- Types of incontinence
- Risk Factors
- Normal micturition
- Stress incontinence
- Urge Incontinence
- Overflow Incontinence
- Post-micturation dribble
- Treatment of Overflow incontinence
- Functional incontinence
- History, Examinations and Investigations
Types of incontinence
- women are more likely to be affected due to weakened pelvic floor / sphincter muscles, as a result of childbirth
- Bowel Dysfunction
- Diestary factors (caffeine, alcohol)
- Drugs (TCA's, diuretics)
- Bed wetting - see Incontinence in Children
Pelvic floor exercises - improves symptoms in 50% of cases
Intravaginal electrical stimulation may help, but many women find this unacceptable.
Ring pessary – this is rubber/metal/plastic ring in which the cervix of the uterus sits. It is usually used to prevent prolapse of the uterus. A prolapsed uterus is basically where the uterus slips downwards – it may move so far that is protrudes out of the vaginal orifice. This occurs due to dysfunction of the muscles that usually hold the uterus in place.
Duloxetine – is a SNRI (serotonin-norepinephrine reuptake inhibitor) that is usually used to treat depression. It will not cure the condition, but will relieve symptoms in about 50% of cases, but has significant side effects, including nausea, vomiting and abdominal pain
Surgery – if pelvic floor exercises are unsuccessful, another option is surgery. You can surgically alter the position of the bladder or the urethra to relieve symptoms of this condition:
Sling procedure – this is about 85% effective and is the procedure of choice for most women. A sling is created, either from native body tissue (such as fibrous connective tissue from the rectum) or man-made materials (such as telfon – although these are not as effective as natural body tissue). The sling is attached to the abdominal wall, and lifts up the top part of the urethra thus increasing pressure around this region and reducing incontinence.
- The procedure involves open surgery, and thus there is a recovery period of 2-4weeks, although patients may return home after 3-4 days.
- There is a chance that the procedure will have to be redone within 10 years
- Tension-free vaginal tape (TVT)– this is a more modern procedure, and basically has fwere side-effects, and higher success rate than a sling procedure. It is does via the vagina under local anaesthetic, and can be done as an outpatient procedure.
- Cholposuspension – this is a large operation in which the bladder is attached to the posterior abdominal wall. It is more effective than a sling procedure, but is a much more serious operation. It also means you can’t have children after you have had it done. This has an 85% success rate. There is a 5% risk of incontinence or difficulty passing urine afterwards.
- Try limiting fluid intake and avoiding irritant foods
- Examine for spinal cord and CNS signs to determine if is it as a result of brain damage.
- Test for vaginitis (inflammation of the vaginal mucosa).If this is present, then treat with estriol. If there is a long history of vaginitis, and there has been no hysterectomy, consider treatment with cyclical progesterone, as this reduces the risk of uterine cancer.
- Basically, this is very hard to treat. Often it involves a disabled patient with a CNS condition. Try a toilet regimen (perhaps every 4 hours) – the aim being to keep the bladder volume below that which triggers the incontinence. It might also be necessary to try aids, such as pads.
- Drugs – there are several drugs available, although their efficacy is debateable. Often anticholinergic drugs may be used as these will reduce the activity of the autonomic nervous system (which will control bladder contraction in the lack of conscious control seen in conditions of brain damage). Examples include oxybutynin and tolterodine. You should avoid giving these if there is a history of UC or glaucoma.
- Botox to the bladder neck may also be considered
- Urethral stricture – such as an enlarged prostate, and perhaps kidney and bladder stones.
- Detrusor weakness –this may be seen in multiple sclerosis, where signals from the bladder about bladder fullness are not transmitted properly. Diabetes may also cause an autonomic neuropathy in a similar manner.
Treatment of Overflow incontinence
- Identify and eliminate the obstruction
- Consider alpha-block for prostatic enlargement (e.g. doxasosin)
- Consider catheterisation
- Use of portable commode and pads can improve QoL, but risk of UTI and skin irritation.
History, Examinations and Investigations
History and Diagnosis
- A detailed history may indicate a relationship with certain activities or drugs. Keeping a voiding diary may be useful including the volume of urine passed, frequency and any precipitating factors.
- Check bowel function and other medications.
- Ask about obstructive symptoms in men.
Examination - Abdomen (identify distended bladder)
- Perineum (look for urine leak with coughing)
- Vagina (prolapse or fistulae)
- Rectum (constipation or prostatism).
- Check perianal sensation and reflexes to rule out neurological deficits - the same nerve root supplied perianal sensation and the sphincter muscles
- General neurological exam to exclude multiple sclerosisLumbar spine should be inspected to rule out spina bifidaFull cognitive and mobility assessment – the bladder could be normal, but they just don’t get there in time!
- Urine dipstick test – rule out UTIPost-voiding bladder scan – identifies residual urine.Urodynamic testing is not diagnostic, but should be performed prior to surgical intervention.