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Urinary Incontinence

Urinary incontinence is defined as objectively demonstrable involuntary loss of urine so as to cause hygienic and/ or social inconvenience for day-to-day activity.

 

 

Classification

Urethral

Extra-urethral

1. SUI

2. Urge incontinence

3. Mixed

4. Overflow incontinence

1. Acquired

 Fistulas

 e.g., VVF, urethral-vaginal fistula

2. Congenital e.g., ectopic ureter

 

Types of Urinary Incontinence

 
 

Stress urinary

incontinence

Urge urinary

incontinence

Mixed incontinence

Functional

incontinence

Bypass incontinence

It is involuntary escape

of urine when intra

abdominal pressure

is increased as in sneezing or coughing

or laughing.

 

Involuntary leakage

accompanied by or

immediately preceeded

by the urge to void.

 

Both SUI and urge

incontinence together

 

It is associated with cognitive,

psychological or physical impairment that makes it difficult to reach the toilet.

 

May be caused by

urogenital fistula or any congenital abnormality

 

It is the most common

variety of urinary

incontinence.

 

Involuntary detrusor

muscle contractions are typically the cause

of urge incontinence.

 

 

A useful mnemonic for functional incontinence

is DIAPERS

D = Delirum

I = Infection

A = Atrophy

P = Pharmacological

drugs

E = Endourinopathy

R = Restricted mobility

S = Stool impaction

 

 

Stress Urinary Incontinence

 

Stress urinary incontinence (SUI) is defined as involuntary escape of urine from external urinary meatus due to sudden rise in intra-abdominal pressure (coughing, sneezing, etc.).
 

SUI:

 

- Bladder neck descent + urethral hypermobility (75 – 80%)

 

- Intrinsic sphincter defect (20-25%)

 

Causes of SUI

  • Prolapse uterus
  • Postmenopausal atrophy
  • Childbirth trauma
  • Pregnancy

Tests for SUI

  • Bonney's test is used to demonstrate SUI and find out the cause for it. In a patient with SUI, two fingers are inserted m the paraurethral region and the bladder neck is lifted up, and then the patient is asked to cough. If SUI gets corrected, then it is due to bladder neck descent urethral hypermobility. If SUI persists, it is due to intrinsic sphincter defect.
  • Marchetti test is same as Bonney's test, except that instead of two fingers two Allis forceps are used.
  • Q tip test: A sterile cotton swab is introduced into the level of bladder neck. Then the patient is asked to strain.
     
    Marked upward elevation of cotton tip (>30°) indicates urethral hypermobility. Goniometer is used to measure the urethero-vesicle angle.
  • Urethral pressure profile test: During strain there is a significant lowering of urethral closure pressure.
  • Leak point pressure test: The patient is asked to strain, and the minimum pressure (cm of water) at which leakage is observed is recorded as valsalva leak point pressure. This gives us an idea of the strength of sphincter.

Surgeries of SUI

 

Midurethral Sling

Newer Surgeries for SUI

 

TVT: tension-free vaginal type

 

TOT: Transobturator tape

 

Urge Incontinence

 

Sensory

Motor (Detrusor Overactivity/Instability)

• UTI/ cystitis/ trigonitis

• Cerebrovascular accident

• Urethral obstruction

• Alzheimer's disease

• Bladder stones

• Parkinsonism

• Bladder cancer

• Multiple sclerosis

• Sub urethral diverticula

• Diabetes

• Foreign bodies

• Peripheral neuropathies

 

• Autonomic neuropathies

 

• Cauda equina lesions

 

Investigation of Urge Incontinence

  • Urine culture (to rule out infection)
  • Cystourethroscopy (to rule out causes like bladder tumor/ calculus)
  • Cystometry: Main objective is to rule out urge incontinence

Drugs Useful in Treating Detrusor Overactivity (Anticholinergic)

  1. Tolterodine
  2. Hyoscyamine sulfate
  3. Oxybutynin chloride
  4. Dicyclomine hydrochloride

Clinical Features

 

Stress Incontinence

Urge Incontinence (Sensory)

Detrusor Instability

Leakage of urine coincides

Unable to control the escape of

The incontinence may occur abruptly

with stress

urine once there is urge to void

even without a full bladder

No prior urge to void

 

 

Amount-small

Amount-large

Amount-large

Patient-fully aware of it

Patient-aware of the urge

Patient-not aware of it

Micturition-normal

Urgency and frequency

Frequency and nocturia





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