Overview and facts :
Urinary incontinence (UI) is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners.There is also a related condition for defecation known as fecal incontinence.
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors:urethral pressure falls and bladder pressure rises.
Urinary incontinence (UI) is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners.There is also a related condition for defecation known as fecal incontinence.
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors:urethral pressure falls and bladder pressure rises.
Types :
- Stress incontinence, also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles.
- Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
- Overflow incontinence: Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan, hence the general name overflow incontinence.
- Mixed incontinence is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.
- Structural incontinence: Rarely, structural problems can cause incontinence, usually diagnosed in childhood, for example an ectopic ureter. Fistulas caused by obstetric and gynecologic trauma or injury can also lead to incontinence. These types of vaginal fistulas include most commonly, vesicovaginal fistula, but more rarely ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.
- Functional incontinence occurs when a person recognizes the need to urinate, but cannot physically make it to the bathroom in time due to limited mobility. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a toilet. People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer's Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes. Disease or biology is not necessarily the cause of functional incontinence. For example, someone on a road trip may be between rest stops and on the highway; also, there may be problems with the restrooms in the vicinity of a person.
- Bedwetting is episodic UI while asleep. It is normal in young children.
- Transient incontinence is a temporary version of incontinence. It can be triggered by medications, adrenal insufficiency, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.
Diagnosis :
Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth and some also treat urinary incontinence in women. Family practitioners and internists see patients for all kinds of complaints and can refer patients on to the relevant specialists.
A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.
The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.
A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.
Other tests include:
Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
Urodynamics – various techniques measure pressure in the bladder and the flow of urine.
Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.
Urinary incontinence in women
Bladder symptoms affect women of all ages. However, bladder problems are most prevalent among older women.[8] Up to 35% of the total population over the age of 60 years is estimated to be incontinent, with women twice as likely as men to experience incontinence. One in three women over the age of 60 years are estimated to have bladder control problems.
Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. Difficulty with bladder control results in higher rates of depression and limited activity levels.
Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living and nursing care facilities. More than 50% of nursing facility admissions are related to incontinence.
Coital incontinence (CI) is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or withmasturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.
See also: female ejaculation
Urinary incontinence in men
Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. But both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.
While urinary incontinence affects older men more often than younger men, the onset of incontinence can happen at any age. Incontinence is treatable and often curable at all ages.
Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.
During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphinctermuscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.
Treatment & Management :
The treatment options range from conservative treatment, behavior management, medications and surgery. In all cases, the least invasive treatment is started first. The success of treatment depends on the correct diagnoses in the first place.
Most treatment options are most appropriate for a specific underlying cause of the incontinence (though these can overlap if there is a mixed component to the incontinence.) However, some approaches (such as use of absorbent products) address the problem symptomatically, and can be applicable to more than one type. It is also sometimes possible to use a treatment for the pathophysiology of one type of incontinence to provide relief for an unrelated type of incontinence.
Absorbent pads and urinary catheters may help those individuals who continue to have incontinence. The absorbent pads are not bulky like in the old days but are close fitting underwear with liners. Men also can use a small urine collector that is worn around the penis.
Absorbent products include shields, undergarments, protective underwear, briefs, diapers, adult diapers and underpads.
Hospitals often use some type of incontinence pad, a small but highly absorbent sheet placed beneath the patient, to deal with incontinence or other unexpected discharges of bodily fluid. These pads are especially useful when it is not practical for the patient to wear a diaper.
Growth and development
Most urinary incontinence fades away naturally. Here are examples of what can happen over time:
Bladder capacity increases.
Natural body alarms become activated.
An overactive bladder settles down.
Production of ADH becomes normal.
The child learns to respond to the body's signal that it is time to void.
Stressful events or periods pass.
Many children overcome incontinence naturally (without treatment) as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.
Medications
Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known asdesmopressin, or DDAVP, which recently became available in pill form. Patients can also spray a mist containing desmopressin into their nostrils. Desmopressin is approved for use by children.
Another medication, called imipramine, is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Unfortunately, total dryness with either of the medications available is achieved in only about 20 percent of patients.
If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.
Bladder training and related strategies
Bladder training consists of exercises for strengthening and coordinating muscles of the bladder and urethra, and may help the control of urination. These techniques teach the child to anticipate the need to urinate and prevent urination when away from a toilet. Techniques that may help nighttime incontinence include:
Determining bladder capacityStretching the bladder (delaying urinating)
Drinking less fluid before sleeping
Developing routines for waking up
Unfortunately, none of the above has demonstrated proven success.
Techniques that may help daytime incontinence include:
Urinating on a schedule, such as every 2 hours (this is called timed voiding)
Avoiding caffeine or other foods or drinks that may contribute to a child's incontinence
Following suggestions for healthy urination, such as relaxing muscles and taking your time
Moisture alarms
At night, moisture alarms can awaken a person when he or she begins to urinate. These devices include a water-sensitive pad worn in pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken or be awakened as soon as the alarm goes off. This may require having another person sleep in the same room to awaken the bedwetter.
Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth and some also treat urinary incontinence in women. Family practitioners and internists see patients for all kinds of complaints and can refer patients on to the relevant specialists.
A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.
The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.
A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.
Other tests include:
Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
Urodynamics – various techniques measure pressure in the bladder and the flow of urine.
Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.
Urinary incontinence in women
Bladder symptoms affect women of all ages. However, bladder problems are most prevalent among older women.[8] Up to 35% of the total population over the age of 60 years is estimated to be incontinent, with women twice as likely as men to experience incontinence. One in three women over the age of 60 years are estimated to have bladder control problems.
Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. Difficulty with bladder control results in higher rates of depression and limited activity levels.
Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living and nursing care facilities. More than 50% of nursing facility admissions are related to incontinence.
Coital incontinence (CI) is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or withmasturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.
See also: female ejaculation
Urinary incontinence in men
Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. But both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.
While urinary incontinence affects older men more often than younger men, the onset of incontinence can happen at any age. Incontinence is treatable and often curable at all ages.
Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.
During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphinctermuscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.
Treatment & Management :
The treatment options range from conservative treatment, behavior management, medications and surgery. In all cases, the least invasive treatment is started first. The success of treatment depends on the correct diagnoses in the first place.
Most treatment options are most appropriate for a specific underlying cause of the incontinence (though these can overlap if there is a mixed component to the incontinence.) However, some approaches (such as use of absorbent products) address the problem symptomatically, and can be applicable to more than one type. It is also sometimes possible to use a treatment for the pathophysiology of one type of incontinence to provide relief for an unrelated type of incontinence.
Absorbent pads and urinary catheters may help those individuals who continue to have incontinence. The absorbent pads are not bulky like in the old days but are close fitting underwear with liners. Men also can use a small urine collector that is worn around the penis.
Absorbent products include shields, undergarments, protective underwear, briefs, diapers, adult diapers and underpads.
Hospitals often use some type of incontinence pad, a small but highly absorbent sheet placed beneath the patient, to deal with incontinence or other unexpected discharges of bodily fluid. These pads are especially useful when it is not practical for the patient to wear a diaper.
Growth and development
Most urinary incontinence fades away naturally. Here are examples of what can happen over time:
Bladder capacity increases.
Natural body alarms become activated.
An overactive bladder settles down.
Production of ADH becomes normal.
The child learns to respond to the body's signal that it is time to void.
Stressful events or periods pass.
Many children overcome incontinence naturally (without treatment) as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.
Medications
Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known asdesmopressin, or DDAVP, which recently became available in pill form. Patients can also spray a mist containing desmopressin into their nostrils. Desmopressin is approved for use by children.
Another medication, called imipramine, is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Unfortunately, total dryness with either of the medications available is achieved in only about 20 percent of patients.
If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.
Bladder training and related strategies
Bladder training consists of exercises for strengthening and coordinating muscles of the bladder and urethra, and may help the control of urination. These techniques teach the child to anticipate the need to urinate and prevent urination when away from a toilet. Techniques that may help nighttime incontinence include:
Determining bladder capacityStretching the bladder (delaying urinating)
Drinking less fluid before sleeping
Developing routines for waking up
Unfortunately, none of the above has demonstrated proven success.
Techniques that may help daytime incontinence include:
Urinating on a schedule, such as every 2 hours (this is called timed voiding)
Avoiding caffeine or other foods or drinks that may contribute to a child's incontinence
Following suggestions for healthy urination, such as relaxing muscles and taking your time
Moisture alarms
At night, moisture alarms can awaken a person when he or she begins to urinate. These devices include a water-sensitive pad worn in pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken or be awakened as soon as the alarm goes off. This may require having another person sleep in the same room to awaken the bedwetter.
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