Urinary incontinence

Urinary Incontinence

Urinary incontinence can have devastating effects on patients' quality of life; it is associated with depression, social isolation, loss of work, and increased falls (due to trying to quickly reach a bathroom).

Urinary incontinence is defined as loss of bladder control with unintentional voiding.

Incontinence is very common:

It effects approximately 20% of all women, and up to 75% of women in nursing homes.
Until age 80, fewer men are affected by urinary incontinence than women; however, after age 80, men experience incontinence at the same rate as women.
Most patients do not readily report incontinence and therefore do not benefit from treatment.

Risk factors for incontinence include obesity, increased age, high parity, vaginal delivery, pregnancy, and prostate surgery. In the cases of vaginal delivery and prostate surgery, incontinence is caused by damage to neural pathways and pelvic floor muscles.

Determining the cause of incontinence can be key to its treatment.

DIAPPERS: mnemonic to remember important reversible causes of urinary incontinence:

Delirium (delirious patients may not be able to get to a toilet)
Infection
Atrophic vaginitis (which can be treated with estrogen supplements)
Pharmaceuticals (including ACE inhibitors, calcium channel blockers, muscle relaxers, opioids, etc.).
Excessive urine output due to excessive fluid consumption, as seen in diabetes mellitus
Psychological issues
Reduced mobility (unable to get to a toilet)
Stool impaction (constipation)

Diagnose urinary incontinence and its causes via history, physical exam, UTI testing, urinary stress tests, and questionnaires and voiding diaries.

Review micturition.

Stress Incontinence

This is form of incontinence is due to a weak urinary sphincter that allows for unintentional voiding when intra-abdominal pressure is increased – for example, when a patient coughs, laughs, or does exercises that engage the core muscles, urine leakage is reported. Pregnancy is also associated with increased intra-abdominal pressure and stress incontinence.

Urge Incontinence

Caused by an overactive detrusor muscle in the bladder; patients experience a sudden urge to urinate, and are unable to postpone urination long enough to make it to a bathroom.

Urge incontinence can be idiopathic, or it can be secondary to other disorders such as Parkinson's disease, multiple sclerosis, spinal nerve injuries, and urinary tract infections.

"Mixed incontinence"

A combination of stress and urge incontinence in a patient – this condition is more common than urge incontinence alone.

Overflow Incontinence

Occurs when urinary tract obstruction or an impaired detrusor muscle leads to bladder distention and incomplete emptying.

Functional incontinence

Occurs when patients have cognitive or mobility impairments that prevent them from getting to the bathroom; we show the example of a patient who is bedridden.

Childhood daytime urinary incontinence:

Caused by: Overactive bladder, urologic anomalies, voiding postponement, and "giggle" incontinence (which is characterized by extensive urination during or after laughing in the absence of other bladder issues; this is rare, and often resolves with age).

Treatments include:

Lifestyle modifications, such as frequently taking in small amounts of fluid (rather than larger quantities all at once), voiding schedules, and avoiding beverages known to promote urination (such as caffeinated or carbonated beverages and alcohol).

Pelvic floor exercises can be effective in patients with stress incontinence.

Medications, including anticholinergics and beta-3 agonists can help control bladder and sphincter functioning, and,

Surgical interventions that facilitate support of the pelvic floor and urinary bladder may be desired if less invasive methods are not effective.

For references, please see full tutorial.

Urinary incontinence

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