Urinary Incontinence


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Urinary Incontinence refers to involuntary loss of urine. It can affect people of all ages. Many adults keep quiet about the discomfort caused and try to live with it. It affects their quality of life, sexual and social. Slowly, they lose confidence and become introvert. Modern medicine has found ways to mange this problem.

First, let's take a look at how the human body works in normal condition.


Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in incontinence.

Complications that may result from urinary incontinence are:
  • Skin infections: Due to constant wet skin, urinary incontinence can result in skin rashes, infections and skin ulcers.
  • Urinary tract infection: Urinary incontinence may result in repeated urinary tract infection.
  • Effect on your social life: You may refrain from participating in social activities and may stop attending social gathering. You might stop visiting new places where you do not know the location of bathroom.
  • Effect on work life: Frequent urge to urinate may cause you to get up often during office hours thus causing disruption at work. Repeated visit to the toilet may keep you awake at night causing fatigue and tiredness.
  • Effect on your personal life: Urinary incontinence may create distress and depression in your personal life. Your family members may not understand the change in your recent behavior and may not be supportive. Your sexual life may be affected as you might fear of urine leakage.
Incontinence may occur while coughing, laughing or any other movement that put pressure on the urinary bladder. It can also occur due to an overactive bladder. The various types of urinary incontinence and their symptoms are mentioned below:

OVERFLOW INCONTINENCE 
Frequent involuntary passage of some urine is called overflow incontinence and is caused by an inability to empty your bladder. Overflow incontinence occurs because the bladder fills too full and urine passively leaks or overflows through the urinary sphincter. This can occur if the flow of urine out of the bladder is constricted or blocked (bladder outlet obstruction), if the bladder muscle has no strength (detrusor atony), or if there are neurologic problems or nerve damage from diabetes, multiple sclerosis or spinal cord injury. Common causes of bladder outlet obstruction in men include benign prostatic hyperplasia (BPH or nonmalignant enlargement of the prostate gland), bladder (vesical) neck contracture (narrowing of the outlet from the bladder due to scarring or excess muscle tissue), and urethral narrowing (strictures). Bladder outlet obstruction can occur in women with significant pelvic organ prolapse (such as a prolapsed uterus).

STRESS INCONTINENCE 
Loss of urine when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy is called stressed incontinence. Urine leaks out of the body when the stomach muscles contract. The most common cause of stress incontinence is because of problems with the muscles of the pelvis. A less common cause of stress incontinence is a muscle defect in the urethra known as intrinsic sphincter deficiency. In women, physical changes resulting from pregnancy, childbirth and menopause can cause stress incontinence. In men, removal of the prostate gland can lead to stress incontinence. 

URGE INCONTINENCE 
Urge incontinence is an involuntary loss of urine due to a sudden, intense urge to urinate. Your bladder muscle contracts and may give you a warning of only a few seconds to a minute to reach a toilet. Urge incontinence occurs due overactivity of the bladder wall muscle (the detrusor). Urge incontinence may be caused by a problem with the muscle, with the nerves that control the muscle, or both. If the cause is unknown, it is called idiopathic urge incontinence. Urge incontinence may be caused by urinary tract infections, bladder irritants, bowel problems, Parkinson's disease, Alzheimer's disease, stroke, injury or nervous system damage associated with multiple sclerosis. If there's no known cause, urge incontinence is also called overactive bladder. 

MIXED INCONTINENCE 
If you experience symptoms of more than one type of urinary incontinence, such as stress incontinence and urge incontinence, you have mixed incontinence.
A complete medical history, incontinence questionnaire and physical examination help the physician determine the type of urinary incontinence and an appropriate treatment plan. 

Medical History 
Your physician may ask you several questions, to have a better understanding of your particular situation and type of incontinence. Questions focus on bowel habits, patterns of urination and leakage (for example, when, how often, how severe), and whether there is pain, discomfort, or straining when voiding. Your doctor will also want to know whether you have had any illnesses, pelvic surgeries, and pregnancies, as well as what medications you currently use. In certain situations (such as an elderly person with dementia), a mental status evaluation and assessment of social and environmental factors may be performed.

Physical Examination 
A physical examination includes tests of the nervous system and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing suggests a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough suggests 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.

Voiding Diary 
Your physician may ask you to keep a record of your bladder activity. You need to record your fluid intake, fluid output, and any episodes of incontinence. This contributes valuable information to help your physician understand your situation. 

Pad Test 
The pad test determines whether the fluid loss is in fact urine. You may be asked to take a medication that colors the urine. As fluid leaks onto the pad, it changes color indicating that the fluid lost is urine. The pad test may be performed during a one-hour period or a 24-hour period. The pads may be weighed before and after use to assess the severity of urine loss (1 gram of increased weight = 1 ml of urine lost). 

Urine Studies 
Bladder infection, or urinary tract infection, can cause symptoms similar to urge incontinence. Bladder cancer can also cause symptoms of urinary frequency and urgency, so a urine sample may be examined for cancer cells (cytology). To confirm for urinary incontinence, your doctor may obtain a sample of urine for urinalysis and urine culture to see if any bacteria or infection is present.

A study of the urine called a chemistry 7 profile may be performed to test for poor kidney (renal) function, obstructed ureter, or urinary retention. 

Postvoid residual Volume 
The postvoid residual (PVR) volume is the amount of fluid left in the bladder after urination. If the PVR volume is high, the bladder may not be contracting correctly or the outlet (bladder neck or urethra) may be obstructed. To determine the PVR urine volume, either a bladder ultrasound or a urethral catheter may be used. 

In ultrasound, a wand-like device is placed over your abdomen. The device sends sound waves through the pelvic area. A computer transforms the waves into an image so your doctor can see how full or empty it is. Catheter, a thin tube inserted through the urethra, is used to empty any remaining urine from the bladder. 

The initial attempt to urinate should be evaluated for hesitancy, straining, or interrupted flow. A PVR volume less than 50 ml indicates adequate bladder emptying. PVR volume of 100-200 ml or higher on more than one occasion represents inadequate bladder emptying. 

Cough Stress Test 
Cough stress test is a direct observation of urine loss. The bladder is filled through a catheter with sterile fluid until it is at least half full (250 ml). The patient is instructed to bear down and tense the abdominal muscles while holding his breath or simply coughing. Leakage of fluid indicates a positive test result. 

Q-tip Test 
In this, a sterile lubricated cotton swab (Q-tip) is inserted into the female urethra. The cotton swab is tightly fit against the outflow tract of the bladder. The patient is then asked to bear down (Valsalva maneuver) or to simply contract the abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is noted as movement of the Q-tip and may correlate with stress incontinence.

Urodynamic Studies

                                                   

Urodynamics is a study of measuring the pressure in the bladder at rest and while filling. It helps the doctor to check the functioning of the bladder and the urethra. It might involve the use of specialized instruments.

Uroflowmetry

Uroflowmetry, or uroflow, is a study that measures the volume, speed of urination and the duration of urine voided. This test helps the doctor to identify abnormal voiding patters and evaluate bladder outlet obstruction.

Cystometry


Cystometry measures the capacity and pressure changes of the bladder as it fills and empties. This helps the doctor to determine the presence or absence of detrusor overactivity or bladder instability. Simple cystometry detects abnormality in the bladder, a bladder that does not expand enough.

The multichannel cystometrogram performs more complex test and measures intra-abdominal, total bladder, and true detrusor (muscle) pressures.

The voiding cystometrogram, or pressure-flow study is used to diagnose dysfunctional voiding, functional urinary incontinence and bladder outlet obstruction.

A filling cystometrogram assesses bladder capacity, how much the bladder can expand, and the presence of contractions. Gas or liquid is used to fill the bladder to perform this test using a catheter.

Assessment of Urethral Function
  • Urethral pressure profilometry: This measures the resting and dynamic pressures in the urethra.
  • Abdominal leak point pressure: This is also known as Valsalva leak point pressure. This measure allows the doctor to determine cause of stress incontinence. Stress incontinence can be caused due to urethral hypermobility, intrinsic sphincter deficiency, or both in combination. 
    In this procedure, the bladder is filled with 250 mL of fluid by a catheter. Then, the patient is instructed to bear down (Valsalva maneuver) in gradients (mild, moderate, severe) to demonstrate leakage. The lowest amount of pressure required to generate leakage is recorded as ALPP.
  • Cough leak point pressure (CLPP) is determined in a similar way.
Cystogram 
A cystogram is an x-ray of the bladder. In this procedure, a solution containing a contrast agent is inserted into the bladder using a catheter, until the bladder is full. Then, x-ray images are taken of the bladder when full and during and after urination. 

A cystogram helps to diagnose stress incontinence, the degree of mobility of the urethra, and the presence of cystocele (a condition occurring in women when the wall between the bladder and vagina weakens and allows the bladder to droop into the vagina causing discomfort and problems with emptying the bladder). These radiographs (x-rays) also may demonstrate problems with the sphincter muscle (intrinsic sphincter deficiency). 

Electromyography 
Electromyography measures the muscle activity in the urethral sphincter. This kind of test uses sensors placed on the skin near the urethra and rectum that evaluates potential nerve damage. Muscle activity is recorded in a machine which helps the doctor to check if the messages sent to the bladder and urethra are coordinated correctly. 

Cystoscopy 
Cystoscopy deals with the examination of the inside of the bladder. The cystoscope has lenses like a telescope or microscope which allow the doctor to focus on the inner surfaces of the urinary tract. It may help the doctor to diagnose the cause of persistent irritation experienced while voiding or blood in the urine (hematuria). Bladder abnormalities, such as a tumor, stone, and cancer (carcinoma in situ) can be diagnosed with cystoscopy. In some cases, urethroscopy can be performed to assess the structure and function of the urethral sphincter mechanism.
BEHAVIORAL TECHNIQUES 
Changes in the lifestyle and behavioral technique can ease off certain types of urinary incontinence.
  • Bladder training: Learning to delay urination and learning to control the urge to urinate may eventually lengthen the time between trips to the toilet. Bladder training includes double voiding, wherein the person is asked to urinate, wait a few minutes and then try again.
  • Timed urination: Visiting the toilet according to the clock creates a scheduled toilet trips and thus creates a routine.
DIETARY MEASURES 
Dietary changes can help improve the symptoms of urge incontinence in certain cases. Reading food labels and avoiding food that contains stimulants can reduce the urinary urgency and frequency. 
Foods
  • Foods containing hot spices irritate the bladder that can contribute to urge incontinence.
  • Citrus fruits like grapefruits, oranges, lemons are acidic in nature. Consumption of this kind of food may aggravate urge incontinence.
  • Chocolate and caffeine may also worsen urinary incontinence.
Drinks
  • Drinking too much water can worsen irritative bladder symptoms.
  • Caffeine-containing products like tea, coffee, hot chocolate and colas produce excessive urine and worsen symptoms of urinary frequency and urgency.
  • Drinking carbonated beverages, citrus fruits drinks, and acidic juices may worsen irritative voiding or urge symptoms.
  • Artificial sweeteners may contribute to urge incontinence.
PHYSICAL THERAPY
  • Pelvic floor muscle exercises. These exercises tighten your pelvic floor muscle and strengthen your urinary sphincter, effective for stress incontinence and in some cases control urge incontinence. 
    Pelvic floor muscle exercise is called Kegel exercise. The muscle that you use to stop your urine flow is the pelvic floor muscle. To perform the exercise, squeeze the muscles, hold for a count of three and repeat. 
    Kegel exercises will be beneficial only if you are contracting the right muscles and in the right manner. In female, sensing a pulling – up feeling means you are using the right muscle. Men may feel their penises pull in slightly towards their body. If you feel the abdominal, buttock or leg muscles pulling then you are not doing it correctly as Kegel exercise does not involve any other muscle except the pelvic muscle. Your doctor may also suggest vaginal cones, which are weights that help women strengthen the pelvic floor.

MEDICATIONS 
Along with behavioural techniques, medications are also used to treat incontinence. Medicines of this kind include:
  • Anticholinergics. The drugs which fall under this category are oxybutynin, tolterodine, darifenacin, fesoterodine, solifenacin and trospium. This kind of medication is helpful in treating overactive bladder in case of urge incontinence. Possible side effects of these medications include dry mouth, constipation, blurred vision and flushing.
  • Topical estrogen. Topical estrogen applied in low doses in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas which may reduce some symptoms of incontinence.
  • Imipramine. Imipramine is a tricyclic antidepressant that may be used to treat mixed incontinence, urge and stress.
  • Duloxetine. The antidepressant medication duloxetine is sometimes used to treat stress incontinence.
INTERVENTIONAL THERAPIES
  • Bulking material injections for urethral bulking: Urethral bulking involves injecting bulking agent materials, such as carbon-coated zirconium beads (Durasphere), calcium hydroxylapatite (Coaptite) or polydimethylsiloxane (Macroplastique), into tissue surrounding the urethra. This closes the hole in the urethra and reduces urine leakage. Though the procedure requires minimal anesthesia and takes about five minutes, repeated injections are usually required.
  • Botulinum toxin type A. Injections of onabotulinumtoxinA (Botox) into the bladder muscle may be beneficial in case of an overactive bladder and has been found to be a promising theory. The downside is that these injections may cause severe urinary retention that requires self-catheterization and also requires repeated injections every six to nine months.
  • Nerve stimulators: Sacral nerve stimulator is a device which is implanted under the skin in your buttock and resembles a pacemaker. A wire from the device is connected to a sacral nerve. A sacral nerve is an important nerve in bladder control that runs from your lower spinal cord to your bladder. The device emits painless electrical pulses that stimulate the nerve and help control the bladder. 
    Tibial nerve stimulator is also used for treating overactive bladder symptoms, which uses an electrode placed underneath the skin to deliver electrical pulses to the tibial nerve in the ankle. Instead of directly stimulating the sacral nerve, these pulses then travel along the tibial nerve to the sacral nerve to help control overactive bladder symptoms.
SURGERY 
Several surgical procedures may fix problems causing urinary incontinence.
  • Bladder Neck Suspension 
    This type of surgery stabilizes the bladder and urethra. Several different techniques are used and may be referred to as retropubic suspension, transvaginal suspension and Marshall-Marchetti-Krantz (MMK) and Burch procedures, for example. These techniques basically elevate the bladder and urethra and are used for stress incontinence. Generally, the surgeon stitches into the ligaments and tendons that provide support to the pelvic organs and these stitches are tied to the pelvic bone, for example, to provide support to the bladder and urethra. This can be done either through the vagina with a long needle or with an incision into the abdomen.
  • Slings
    The sling procedure is used in females with stress urinary incontinence. A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine, porcine) or the patients' own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a "backboard" or "hammock" of support under the urethra. According to published peer-reviewed studies, these slings are approximately 85% effective. 
    There is a great variety of slings that have been marketed in the U.S. Three of the most common are the Tension-free Transvaginal Tape, the Trans-obturator Tape, and the Minislings. The decision regarding the brand or type of sling to be used is based primarily on individual surgeon’s experience, patient preference and co-morbidities such as prior abdominal surgery or previous anti-incontinence surgery.
Types of Slings
  • Tension-free transvaginal (TVT) sling 
    The tension-free transvaginal| (TVT) sling procedure treats urinary stress incontinence by positioning a polypropylene mesh tape underneath the urethra. The surgery involves two miniature incisions and has an 86-95% cure rate and is a 20-minute outpatient procedure. 
    The complications of TVT sling include, bladder perforation, which can occur in the retropubic space if the procedure is not done correctly. However, recent advancements have proven that the minimally invasive TVT sling procedure is regarded as a common treatment for stress urinary incontinence (SUI). There are many other complications associated with the Tension Free Transvaginal (TVT) Sling including mesh erosion from day 1 up to 7 years later.
  • Transobturator tape (TOT) sling 
    First developed in Europe and later introduced to the U.S. by urogynecologist Dr. John R. Miklos, the transobturator tape (TOT) sling procedure is meant to eliminate stress urinary incontinence by providing support under the urethra .The minimally-invasive procedure eliminates retropubic needle passage and involves inserting a mesh tape under the urethra through three small incisions in the groin area.
  • Mini-sling procedure 
    The mini-sling procedure was released in the United States in late 2006 by Gynecare/Johnson and Johnson under the name of TVT-Secure. American Medical Systems' (AMS) have released a similar version called MiniArc. The TVT-SECUR was designed to overcome two of the perioperative complications reported with use of TVT-Obturator: thigh pain and bladder outlet obstruction. The TVT-SECUR was designed to minimize the operative procedure as much as possible in order to reduce those undesired complications. This new device is composed of an 8 cm long laser cut polypropylene mesh and is introduced to the internal obturator muscle (Hammock position) by a metallic inserter, while no exit skin cuts are needed. The MiniArc is also quite simple and again eliminates the need for skin incisions other than the vaginal incision.
  • Artificial urinary sphincter
    This small device is particularly helpful for men who have weakened urinary sphincters from treatment of prostate cancer or an enlarged prostate gland. Shaped like a doughnut, the device is implanted around the neck of your bladder. The fluid-filled ring keeps your urinary sphincter shut tight until you're ready to urinate. To urinate, you press a valve implanted under your skin that causes the ring to deflate and allows urine from your bladder to flow.
Using a Catheter 

A catheter is a long, thin tube inserted up the urethra or through a hole in the abdominal wall into the bladder to drain urine (subrapubic catheter). Draining the bladder this way has been used to treat incontinence for many years. Bladder catheterization may be a temporary or a permanent solution for urinary incontinence. Different types of bladder in use are:

Indwelling Urethral Catheterization (Foley Catheterization): Indwelling urethral catheters also known as Foley catheters are inserted in the bladder to drain urine. These catheters may be changed at an office, a clinic, or at home by a visiting nurse. Foley catheters are used only in the following situations:
  • As comfort measures for terminally ill patients
  • To avoid contamination or to promote healing of severe pressure sores
  • In case of urethral obstruction that prevents bladder emptying and cannot be operated on
  • In individuals who are severely impaired for whom alternative interventions are not an option
  • When an individual lives alone and a caregiver is unavailable to provide other supportive measures
  • For acutely ill people in whom accurate fluid balance must be monitored.
  • For severely impaired people for whom bed and clothing changes are painful or disruptive.
Indwelling catheters that stay in the urinary bladder for more than two weeks increases the risk of bladder infection. Thus, urethral catheters used for extended treatment needs to be changed every month. Other problems associated are:
  • Encrustation of the catheter
  • Bladder spasms resulting in urinary leakage
  • Blood in the urine (hematuria)
  • Inflammation of the urethra (urethritis)
  • Formation of bladder stones
  • Development of a severe skin infection around the urethra (periurethral abscess)
  • Kidney (renal) damage
  • Damage to the urethra (urethral erosion).
Suprapubic Catheterization: A suprapubic catheter is a tube surgically inserted into the bladder through an incision made in the abdomen (above the pubic bone). This type of catheter is used for long-term catheterization. The hole in the abdomen seals up within one or two days when the tube is removed. Suprapubic catheter is commonly used in people with spinal cord injuries and a malfunctioning bladder. As in the urethral catheter, a doctor or nurse must change the suprapubic tube at least once a month on a regular basis. The advantages of suprapubic catheter as compared to the urethral catheter are:
  • Risk of urethral damage is eliminated
  • Suprapubic tube is more patient-friendly
  • Bladder spasms occur less often because the suprapubic catheter does not irritate the outflow area of the bladder
  • Suprapubic tubes are more sanitary because the tube is away from the urethra/anal area (perineum)
  • Suprapubic tubes may cause fewer urinary tract infections than standard urethral catheters.
Suprapubic catheters are not used in people with chronic unstable bladders or intrinsic sphincter deficiency because involuntary urine loss is not prevented. Potential problems with long-term suprapubic catheterization are similar to those associated with indwelling urethral catheters, including leakage around the catheter, bladder stone formation, UTI, and catheter obstruction. Other potential complications include skin infections (cellulitis) around the tube site.

Intermittent Catheterization: Also known as self-catheterization, the bladder is drained at timed intervals rather than continuously. You can perform intermittent catheterization yourself or you can take the help of a caregiver or health professional. Intermittent catheterization works best for people who are motivated and have intact physical and cognitive abilities. Of all three possible options (urethral catheter, suprapubic tube, and intermittent catheterization), intermittent catheterization is the best way to empty the bladder for motivated individuals who are not physically handicapped or mentally impaired. 
The bladder must be drained on a regular basis, either based on a timed interval (for example, on awakening, every three to six hours during the day, and before bed) or based on bladder volume. 

Advantages of intermittent catheterization include independence and freedom from an indwelling catheter and bags. Also, sexual relations are uncomplicated by a catheter. 

Potential complications of intermittent catheterization include bladder infection, urethral trauma, urethral inflammation, and stricture formation. However, studies have demonstrated that long-term use of intermittent catheterization appears to be better compared to indwelling catheterization (urethral catheter or suprapubic tube), with respect to urinary tract infections, renal failure, and the development of stones within the bladder or kidneys.

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