Definition of Incontinence
It is leakage of urine which is involuntary causing social or hygienic problems and it is objectively demonstrable.Types of incontinence
Stress urinary incontinence- Also commonly known as SUI, (In this article SUI word may be synonymously used for leakage of urine)-It is leakage of urine on pressure on abdomen like coughing straining for stool laughing etc. It is more commonly seen with advancing age
-SUI is not a disease, it is a symptom which can have many causes behind it. Most of the causes are curable and patient can be made dry and safe
-SUI is more common than diagnosed. Many women feel that SUI is normal and they don't seek medical advice
-SUI is also seen associated with minor prolapse. The urinary symptoms are minor and they improve by pelvic floor exercises known as Kegel’s exercises
-In old post-menopausal women of age more than 60, prevalence of SUI is 15 to 20%
-Many a times post micturition dribble is confused with SUI. What happens in these cases is that after passing urine women get up too soon. The last part of residual urine dribbles and gets collected into vagina. when women get up, this urine leaks and gives rise to symptom of incontinence. Detailed history will give clinician an idea and this condition requires no treatment and only e patient education
-SUI is more common in women than men
-One in three women of more than 55 years of age have incontinence issues
-While 1 in 10 men of more than 55 years of age have incontinence issues
-More than 28 % women in their 30s experience loss of bladder control once a month
-Urge urinary incontinence
-In this condition the woman will get a sensation to pass urine and when she goes she can't reach the toilet, and she will leak even before sitting on commode.
-In this condition there is no rise in abdominal pressure, only the bladder contractions are at fault.
-Normally what happens, bladder relaxes when it is being filled with urine. When it is full the person will get the sensation. She will go to the toilet, then bladder contracts and woman will pass urine.
-In condition of urge incontinence, the bladder contracts during filling phase
-Overflow incontinence also known as hypotonic or paralyzed bladder
-In this condition either there is no sensation or less sensation during filling phase-Bladder has no capacity to contract when full. It happens in neurogenic cases like spinal injuries, CNS disturbances like stroke, multiple sclerosis, Parkinson's disease, if the nerve supplying bladder is injured or damaged
-In this condition the bladder is always full, never empty and when it is reached its capacity of 600 ml it will leak the extra urine. This is overflow incontinence.
-It is not necessary that patient will come to doctor with only one kind of incontinence whether urge or stress.
-Large number of patients with come with mixed incontinence some urge plus some stress incontinence
- Continuous incontinence - It is seen in cases of fistulas like vesico- vaginal fistula, urethro- vaginal fistula
Bladder functions are divided into two phases
Filling or storage phase
- In this phase, the sphincters are closed, bladder neck is closed, and it is accepting urine until it reaches 400- 500 ml
Emptying or voiding phase
In this phase bladder neck is open, sphincters are open, bladder is contracting.
Picture of bladder anatomy
Trigone
- it is area of bladder between two ureteric orifices above & bladder neck below which is surrounded by internal and external sphincters and pelvic floor muscles.
Body of bladder is made of detrusor muscle which has two types of receptors.
Parasympathetic receptors- helps in voiding
-There are two varieties of receptors, Acetylcholine and Muscarinic receptors. Their function is to contract bladder and detrusor muscles, and they relax sphincters. This results in voiding of urine.
Sympathetic receptors are of two kinds,
Alfa fibres in sphincters - Their job is contraction of sphincters
Beta fibres in bladder- their job is relaxation of bladder.Their action results in filling of bladder.
Bladder filling and micturition cycle
-When sympathetic system is acting, parasympathetic is suppressed by our brain and bladder is in filling phase.
-When bladder is full signal passes to brain and brain stops suppressing parasympathetic. Now Parasympathetic becomes active and contraction of Detrusor muscles happens as well as relaxation of sphincters. This is voiding phase.
-Pelvic muscles and external sphincters are in our control. Even if detrusor is contracting and toilet is far away, woman can voluntarily contract the pelvic floor and control sphincters and not let the urine leak.
-When she has reached toilet and it is socially acceptable to pass urine then the pelvic floor muscles relax along with external sphincter and voiding happens.
-If bladder is unable to relax completely in filling phase it will hold only small amount of urine leading to frequency of urination along with urgency. If contractions are strong there will be urge incontinence.-If bladder is not able to contract properly there will be, only partial emptying, now in next cycle bladder will take less time to refill, leading to complain of frequency. The residual urine in the bladder make get infected.
-The detailed history will tell what is the core problem.
Summary
-Urge incontinence
- bladder muscle is contracting more than required. For overactive bladder-symptoms are frequency, urgency that are present both in day-time and night-time.
-Stress urinary incontinence
- on increase of abdominal pressure during coughing or sneezing the urine leaks. This happens basically when sphincters are weak especially external sphincter. When pelvic floor muscles are weakened during childbirth all the pelvic organs sag down. In female urethra is small that is 4 cm. when woman coughs and sneezes, pelvic floor muscles do not support in closing the urethra. This will lead to stress urinary incontinence
-If woman is overweight it puts extra pressure on pelvic floor.
-In elderly people secretion of ADH- that is antidiuretic hormone from brain is reduced. They tend to produce more urine and especially in the night. Lack of support from pelvic muscles and other co-morbid conditions like diabetes, Parkinson's disease and CVA- cerebrovascular accidents add to difficulty
- Over consumption of caffeine, alcohol, chocolates, citrus fruit juices may add to problem.
-Overflow incontinence
- in neurological conditions like stroke, CVA
-When patient first presents to OPD, temporary causes of incontinence should be ruled out like- -Infections which may present with frequency and urgency- psychological causes
-Drugs like diuretics, NSAID’S (painkiller) which cause fluid retention and will lead to increased frequency in night as the blood supply to kidney is more at night and it will lead to diuresis which means increased formation of urine
- Anti Parkinson drugs, nasal decongestants, antidepressants, anti psychotics -they usually have anticholinergic component in them. This will lead to decreased bladder contraction which in turn will lead to retention of urine and later on mostly overflow incontinence
- BP medicines like Alpha adrenergic antagonist can cause urethral relaxation and SUI
Diagnosis
Diagnosis is by history and physical examination.
-Urine frequency of up to 7 times in a day is normal. At times we find that patients are drinking lots of water maybe up to 4-5 liters per day and that is why they are passing lot of urine.
-History will also suggest whether woman gets urge and leaks before she reaches toilet or she is not feeling anything but when she laughs and coughs it leaks without any sensation.
-If we come across mixed variety, then we inquire what is troubling her more and treat her for that first.
- If there is burning or pain during passing of urine or there is fever, urine infection should be ruled out.
-If she is drinking lots of water it should be reduced to 2 liters per day.
-CVA/ Stroke/ Parkinson's disease/ multiple sclerosis/ spine injuries should be ruled out.
Physical examination
-If bladder is found full, overflow incontinence should be ruled out
- Bonney’s test -This test is done to assess if there is hypermobility of urethra.
- Neurological examination- anal tone, anal sensation Is checked.
- Bulbo-cavernous reflex on touching clitoris the anal sphincter will contract that means that sensory pathways are intact.
- Voiding diary for overactive bladder (more than 2 times in night).In this diary the time and amount of urination is noted every time with a measuring beaker. Home-stay for 24 hours is mandatory. Whatever is drunk is measured through glass. This test will give idea about functional bladder capacity.
- Ultrasound is done to check post void residue- hypotonic weak bladder will always be partially full and it will fill up early.
Uroflowmetry
-In this test woman passes urine in a commode and there is a transducer below which gives parameters like how much urine is passed, maximum flow rate in ml per second, average flow rate, time of voiding, whether she hesitates. I
n general voiding characteristics can be known.
Before starting anticholinergic drugs, it is very important to know that she is emptying bladder completely with good flow.
Otherwise it will relax the already poorly contracting bladder and her post void residue will increase more.
Urodynamics
-Urodynamics is a general term to describe storage and voiding function of lower urinary tract.
-This study is done in sitting position.
-Two small tubes are passed in the bladder through urethra. One tube is used to fill the bladder at a desired rate of 10 to 30 ml per minute and the other tube is used to measure pressure inside bladder.
- Normal saline is used.
There is one more rectal catheter which measures intra-abdominal pressure.
-When should we do urodynamic study
-If persistent urinary tract symptoms like incontinence, retention, neurogenic bladder for overactive bladder are there.
- If despite presumed appropriate therapy patient still has symptoms like urgency, frequency, and SUI.
-If a surgery is being planned like TOT, Burch’s repair, pubo- vaginal sling, intravesical Botox injections.
-While performing this test privacy should be maintained, adequate antibiotic prophylaxis should be given, if there is UTI it should be treated first.
-During urodynamic studies the patient’s symptoms need to be replicated in real time.
-Before urodynamic studies an ultrasound is important to rule out vesico-ureteral reflux otherwise bladder will not get filled and much of saline will go into kidney.
-In case of mixed incontinence urodynamic study must be done before deciding type of surgery.
-If following symptoms are present like patient is not passing urine freely, post void volume is not less than 50 ml, stream is not good, that means patient is having voiding issues and likely to have bladder weakness. If TOT- tension free obturator sling surgery if done in this patient, her symptoms may worsen as she is already not passing urine well.
Mechanics of bladder filling
-The catheter inside bladder is used for measuring bladder pressure.
-Bladder is an intra -abdominal organ.
-When patient coughs intra-abdominal pressure rises as well as bladder pressure rises.
-Intravesical pressure/ bladder pressure is (Detrusor pressure + abdominal pressure)
-Detrusor pressure is (abdominal pressure - intravesical pressure)
- During filling phase Detrusor muscle is relaxed.
- During voiding- Detrusor contracts but abdominal muscle is relaxed and abdominal pressure does not increase.
Urge incontinence/ overactive bladder
In this type of incontinence during filling phase of bladder itself, so many contractions of detrusor muscle happen
To demonstrate SUI
-Ask patient to cough, the abdominal pressure will increase, intravesical pressure also will increase, but the Detrusor muscle is not contacting.
Valsalva leak point pressure
- helps in differentiating types of SUI.
-If leaking happens at pressure less than 20 CM of water that means sphincters are faulty. In this case Pubo- vaginal sling or tension sling is needed.
-If leak happens at 40 to 50 cm of water pressure that means sphincters are alright but there is urethral hypermobility and urethral support is bad and it does not get squeezed by pelvic floor muscles on rise of intra-abdominal pressure. TOT- Trans Obturator Tension free sling for treatment will be a good option.
Urinary incontinence surgery should be planned as per these guidelines
- High post void residue
- Voiding difficulties
- Overactive bladder
- SUI
-Prolapse of pelvic organs like uterus and SUI may occur together but they may not always be related.
Prolapse surgery should be done on its own guidelines
If patient is having SUI along with prolapse, only prolapse surgery cannot be relied upon for cure of her symptoms.
-Burch’s colpo-suspension is a good option if only abdomen is opened for another surgery. It is very effective.
-50% of patients with SUI can be treated without surgery with the help of Kegel’s exercises if only compliance is maintained and biofeedback is used. 20 repetitions in all three positions that is lying down, sitting and standing with each contraction lasting 6 to 10 seconds. Do contractions in pairs.
- Bladder training with the use of voiding diary, timed voiding is also used.
- Intermittent self-catheterization can be used as a last resort every 3 hours
-Botulinum injections- intravesical for overactive bladder which is not responding to anticholinergic drugs.
-At times in overactive bladder surgery is needed and intestinal conduit is put as a last resort.
-Drug therapy
-Solifenacin
- Oxybutynin
- Flavoxate
- Mirabegron
- Tolterodine
Contraindications to these drugs
- Narrow angle glaucoma
- Pregnancy
- Lactation
Side effects
- Constipation
- Dry mouth
With expert medical care most of women can lead a long, active and successful life.
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