Urinary incontinence

Definition

Urinary incontinence is defined as any uncontrolled loss of urine from the urethra. Continence depends on the functional integrity of the bladder and the urethral sphincter mechanism.

Incidence

Up to 15% of women between the age of 30 and 40 are incontinent as are 25% of the women between the age of 40 and 50. Over 60% of women on geriatric wards have been reported to be incontinent.

Classification

Five forms of incontinence are distinguished:

  1. Imperative urinary urge incontinence: Urine loss with an uncontrollable urge to void, as with infections, bladder stones and rarely bladder tumors.
    1.a. sensory urge: hypersensitive bladder, without bladder contractions
    1.b. motor urge: with bladder contraction
  2. Reflex incontinence: Urine loss through uncontrollable bladder contraction without urgency, e.g. neurologic disorders.
  3. Stress incontinence: Insufficiency of the urethral sphincter mechanism. There are 3 degrees:
    I Urine loss when coughing, sneezing, laughing;
    II Urine loss with movement  as when climbing stairs or lifting weights;
    III Urine loss when lying as well as standing.
  4. Overflow incontinence: As consequence of a chronic lower urinary tract obstruction with stretching of the bladder musculature, as for example with benign prostatic hyperplasia.
  5. Extraurethral incontinence: Fistulas, as between the bladder and vagina.

Frequency

Stress incontinence 40%, urge incontinence 20%, mixed forms 38%, other 2%.

Evaluation

  • History: voiding habits, incontinence characteristics (when? where? why? how often?), previous surgery and medications
  • Clinical examination including gynecological and neurological examination
  • Depending on the findings of the clinical examination: urinary sediment, cystoscopy, x-ray and urodynamic (pressure measurements in the bladder) evaluation.

Treatment

Treatment basicly depends on the form of incontinence.

a) Conservative: Exercises and rehabilitation of the pelvic floor. Changes in drinking habits, drug consumption, the use of pads, pessaries, catheters etc.

b) Surgical: Again the treatment depends on the etiology of the incontinence.

  • Urge incontinence: treatment of the cause such as bladder stone removal
  • Reflex incontinence: electrical neuromodulation of the nerve roots, bladder augmentation with a piece of small intestine
  • Stress incontinence: collagen injection, abdominal bladder neck suspension (Marshall-Marchetti-Krantz, Burch) or vaginal bladder neck suspension, sphincter prosthesis
  • Overflow incontinence: Treatment of the outflow obstruction, e.g. transurethral resection of the prostate
  • Extraurethral incontinence: treatment of the fistula.