B19. Urinary incontinence and treatment

Definition and epidemiology

Urinary incontinence is the involuntary leakage of urine. There are multiple types:

  • Stress urinary incontinence
  • Urge urinary incontinence
  • Overflow incontinence – the bladder fills, causing urine to overflow out
  • Functional incontinence – due to mental or physical problems

Stress and urge, as well as a mix of the two, account for 97% of cases of urinary incontinence.

15 – 55% of women are affected by urinary incontinence.

Risk factors

  • Old age
  • White ethnicity
  • Obesity
  • Menopause
  • Multiparity
  • Smoking and COPD
  • Hysterectomy

Stress incontinence

Stress incontinence is the involuntary loss of urine in association with increased intraabdominal pressure, like laughing, coughing, lifting.

Urge incontinence

Urge incontinence is the involuntary loss of urine after feeling a sudden, urgent need to void. It’s sometimes called overactive bladder because it occurs due to a detrusor muscle which is constantly contracting. This reduces the capacity of the bladder, decreasing the amount of urine in the bladder necessary to give the urge to urinate. Patients usually have to go to the bathroom every 30 minutes, even during the night.

It is known simply as “urge” if there is a strong urge to urinate but no incontinence.

Possible causes are:

  • UTI
  • Pelvic organ prolapse
  • Urinary tract tumour
  • Urolithiasis

Diagnosis and evaluation

History is important, especially how many times the patient urinates every day. > 8 can be abnormal, due to urge incontinence, UTI, POP, urethral pathology.

Targeted questions and questionnaires can be used to distinguish the type of urinary incontinence.

Voiding diaries are helpful. For 3 days, the patient fills in what and when they drink, the volume of urinary leakage, and provoking factors of incontinence.

The patient should be examined for urinary retention, which is a sign of incomplete emptying. After urination, the residual urine volume should be assessed by ultrasound or catheterisation.

Physical examination includes checking for urine loss with Valsalva or coughing, as well as a neurological examination. It’s important to check the bulbocavernosus and anocutaneous reflexes, which evaluate the function of S2 – S4.

Other important examinations are:

  • Evaluation for POP
  • Q-tip test (see topic B17)
  • Bimanual rectovaginal examination
  • Urine analysis and culture
  • Urodynamic studies

Urinary tract tumour should be excluded in cases of urge incontinence.

Treatment

The first line treatment is nonsurgical:

  • Pelvic floor exercise (Kegel exercises)
  • Electrical stimulation – if bladder innervation is poor
  • Avoid caffeine
  • Schedule voiding
  • Local oestrogen replacement therapy

In case of stress incontinence, the second line can be surgical:

  • Midurethral sling
    • Gold standard
    • Placement of a synthetic mesh to overcome the loss of pelvic floor support
    • Two approaches are possible:
      • Transobturator approach (transobturator tape) (better)
      • Retropubic approach (tension-free vaginal tape)
  • Other option (not much used)
    • Either Marshall Marchetti Krantz (MMK) bladder suspension procedure or Burch bladder suspension procedure
    • Sutures are attached between the anterior vaginal wall and the Cooper ligament

In case of urge incontinence, the second line can be medical:

  • Muscarinic antagonists – block muscarinic acetylcholine receptors to decrease detrusor contraction
    • Oxybutin
    • Tolterodine
    • Fesoterodine
  • Beta-3 agonist
    • Mirabegron (Betmiga)
  • Intravesicular botulinum toxin injection

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B18. Pelvic organ prolapse; therapy

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B20. Endometrial cancer; FIGO classification and therapy

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