 2004; 6(Suppl 3):
S10–S18.
• Drug Therapy for Urinary Incontinence; D r V i k K h u l l a r
Senior Lecturer and Consultant Urogynaecologist,
Urogynaecology Unit,Department of Obstetrics and Gynaecology,