Disease - Incontinence

From CambridgeNotes

Incontinence is the involuntary loss of urine

  • Causes of incontinence
    • Genuine stress incontinence (GSI) – accounts for ~50% causes
    • Overactive bladder – accounts for ~36% causes
    • Bladder distention with overflow incontinence - <1% causes
    • Fistula - <1% causes

History and Examination

  • Main symptoms of overactive bladder = Urgency (severe desire to void), urge incontinence (urgency with leakage), frequency (>6x/day), nocturia (micturition >1/night), nocturnal enuresis (incontinence during sleep).
  • Main symptom of GSI = stress incontinence (leak when coughing)
  • Symptoms suggestive of overflow incontinence = voiding problems (hesitancy, poor stream, incomplete emptying)
  • Symptoms often overlap
  • Also ask: Haematuria? (may suggest malignancy) Dysuria? (may suggest UTI) Fluid intake? Affect on patients life?
  • Ask if fecal incontinence
  • Weight, chest problems (chronic cough); abdominal masses and urinary retention; pelvic masses, prolapse (cystocele?)

Differential Diagnosis

  • Genuine stress incontinence (much more common in women), retention with overflow (much more common in men), overactive bladder, fistula
  • Transient causes e.g. urinary tract infections (UTI), diuretics, diabetes

Investigations

  • MSU and urine dipstix (determine presence of a UTI)
  • Diary: nocturia with small volume suggests neurogenic causes (overactive bladder)
  • Consider pad test to quantify degree incontinence – rarely used
  • Consider methylene blue/IVP to identify a fistula. IVP can also detect stone.
  • Consider cystoscopy if haematuira or abnormal cytology
  • Consider Ultrasound (can visualize cysts and diverticula) or post-micturition catheterisation (determine overflow)
  • If none then do Urodynamics (essential if contemplating surgery). Includes:
    • Cystometry (measures abdominal and bladder pressure when provoked e.g. coughing) . Note can only diagnose GSI if bladder Pressure>Urethral pressure in absence of detrusor contractions. Therefore need cystometry.
    • Uroflowmetry – measure urine flow rate. Normal ~15ml/sec

Treatment

  • Continue to use absorbent pads
  • Simple measures: review medication e.g. diuretics, restrict fluid intake & caffeine, loose weight (especially if GSI)
  • Further treatment depends on cause
    • GSI: If cough or constipation treat. Also physiotherapy (pelvic floor exercises strengthen levator ani) and can enhance with biofeedback or vaginal cones. Medication: Duloxetine. Surgery: colposuspension or tension free vaginal tap (TVT)
    • Overactive bladder: Bladder re-training, Medication: anti-cholinergics (tolterodine XL, oxybutynin XL), Desmopression if nocturia, Imipramine if enuresis. Surgery less helpful (clam augmentation)
    • Fistula: surgery
    • Retention with overflow: treat cause, and intermittent bladder catheterisation
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