Urinary incontinence – diagnosis & treatment

By Dr Afaf El Ghanimi

Urinary incontinence is defined as the involuntary leakage of urine. It is a common but tabooed problem among many women who suffer from this medical condition in silence. The problem usually ranges from a small leak to releasing larger amounts of urine. For many sufferers, the shame associated with the disease keeps them from enjoying many activities with their family and friends or even completely refraining from sexual activity which in turn cause tremendous emotional distress or secondary problems. Although urinary incontinence is not strictly a woman’s health problem, pregnancy and childbirth, menopause, and the structure of the female urinary tract can make females more susceptible to this ailment which advances with age.

Physiology of incontinence

Urinary incontinence is a result of an imbalance between the urethral closure and detrusor muscle. While the bladder retains a lower pressure than the urethra normally, when we need to void this balance is reversed. In urinary incontinence sufferers, any activity which exerts pressure on the muscle like coughing or sneezing increases the intra-abdominal pressure leaving the differential pressure unchanged i.e. urine is leaked.

Causes

Although urinary incontinence usually signals an underlying problem, excessive consumption of diuretics or even prescription medications which have a diuretic effect, can aggravate the problem.

While urinary incontinence is most common in women, prostate-related problems is the most common cause of incontinence in men. Other problems like kidney stones, multiple sclerosis, Parkinson’s disease, strokes and spinal cord injury can all interfere with nerve function of the bladder.

Types

 ● Stress incontinence

In young women the most common type of urinary incontinence is called stress urinary incontinence (SUI). This is caused by deficient pelvic floor muscle strength which leads to the pressure in the bladder is being greater than the pressure in the urethra, leading to urine leakage while coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure i.e. increase pressure on the bladder. In this case if the pelvic floor muscles are not strong enough the urethra is pushed down at times of increased abdominal pressure, therefore allowing urine leakage.

● Urge incontinence

Urge incontinence also named “overactive bladder” or “spastic bladder” is another type of urinary incontinence which usually affects elderly females. It usually occurs when a person has a strong, sudden need to urinate which usually alarms to an underlying problem. The underlying problem for example, stroke, multiple sclerosis, or Parkinson’s disease causes abnormal bladder contractions. These muscles contract with enough force to override the sphincter muscles of the urethra eventually leading to urine leakage.

● Functional incontinence

Functional incontinence is associated with mental or physical disabilities like Alzheimer’s disease and other forms of dementia or mental confusion although the urinary system itself is intact and functional. In such cases, people may become incontinent because they are indifferent to self-control.

● Structural incontinence

Although rare, structural incontinence can be caused by fistulas resulting from trauma to the area like difficult or obstructed childbirth or even rape. Childhood birth defects like ectopic urether also can cause structural incontinence. A vaginogram aided with contrast media are useful tool in diagnosing this type of incontinence.

● Overflow Incontinence

Patients suffering from overflow incontinence never feel the urge to urinate; which means the bladder never empties and small amounts of urine are leaked continuously. Overflow incontinence is rare in women and are usually caused by conditions like neurogenic bladder, tumours and urinary stones.

● Mixed incontinence

Patients with mixed incontinence suffer from a combination of Stress and urge incontinence and studies suggest that mixed incontinence is the most common reason of urine loss in females.

● Transient incontinence

This type of incontinence can be caused by urinary tract infections, Medications and restricted mobility. This condition is usually temporary. Diagnosis Most patients are advised to keep a diary of their problem. Keeping a record the times of micturitions and voided volumes, incontinence episodes, pad usage, the degree of urgency and physical exercise during urinary leakage are important evaluation tools for assessing the patient’s problem.

● Physical examination

A thorough physical examination includes examination of the abdomen, rectum, genitals, and pelvis followed by the cough stress test. In this test the recompatient is required to cough forcefully. Instantaneous leakage with coughing indicates a diagnosis of stress incontinence while leakage that is delayed or persistent after the cough indicates urge incontinence. The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

● Urinalysis

A thorough urinalysis could identify medical conditions associated with urinary incontinence, such as the following:

● Bacteriuria – presence of bacteria in urine; indicates infection

● Glycosuria – excess glucose in urine; may indicate diabetes

● Hematuria – blood in urine; may indicate kidney disease

● Proteinuria – excess protein in urine; may indicate kidney disease, cardiac disease, blood disease

● Pyuria – presence of pus in urine; indicates infection

● Measuring post void residual urine volume

PVR stands for Post Void Residual urine which measures the amount of urine left in the bladder after urination. While 50 mL of residual urine is considered normal, more than 100 mL suggests an abnormality and 200 mL is a serious warning sign. The most common method for measuring PVR is the use of a catheter which is inserted into the urethra after a few minutes of urination while an Ultrasound scan can be another useful tool in determining the volume of urine.

● Urodynamics

Urodynamics is a medical procedure consists of evaluating the problems in the urinary system and the bladder functions of storing and releasing urine; it’s used to measure the urine flow rate and the bladder capacity.

● Cystometry

Cystometry is a test of a bladder function using a catheter, it helps to evaluate how the bladder is working, and how it stores and releases urine. Cystometry can be performed at the same time as the PVR test.

● Uroflowmetry

Uroflowmetry is a clinical test that measures the speed of urinary flow and the volume of released urine to evaluate if there is an obstruction.

Treatment

There is a wide range of treatments available for urinary incontinence. It ranges from conservative treatment, behaviour management, medications and surgery usually starting with the least invasive treatment first.

● Behavioral techniques

Behavioural treatments include pelvic muscle rehabilitation, retraining the bladder, weight loss and dietary changes, such as alleviating caffeinebased and carbonated beverages, citrus foods and juices, chocolate, highly spicy foods and alcohol. While losing few kilos, especially in the abdomen, can relieve pressure on the bladder and pelvic floor muscles, at the same time patients are taught to “hold on” for increasing amounts of time and to void at regular, scheduled intervals. This technique teaches patients to resist the urge to void and gradually expands the intervals between voiding.

● Exercises

Pelvic floor muscle exercises also known as Kegel exercise is the most common treatment recommendations given to patients with urinary incontinence. It works by strengthening pelvic floor muscles which in turn can reduce stress leakage. Younger patients or new mothers suffering from urinary incontinence resulting from child birth usually benefit the most from this exercise if done least 24 times daily for at least 6 weeks.

● Electrical stimulation

Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This can stabilise overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.

● Medications

There are several medications available in the market prescribed to urinary incontinence sufferers. Menopause can bring incontinence due to the thinning or drying of the urethral wall, in this case a vaginal estrogen cream is recommended.

● Anticholinergic medicines are used to treat urge incontinence by controlling and relaxing the bladder muscles. Such as oxybutynin (Ditropan), tolterodine (Detrol), darifenacin (Enablex) solifenacin (Vesicare) and trospium (Sanctura).

● Imipramine. Imipramine (Tofranil) is a drug used to treat depression, it can be used also to treat mixed – urge and stress – incontinence.

● Alpha-adrenergic agonists such as phenylpropanolamine is very recommended to treat urge incontinence, it may improve symptoms of stress incontinence, especially when combined with estrogens

● Peri/Trans urethral injections

A variety of materials have been previously used with limited success to add bulk to the urethra and thereby increase outlet resistance but associated with the disadvantage of repeating the procedure periodically.

● Surgery

Surgery is considered the last resort for doctors to treat urinary incontinence although most surgical interventions have had high success rates.

The most successful type of surgical intervention for urinary incontinence is called “Marshall Marchetti Krantz (MMK)” with a success rate of 85-90%. It involves placing the surgical sutures at the bladder neck and tying them to the Cooper ligament. However, patients with severe stress incontinence and intrinsic sphincter deficiency undergo the so called “sling procedure”. The goal of this treatment is to create sufficient urethral compression to achieve bladder control.

Urinary incontinence sufferers diagnosed specifically with intrinsic sphincter defect undergo “Tension-Free Vaginal Tape (TVT) placement”. This is procedure in which through a small vaginal incision, permanent mesh-like material is placed underneath the urethra and anchored to the abdominal muscles above the pubic bone. In addition to high success rates ranging from 84 to 95%, it is considered a minimally invasive procedure in which the patient can return to normal work within 2-3 weeks.

In recent years a newer version of this procedure called “Transobturator tape (TOT) sling” has proven popular with doctors and patients – since it is performed as an outpatient procedure with exceptionally speedy recovery where the sling is also inserted vaginally and attached underneath the pubic bone using a smaller, more easily managed needle. Although the sling is placed in the same position as in the T.V.T., the chance of complications is greatly diminished during the surgical insertion because of a greater distance from the vital structures.

Furthermore the T.O.T sling method was further perfected by using the Mini-Sling – the new T.O.T. – which has proven to be safer for the patient and easier for the treating physician since it does not require insertion of long introducer needles through abdominal wall or in close proximity of critical nerves, blood vessels or body organs. As a result, the risk of accidental damage to surrounding body organs and bladder perforation is also minimised.

Additionally, the Mini Sling with adjustable or fixed anchoring means can be positioned into fibro- muscular tissue surrounding urethra, using straight or curved introducer based on patient’s anatomy and physician’s preference for optimum clinical outcome.

● Dr Afaf El Ghanimi is a consultant in Obstetrics & Gynecology at the HealthPlus Women’s Health Center, Abu Dhabi, UAE.


 Date of upload: 20th June 2010