URINARY INCONTINENCE

•	Introduction.
•	History. 
•	Clinical examination.
•	Investigations.
•	Genuine stress incontinence.
•	Detrusor instability. 

Introduction

1.	Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.

2.	It has multiple and broad-reaching effects that influence daily activities, social interactions and self-perception of health.

3.	The prevalence increases with age:

a.	15 – 44 years old: 5% of women.

b.	45 – 65 years old: 10%.

c.	> 65 years old: 20%.

4.	Causes:

a.	Genuine stress incontinence (GSI).

b.	Detrusor instability (DI).

c.	Retention with overflow.

d.	Congenital.

e.	Fistula: urethral, vesical, ureteral.

f.	Underlying disease: diabetes mellitus, diabetes insipidus, cardiac failure, hypercalcaemia.

g.	Pharmacological causes: diuretics, tranquilizers, cholinergic agents, prazosin. 

History

1.	Presenting complaint: duration.

2.	Frequency: day and night.

3.	Incontinence symptoms:

a.	Stress incontinence: urine leaking with straining, sneezing, coughing.

b.	Urge incontinence: urgency, unable to control urge to pass urine.

c.	Nocturia: have to wake up more than once every night to pass urine.

d.	Passage of urine PV: fistula. 

4.	Voiding characteristics:

a.	Hesitation: obstruction when voiding, urethral stricture.

b.	Post-micturition dribble: urethral diverticulum, cystourethrocele.

c.	Incomplete emptying: cystocele or rectocele can press anteriorly on urethra.

d.	Unable to interrupt flow.

e.	Poor stream: bladder outflow obstruction, decreased bladder contractility. 

5.	Symptoms of infection:

a.	Dysuria: urethritis, endometriosis, PID.

b.	Suprapubic pain: inflammation of bladder, bladder stones or tumor.

c.	Loin pain.

d.	Haematuria.

6.	Prolapse:

a.	Lump at introitus.

b.	Dragging sensatioin.

c.	Aggravating factors.

d.	Back pain.

7.	Menstrual history.

8.	Obstetric history:

a.	Parity. 

b.	Prolonged second stage of labor.

c.	Instrumentation.

d.	Big baby requiring forceps delivery.

e.	LSCS.

9.	Past medical history:

a.	Relevant to DI: CVA, head trauma, multiple sclerosis, DM.

b.	Relevant to GSI: chronic cough, constipation, heavy lifting and hernia, intra-abdominal tumors.

c.	Cardiac and renal failure. 

10.	Past surgical history:

a.	Previous incontinence operations have an important influence on future successes of such surgery.

b.	Radical hystectomy: may cause denervation of bladder.

c.	Pelvic radiotherapy: can cause bladder fibrosis.

d.	Surgery to spine and neurological impairment after this.

e.	Operations on large bowel: may result in denervation. 

11.	Drug history:

a.	Diuretics: can produce urgency, frequency and urge incontinence.

b.	Benzodiazepines: sedate and may cause confusion and secondary incontinence.

c.	Anti-cholinergics: impair detrusor contractility. 

d.	Prazosin: cause urethral relaxation and urinary incontinence. 

12.	Assess severity:

a.	Number of pads used.

b.	Impact on social lifestyle. 

Clinical examination

1.	General:

a.	Height and weight: BMI.

b.	Vital signs: pulse rate, BP, temperature.

2.	Cardio-respiratory: cardiac failure and COPD.

3.	Abdomen: scars, abdominal mass, ascites.

4.	Vaginal examination:

a.	Vulval skin: signs of excoriation, edema or erythema due to exposure of skin to urine.

b.	Vaginal atrophy in menopausal women.

c.	Genital prolapse in Sim’s position:

i.	patient in left lateral position.

ii.	insert Sim’s speculum and apply traction on posterior wall.

iii.	separate vaginal walls using a sponge forceps.

iv.	withdraw speculum and look for enterocele / rectocele.

d.	Booney test:

i.	patient told to cough and escape of urine is noted.

ii.	index and middle finger inserted into vagina and the anterior vaginal wall pressed against sub-pubic angle.

iii.	patient now told to cough again.

iv.	if pressure of fingers prevents the leak, anterior repair will cure her.

e.	Urethra: discharge, inflammation, fixation or scarring.

f.	Anterior vaginal wall: any mass that may be a urethral diverticulum or a urethral or vaginal cyst.

g.	Bimanual examination: exclude abnormal pelvic organs, masses, uterine impaction.

h.	Rectal examination: exclude faecal impaction in elderly. 

5.	Q-tip test:

a.	The mobility of the urethra and bladder neck is evaluated by inserting a sterile, lubricated ‘Q-tip’ cotton bud into the urethra to the level of the bladder neck.

b.	The patient is then asked to strain.

c.	The rotational movement of the bladder neck around the symphysis pubis causes the Q-tip to move cranially.

d.	The angle of the Q-tip is measured relative to the horizontal, using an orthopaedic geniometer.

e.	The resting and straining angles are measured and the difference between the two angles is calculated: a change of more than 30 degrees represent a hypermobile urethra. 

6.	Neurological examination:

a.	Tone, strength and movement of lower limbs.

b.	Anal tone.

c.	Sacral reflex. 

Investigations

1.	Mid-stream urine specimen for urinalysis and culture.

2.	Urinary diary:

a.	A urinary diary is a simple record of the patient’s fluid intake and output.

b.	Episodes of urgency and leakage and precipitating events are also recorded.

c.	Can be utilized to monitor conservative treatment.

3.	Pad test:

a.	Pad test are used to verify and quantify urine loss.

b.	The patient wears a preweighed sanitary towel, drinks 500ml of water and rests for 15 minutes.

c.	After a series of defined manoeuvres the pad is reweighed; a urine loss of more than 1g is considered significant.

4.	Uroflowmetry:

a.	Uroflowmetry is the measurement of urine flow rate.

b.	It provides an objective measurement of voiding function.

c.	Indications:

i.	hesitancy or difficulty in voiding in patients with neuropathy or a past history of urinary retention.

ii.	prior to bladder neck or radical pelvic cancer surgery to exclude voiding problems that may deteriorate afterwards. 

d.	The normal flow curve is bell-shaped.

e.	A flow rate below 15mL on more than one occasion is considered abnormal in females.

f.	A low peak flow rate and a prolonged voiding time suggest a voiding disorder. 

5.	Cystometry:

a.	Cystometry involves the measurement of the pressure-volume relationship of the bladder.

b.	Electronic subtraction of abdominal from intravesical pressure enables determination of the detrusor pressure.

c.	Indications:

i.	previous unsuccessful continence surgery.

ii.	multiple symptoms.

iii.	voiding disorders.

iv.	neuropathic bladder.

v.	prior to primary continence surgery.

d.	Procedure:

i.	prior to cystometry, the patient voids on the flowmeter.

ii.	a 12 French gauge catheter is inserted to fill the bladder and any residual urine is recorded.

iii.	intravesical pressure is measured using a 1 mm diameter fluid-filled catheter, inserted with the filling line, connected to an external pressure transducer.

iv.	a fluid-filled 2 mm diameter catheter covered with a rubber finger cot to prevent faecal blockage, is inserted into the rectum, to measure intra-abdominal pressure.

v.	the bladder is filled with a continuous infusion of normal saline at room temperature.

vi.	during filling, the patient is asked to indicate her first and maximal desire to void and these volumes together with symptoms of urgency, pain and systolic detrusor contractions are noted.

e.	Parameters of normal bladder function:

i.	residual urine of less than 50ml.

ii.	first desire to void between 150 and 200ml.

iii.	capacity between 400 and 600ml.

iv.	detrusor pressure rise of less than 15cm H20 during filling and standing.

v.	absence of systolic detrusor contractions.

vi.	no leakage on coughing. 

f.	Interpretation of results:

i.	DI: spontaneous or provoked detrusor contractions occur which the patient cannot suppress.

ii.	GSI: leakage occurs as a result of coughing in the absence of a rise in detrusor pressure. 

6.	Videocystourethrogrpahy:

a.	If a radio-opaque filling medium is used during cystometry, then the lower urinary tract can be visualized by X-ray screening with an image intensifier.

b.	During voiding, vesico-ureteric reflux, trabeculation and bladder and urethral diverticulae can be noted. 

Genuine stress incontinence

1.	GSI is defined as the involuntary loss of urine occurring, when in the absence of a detrusor contraction, the intravesicular pressure exceeds the maximum urethral pressure. 

2.	Prevalence:

a.	More common between the ages of 45 and 54. 

b.	Maximum prevalence of 43% in the 50-year-old age group.

3.	Pathophysiology:

a.	Abnormal descent of the bladder neck and approximate urethra, so that there is failure of equal transmission of intra-abdominal pressure to the proximal urethra.

b.	An intraurethral pressure which at rest is lower than the intravesical pressure may be due to urethral scarring as a result of surgery or radiotherapy.

c.	Laxity of suburethral support normally provided by the vaginal wall, endopelvic fascia and levator ani muscles.

d.	Damage to nerve supply of the pelvic floor and urethral sphincter caused by childbirth.

e.	Menopause and associated tissue atrophy.

f.	Chronic causes: obesity, COPD, constipation. 

4.	Conservative management

a.	Provides cure of up to 60% of incontinent women and has only few complications.

b.	It is inexpensive and does not compromise future surgery. 

c.	Indications:

i.	pregnant women.

ii.	desire to become pregnant.

iii.	unfit for surgery.

iv.	elderly.

v.	waiting for surgery.

vi.	GSI associated with voiding disorders or DI.

5.	Behavioral changes:

a.	Changing fluid intake and voiding pattern.

b.	Weight loss.

6.	Treating aggravating factors that raise intra-abdominal pressure.

7.	Physiotherapy:

a.	Kegel exercises: strengthen muscles of pelvic floor, thereby improving the urethral sphincter function.

b.	Vaginal cones: the woman should try to contract the pelvic floor muscles in an effort to hold the device in place for up to 15 minutes.

c.	Biofeedback: electrodes placed on abdomen and anal area connected to a monitor showing which muscles are contracting.

d.	Electrical stimulation therapy: uses low-voltage electrical current to stimulate and contract the correct group of muscles.

8.	Drug therapy:

a.	Alpha-adrenergic drugs such as phenylpropanolamine.

b.	Estrogen therapy. 

9.	Surgery:

a.	Burch’s colposuspension:

i.	gold standard with success rate of up to 80%.

ii.	suspend the paravaginal fascia to Cooper’s ligaments to create a more acute angle. 

iii.	abdominal procedure.

b.	Transvaginal tape:

i.	small incisions are made in the vagina and the permanent tape is introduced via the vagina to sit under the urethra.

ii.	very high success rate.

iii.	a vaginal procedure.

c.	Periurethral collagen injection.

d.	Anterior colporrphaphy with Kelly’s sutures. 

Detrusor instability

1.	The overactive bladder is defined as a disorder of filling / storage in which involuntary bladder contractions are demonstrated while the patient is attempting to inhibit.

2.	Prevalence:

a.	Overall prevalence in the general population is 10%.

b.	It increases with age, especially after 30.

3.	Etiology:

a.	Idiopathic in 90%.

b.	Neurologic disease.

c.	Bladder outlet obstruction due to pelvic organ prolapse.

d.	Previous pelvic surgery.

4.	Conservative management:

a.	Bladder retraining drills: a programme of scheduled voiding with progressive increase in the interval between each voiding.

b.	Functional electrical stimulation: stimulates the afferent limb of the pudendal reflex resulting in an increase in pelvic floor and urethral striated muscle contractility. 

5.	Drug therapy:

a.	Oxybutynin: it has antispasmodic and anticholinergic properties, reducing the amplitude and frequency of detrusor contractions.

b.	Tolterodine: it is a competitive, specific muscarinic receptor antagonist with selectivity for urinary bladder.

c.	Imipramine: effective in patients with combined GSI and DI.

6.	Surgery:

a.	Bladder distension.

b.	Subtrigonal injection of phenol.

c.	Selective sacral blockades.

d.	Transvaginal denervation of the bladder. 

7.	Mixed incontinence:

a.	Overactive bladder can co-exist with GSI in 30% of patients.

b.	Medical management of DI reduces the need for bladder incontinence surgery.

c.	If patients fail medical management, bladder neck surgery is recommended.