- A definition of incontinence involves:
- Involuntary loss of urine
- Causing social or hygiene problems
- That can be objectively demonstrated
- Common and under reported problem
- Affects 4 million people in United Kingdom
- Affects women more than men, particularly the elderly
Classification
- Stress incontinence
- Urge incontinence
- Overflow incontinence
Stress incontinence
- Affects about 30% of women over 30 years
- Usually develops after childbirth
- Symptoms worsen with age
- Incontinence occurs with effort or exertion and is worse when
upright
- Urine loss is seen immediately after a rise in intra-abdominal
pressure
Urge incontinence
- Part of the overactive bladder symptom syndrome
- Patients experience frequency, urgency and incontinence
- Due to detrusor muscle overactivity
Overflow incontinence
- Occurs in both sexes
- Symptoms are often relatively few
- Patients tend to dribble urine
- Men often have a full and palpable bladder
- Women often have abnormal anatomy or a vesicovaginal fistula
Investigation
- The following investigations should be considered
- Mid stream urine specimen
- Renal function
- PSA in men
- Renal ultrasound
- Flexible cystoscopy
- Urodynamic assessment evaluates the function of the bladder
- Results must be interpreted with the clinical presentation
- Assessment can involve
- Frequency-volume chart
- Pad test
- Flow rates
- Residual volume by ultrasound
- Conventional cystometry
- Videocysturethrography - filling and voiding
Management
- Management of incontinence should start with general support
- This involves specialist nurses using appliances, pads, catheters
etc
- Specific treatment will depend on the underlying cause
Urge incontinence
- Overactive bladder syndrome can be managed by
- Behaviour change
- Drugs - anti-muscarinic agents, desmopressin
- Surgery
- Surgical options include:
- Injection of botulinum toxin
- Neuromodulation
- Clam cystoplasty
- Detrusor myectomy
- Urinary diversion
Stress incontinence
- Stress incontinence can be managed by:
- Physiotherapy
- Biofeedback
- Electrical stimulation
- Drugs - duloxetine
- Surgical options include:
- Burch colposuspension
- Anterior colporrhaphy
- Marshall-Marchett-Kranz procedure
- Needle suspension of bladder neck
- Pubovaginal slings
- Periurethral bulking agents
- Implantation of artificial sphincters
Complications of urinary diversions
- Renal and intestinal reservoir stones
- Urinary tract infections
- Metabolic derangements
- Hyperchloraemic acidosis
- Bone demineralisation
- Gallstone
- Reservoir rupture
- Neoplasia
Post-prostatectomy incontinence
- Is a transient phenomenon in many men
- Becomes a persistent problem in about 5% men
- Risk factors include
- Preoperative incontinence
- Neurological disease
- Previous pelvic or prostatic surgery
- Large benign prostate
- 75% cases due to sphincter damage
- 15% due to detrusor abnormality
- Conservative management improves symptoms in 50% patients
Bibliography
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evaluation and management of stress incontinence in women. Curr
Opin Urol 2005; 15: 236-243.
Farnham S B, Cookson M S. Surgical complications of urinary
diversion. World J Urol 2004: 22: 157-167.
Hay-Smith J, Herbison P, Ellis G et al. Which
anticholinergic drug for overactive bladder symptoms in adults.
Cochrane Database Syst Rev 2005; CD005429.
Patki P, Woodhouse J, Bycroft J et al. Stress
urinary incontinence: current understanding. Hosp Med
2005; 66: 335-340.
Pesce F. Current management of stress incontinence. BJU
Int 2004; 94 (Suppl 1): 14-22.
Sutherland S E, Goldman H B. Treatment options for female
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