Urinary Incontinence in women

Urinary incontinence

• Stress – involuntary leakage of urine on effort, sneezing or coughing

• Urgency – involuntary leakage accompanied or immediately preceded by a sudden desire to pass urine which is difficult to defer.

• Mixed – Combination of above

Other urinary problems

• Overactive bladder – urgency, frequency and nocturia

• Chronic urinary retention ( overflow) – bladder can’t empty completely and becomes over distended

• Detrusor over activity – seen by urodynamic study's – detrusor contractions during the filling phase (spontaneous or provoked)

SUI• Bladder pressure exceeds the urethral pressureAssociated with-• loss of pelvic floor or damage to urethral

sphincter (pudendal nerve often damaged during NVD)

• Increase in intra-abdominal pressure eg if pregnant or obese

• Deficiency in supporting tissues – prolapse• Lack of oestrogen – may decrease urethral

closure pressure

OAB

Multiple causes including•Lower urinary tract conditons – eg UTI, obsturction, oestrogen deficiency•Neurological conditions – brain stem, spinal cord or peripheral nerves•Systemic conditions – eg HF or DM•Functional and behavioral disorder – excess caffeine of constipation

Overflow

• Outflow obstruction – tumour, cystocele or constipation

• Detrusor under activity causing distension often from neurological cause (spinal cord injury, pelvic fractures, DM, MS, surgery)

Other cause

• Fistula• Urethral diverticula• Intercurrent illness• Congenital lesions• Cognitive impairment• Prolapse• Drugs – alcohol, diuretics, alpha adrenergic

blockers or agonists, diuretics etc

Risk factors

• Increasing age• Vaginal delivery• Increase parity• High birth weight• Obesity• Family history

Consequences• Psychological problems: depression, feelings of shame, loss

of self confidence, poor self-rated health, low self esteem, guilt, social isolation.

• Sexual problems: incontinence during sex may cause embarrassment

• Loss of sleep: nocturia and fear of leakage.• Constipation: due to limiting fluid intake.• Falls and fractures: particularly in older people who have

to rush to the toilet.• Impairment in quality of life.• Financial problems: cost of pads, protective bedding, and

laundry.

Differential

• Vaginal discharge• Sweat• Amniotic fluid (if pregnant)• Psychological• Normal - The normal volume of urine passed

per void is between 200 mL and 400 mL, average voiding frequency is 4-8 times daily, including one void per night.

Management

• History and exam ( check for prolapse, dryness, vaginal tone)

• Dipstick urine – if positive M,C&S.• Bladder diaries• Lifestyle advice• Pelvic floor excercises

SUI management

• At least 12 weeks pelvic floor exercises• Surgery - Retropubic mid-urethral tape (open

colposuspension and autologous rectal fascial sling are recommended alternatives)

• Duloxetine 2nd line if not for surgery• Continence advisor

Urge Incontinence

• Bladder training• Oxybutynin ( if not tolerated other anti-

muscarinics eg tolteridine, solifenacin) – review after 6 weeks and discuss s/e

• Consider vaginal oestrogen• Desmopressin for nocturia (unlicensed)• If all fail consider referral for sacral nerve

stimulation, botox or surgery