Incontinence

DIfferentials – DIAPPERS

• Delirium, dementia, or other cognitive impairments
  • Impaired ability or willingness to reach a toilet
  • Illness, injury, or restraint that interferes with mobility
• Infection (urinary tract infection)
  • symptomatic with frequency, urgency, sudden onset, or worsening of continence, unexplained fever, or decline in functioning
• Atrophic vaginitis or urethritis
• Pharmaceuticals or substances (e.g., diuretics, caffeine, alcohol)
  • Increased urine production
• Psychological disorder
• Excessive urine output (e.g., diabetes, diabetes insipidus)
• Reduced mobility or reversible urinary retention
• Stool impaction

Other conditions to consider include:

• Neurologic conditions such as spinal cord injuries, cauda equina syndrome, multiple sclerosis, cerebral vascular accidents, normal pressure hydrocephalus, spinal stenosis
• Renal or ureteral calculi
• Intraabdominal or pelvic mass
• Anatomic abnormalities such as urogenital fistulas, diverticula, and ectopic ureters (though these are less common

Red Flags

• Haematuria
• Recurrent/ persisting UTI with haematuria if >40
• Suspected pelvic mass

specific definitions for the terminology commonly used in clinical practice that relate to incontinence:

Types of Urinary Incontinence

1. Stress Urinary Incontinence (SUI)

Symptom:Involuntary leakage of urine during physical exertion, sneezing, or coughing.

Sign: Observation of involuntary urinary loss from the urethra synchronous with exertion, sneezing, or coughing.

Urodynamic Testing: Involuntary leakage of urine during increases in abdominal pressure without a detrusor contraction, observed during filling cystometry.

2. Urge Urinary Incontinence (UUI)

Symptom: Involuntary leakage of urine accompanied by or immediately preceded by urgency.

Sign: Observation of involuntary urinary loss from the urethra accompanied by or immediately preceded by urgency.

Urodynamic Testing: Incontinence related to an involuntary detrusor contraction during urodynamics.

3. Mixed Urinary Incontinence (MUI)

Symptom: Involuntary leakage of urine associated with both urgency and physical exertion, effort, sneezing, or coughing.

other definitions:

Overactive bladder syndrome	Storage symptoms of urgency with or without urgency incontinence, usually with frequency and nocturia
Detrusor overactivity	Diagnosis made on urodynamics testing confirming involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked
Nocturia	Interruption of sleep one or more times at night to void (in practice, a three-day bladder diary should be recorded and assessed)
Nocturnal polyuria	>33% of the total daily urine production occurs at night in older people; >20% in younger people
Nocturnal enuresis	Involuntary loss of urine during sleep
Lower urinary tract symptoms	Includes both storage (ie frequency, urgency, nocturia) and voiding symptoms (ie hesitancy, poor stream, incomplete emptying, post-void dribbling)

subtypes of urinary incontinence may overlap and complicate the clinical picture for the treating physician

Stress urinary incontinence

• Usually due to dysfunction urethral sphincter
• Involuntary leakage due to increases in intra-abdominal pressure on effort or exertion (eg on laughing, sneezing, coughing and lifting)
• Patient can usually predict which activities will cause leakage
• In severe cases, it occurs with minimal activity (eg walking, standing from sitting) and limited awareness of leakage
• Risks
  • prostatectomy
  • TURP
  • pelvic trauma
  • Childbirth
  • Obesity
  • Post-prostatectomy
• Clinical Presentation
  • Triggers (e.g. coughing, laughing, jumping (↑ IAP)) transiently increase intra-abdominal pressure
    • Results in involuntary small-volume leakage of urine
  • Small amounts of urine lost
    • Contrast with large volumes in Urge Incontinence
  • Urine loss stops immediately after activity stops
• Management
  • 1^st line: Pelvic floor exercises
  • general measures:
    • wt loss
    • smoking cessation
    • Tx – chronic cough
    • vaginal ring pessary
  • Vaginal cones → strengthen pelvic floor
    • a wt is placed into the vagina → held in by contraction of the levator ani
    • progress up wts as appropriate
  • Medications
    • Medications have poor efficacy in Stress Incontinence
    • Avoid Anticholinergics (e.g. Oxybutynin) – Not effective in Stress Incontinence (and may worsen symptoms)
    • SNRI – Duloxetine –  stimulates Urethral sphincter contraction – appears effective in some cases
    • Alpha Adrenergic Agonists – No strong evidence supporting use
    • Tricyclic Antidepressants or SNRI – Mixed Urge Incontinence and Stress Incontinence (esp. if comorbid depression, anxiety or Neuropathy), Not indicated in Stress Incontinence alone
  • Surgical Mx
    • Mx of choice
    • only if genuine stress incontinence is proven on urodynamic testing
    • aim – correcting bladder neck relationships
    • Anterior colporrhaphy
    • Retropubic therapy
      • Burch colposuspension
      • MMK
    • Needle suspensions
    • Slings
    • Bulking agents
    • Paravaginal repair
    • Bone anchors

Urge urinary incontinence/ overactive bladder

• Associated with strong sense of urinary urgency
• Urinary Frequency and Nocturia may be present
• inability of the bladder to retain even small amts of urine 2⁰ to:
  • → ↑ sensitivity to filling
  • → ↑ irritability of the detrusor muscle → muscle contraction
• Rule out UTI, stones, carcinoma in situ
• Classification
  • sensory incontinence
    • passes urine b/c it hurts if she does not empty her bladder
      • NOT b/c of involuntary detrusor activity
    • clinical presentation:
      • frequency
      • nocturia
      • + dysuria
      • + S&S of UTI
  • motor urgency (detrusor instability)
    • urge to micturate before the bladder is full
      • occurs at variable intervals
      • volume of voids can vary
    • clinical presentation:
      • frequency
      • + incontinence → if unable to reach to toilet in time
      • + may wet the bed at night
      • dysuria
      • urinary frequency
      • urinary urgency
      • urge incontinence
• Epidemiology F > M
• Risk Factors
  • ↑ age
  • Hx – bed wetting
  • neurological conditions
  • parkinsons
  • stroke
  • inflammatory
  • ageing – atrpophic changes
  • stressors
• Aetiology
  • Unknown
  • Neurologic – Stroke, Demyelinating disease
  • Local Irritation – Urinary Tract Infection – Bladder tumor
  • Idiopathic (most common)
  • Medications
    • Alcohol
    • Caffeine
    • Diuretics
• Triggers
  • running water
  • key in the door
  • anxiety
  • laugh or cough
• Urine Volume lost
  • Few drops to entire Bladder contents
  • Urine loss timing
    • Begins seconds after trigger
    • Continues beyond trigger while detrussor contracts
    • Often occurs while on the way to the toilet
• Complications
  • ↓ quality of life
• Management
  • urethrocystoscopy – exclude a pathological cause
  • bladder retraining
    • → ↑ capacity
    • Kegels
    • Behavioural therapy
  • lifestyle:
    • removal of bladder irritants
    • avoid constipation
    • avoid diuretics – coffee
  • medical: anticholinergics
    • MOA: blocks muscarinic Rcs (detrusor & non-detrusor sites) → prevent OAB symptoms & detrusor overactivity
      • AInhibit parasympathetic – decrease smooth muscle contraction
      • AE – dry mouth, dry skin, blurred vision & constipation
      • Oxybutynin – 5mg TDS
        • Non selective- more SE’s – dry mouth, constipation, blurred vision, drowsiness, delirium
        • Caution drug interactions
        • Contraindicated glaucoma
        • Can try patches – less systemic side effects – skin can react though
      • Solifenacin – 5- 10mg OD
        • Selective M3 receptor
        • Fever side effects
        • Can cause liver damage
  • medical: Beta 3 agonist – mirabegron
    • Upregulates sympathetic activity – reduces destrusor
    • Caution if HTN or long QT
    • Can combine with anti-cholinergic
  • Medical: Vaginal estrogen – estradiol pessaries 10mcg weekly
  • If cystocele – pessary rings – womens health physio
  • OtheR:
    • Intravesciualr botox
    • Sacral nerve stimilation

Functional or behavioural incontinence

• It occurs in otherwise continent people who are unable to reach the toilet in time or who are not cognitively able to recognise the need to void in an appropriate place at an appropriate time.
• Common causes include mobility problems (eg arthritis, insufficient assistance, medications, Parkinson’s disease) and cognitive or psychiatric disorders affecting recognition of the need to void (eg dementia, depression, medications).

Mixed incontinence

• Mixed incontinence is a combination of urge and stress incontinence, for example
  • older women with pelvic floor weakness that leads to idiopathic detrusor overactivity
  • development of urge and stress incontinence following radical prostatectomy.

Overflow (urinary retention)

• Involuntary leakage with loss of fullness sensation from an overdistended bladder
• Associated with obstructive symptoms such as dribbling, hesitancy and poor stream
• Patient often feels that there is incomplete bladder emptying
• Tends to occur with post-void residual volumes of >300 mL
• Due to
  • Overdistention of the bladder from impaired detrusor contractility or bladder outlet obstruction
• Etiology
  • anticholinergic agents
  • Benign prostatic hyperplasia
  • Pelvic organ prolapse
  • Diabetes mellitus
  • Multiple sclerosis
  • Spinal cord injuries
  • Faecal impaction
  • Prostatomegaly or pelvic mass

Estimated prevalence

• Stress urinary incontinence : 24% to 45% in women over 30 years
• Urge urinary incontinence :
  • 9% in women 40 to 44 years
  • 31% in women over 75 years
  • 42% in men over 75 years
• Mixed urinary incontinence : 20% to 30% of those with chronic incontinence
• Overflow urinary incontinence : 5% of those with chronic incontinence
• Functional urinary incontinence: Uncertain

Stages of Assessment

History

• Symptoms: frequency of incontinence, amount of urine loss, use of incontinence products (e.g., pads)
• Fluid intake: volume and type (including caffeine and alcohol)
• Bowel frequency, stool consistency, need to strain
• Medical, past surgical or obstetric history, conditions affecting mobility or dexterity
• Psychological factors
• Patient management and effect of incontinence: anxiety, low self-esteem, embarrassment, social isolation, depression, hygiene problems

patient questionnaire/diary

• International Consultation on Incontinence Questionnaire (ICI-Q), can often provide symptom clarification and serve as a marker for improvement.
• A three-day frequency–volume chart or bladder diary
  • indicating daytime and night-time frequency of micturition
  • episodes of incontinence
  • voided volumes
  • 24-hour urine output
• is often very useful in men who report mixed incontinence

Medication Review

• Urge incontinence: may be caused/aggravated by diuretics, SSRIs, cholinergic and anticholinesterase agents
• Stress incontinence: may be caused/aggravated by alpha-adrenergic blockers
• Chronic urinary retention: may be caused/aggravated by anticholinergic agents, verapamil, pseudoephedrine, opioids, psychotropic medications
• Functional incontinence: may be caused/aggravated by psychotropics, analgesics

Physical Examination

• Frailty: does the patient appear frail?
• Physical disability: observe mobility and transfers
• Cognitive impairment: briefly assess cognitive function
• Abdominal assessment: check for enlarged bladder, pelvic masses
• Gynaecological examination: atrophic vulval/vaginal changes, prolapse, urine loss on coughing
• Rectal examination: constipation/faecal impaction, prostatic hypertrophy, anal tone, perineal sensation
• Perineal skin examination: inspect for dermatitis or thrush
• Lower-limb neurological examination: focus on weakness and upper motor neuron signs
• Signs of associated conditions: diabetes, neuropathy, cerebrovascular disease, Parkinson’s disease, depression

Initial Tests

• Urinalysis
• Bladder diary
• Bladder scan for post-void residual
• Renal function
• Fasting glucose level
• PSA
• Renal ultrasound (USS):
  • Haematuria on urinalysis
  • Recurrent UTIs
  • Benign prostatic hypertrophy: estimate prostate size
  • Chronic retention: observe bladder trabeculation
  • Upper-tract dilatation: lower urinary tract obstruction
• Cysto-urethrography or CT:
  • Identification of fistulas, strictures, bladder diverticulae, tumours

Specialised Tests

• Cystoscopy:
  • Depends on patient’s clinical circumstances
• Urodynamic Study:
  • Specialised study of bladder function during filling and voiding
  • Conducted by urologists, urogynaecologists, or geriatricians
  • Considered if results will influence management (e.g., surgical treatment)
  • Generally not considered for most older patients
  • Appropriate for mobile, medically fit patients who are surgical candidates

Indications for specialist (Red flags)

• Lack of response to an adequate trial of conservative therapies
  • bladder training
  • pelvic floor muscle therapy
  • drug therapy
• Haematuria –  without infection and/or abnormal urine cytology
• neurological condition
  • multiple sclerosis
  • spinal cord lesions
  • cerebrovascular disease
• Prostate nodule or family history of prostate cancer
• Suspected pelvic mass or urogenital fistulae
• Symptomatic prolapse
• high postvoid residual urine volume/Palpable bladder after voiding
• Persistent pelvic pain
• Voiding difficulty
• Previous continence surgery or pelvic cancer surgery
• Poor response to conservative management
• Unclear type/diagnosis of incontinence

Treatment

• Aim: first-line treatment for urinary incontinence and can improve urinary symptoms and QoL

“feeling dry, being natural, not causing embarrassment, being easy and not resulting in dependence”

	STRESS	URGE / Overactive Bladder
Non-pharm	Lifestyle Modifications Weight Loss and Exercise– Reduces SUI Fluid and Caffeine Restriction: caffeinated beverages, alcohol, citrus fruits, chocolate, tomato, spicy foods, tobacco Constipation and Straining – May increase the risk of pelvic organ prolapse and SUI. Bladder Retraining (Timed Voiding): Regularly scheduling urination to empty the bladder for longer periods. Biofeedback: Visual or audio signals to assist in proper pelvic floor muscle contractions.	Lifestyle Interventions Weight Loss and Exercise– Reduces to a certain extent, UUI, in morbidly obese patients. Fluid and Caffeine Restriction: May reduce urinary incontinence (UI). Constipation Avoidance: Soft stools every 1–2 days, Increase daily fiber intake. Use stool softeners, bulking agents, osmotic laxatives, stimulant laxatives. Pelvic floor muscle training (PFMT) Bladder Training
Non-pharm women specific	Pelvic Muscle Exercises (Kegel Exercises) Pessaries: Common types: ring and Gellhorn pessary. Assist in elongating and elevating the urethrovesical angle. Requires proper fitting to avoid complications.
Pharmacological	Medical treatments are generally less effective for stress urinary incontinence (SUI) SNRIs –Duloxetine: Relaxes the bladder and increases outlet resistance. Tricyclic Antidepressants: Alpha-adrenergic effects aiding in urethral contraction and closure. avoid Avoid Anticholinergics (e.g. Oxybutynin) in stress incontinence, Not effective in Stress Incontinence (and may worsen symptoms), can cause confusion, can interfere with the positive effects of cholinesterase inhibitors used for the treatment of dementia	Antimuscarinic Agents – Reduce involuntary detrusor contractions mediated by acetylcholine. – Oxybutynin – Tolterodine – Darifenacin – Solifenacin Beta-3 Agonist Therapy – Mirabegron
Pharmacological men specific	Antibiotic Prophylaxis: For recurrent UTIs (controversial due to potential microbial resistance).	Alpha-Blockers: for BPH related OAB ie: Tamsulosin, alfuzosin, silodosin, Dutasteride-Tamsulosin Combo
Pharmacological women specific	Topical/intravaginal Estrogen: Applied topically to increase urethral blood flow and sensitivity of alpha-adrenergic receptors.
Surgery	Reinforce pubourethral ligaments and paraurethral connective tissue at the mid-urethra.	Intravesical Botulinum Toxin A:Bladder injections inhibit muscle contractions Effective for 6–12 months, repeatable Risks: Urinary retention, need for temporary catheterization Sacral Nerve Stimulation: Implant electrode in S3–S4 sacral foramen 90% show >50% improvement in symptoms Risks: Pain, infection, need for surgical revision, battery replacement Peripheral Tibial Nerve Stimulation (PTNS):Electrode inserted above medial malleolus Weekly treatments for up to 12 sessions Mild pain and bleeding as possible side effects Contraindications: Pacemakers, pregnancy, prior nerve damage Indwelling/Suprapubic Catheter: Long-term solution for intractable incontinence. Last resort, due to risk of UTIs and other complications. Urinary Diversion (Extreme Cases):Ileal conduit with/without cystectomy, Considered after thorough counseling in high-volume centers
Surgery men specific	Male Sling Procedures: Provides support to the urethra. Artificial Urinary Sphincter (AUS): Considered the gold standard for severe cases, especially post-prostatectomy. Dilation of Urethral Stricture Prostatectomy
Surgery women specific	Urethropexy Sling procedures Colposuspension

Other Non-Pharmacological Measures:

• Regular Toileting Habits: Encourage complete bladder emptying.
• Incontinence Products: Disposable pants, absorbent bedding.
• Mobility Aids: Bedside commode, urinal, over-toilet frame.
• Trip Planner/Toilet Map App:
  • Provides locations of accessible toilets.
  • Opening hours and accessibility details.
  • MLAK (Master Locksmith Access Key) access for public facilities.

Role of Healthcare Professionals

• Continence Therapist
  • Assist in PFMT and bladder training.
• Physiotherapist
  • Specialized in PFMT and bladder training for urinary incontinence.

Pelvic Floor Muscle Training (PFMT)

• encompasses a variety of exercises and techniques aimed at improving pelvic floor function/strengthening the pelvic floor muscles.
• may include Kegel exercises, biofeedback, electrical stimulation, and other pelvic floor strengthening techniques.
• Goals: Improve muscle strength, endurance, and coordination to manage and prevent incontinence, support pelvic organs, and enhance sexual function.
• Continued for 3-4 months before assessing success.
• Three sets of 8-12 slow maximal contractions sustained for 6-8 seconds, repeated 3-4 times per week.
• 2001 Cochrane review: Women undergoing PFMT were seven times more likely to be cured and 23 times more likely to show improvement.
• Can be combined with biofeedback equipment (intravaginal resistance devices or weighted vaginal cones), though these do not improve PFMT efficacy.

Bladder Training (UUI)

• Noninvasive, inexpensive, and easy.
• Includes PFMT, a scheduled voiding program with gradual increases in duration between voids, and urge suppression techniques (distraction or relaxation).
• Cochrane review suggests bladder training may be more effective than placebo but lacks sufficient data to determine its usefulness as a supplement to other therapies.
• Recommended Initial Bladder Training
  • Bladder Diary: Keep a record of urination times, fluid intake, and incontinence episodes for 3-7 days to establish a baseline.
  • Scheduled Voiding:
    • Fixed Intervals: Start with a set schedule, such as every 1-2 hours, regardless of the urge to urinate.
    • Gradual Increase: Gradual increase by 15-30 minutes per week until a 2-3 hour voiding interval is reached.
  • Delay Techniques:
    • Suppress Urge: When feeling the urge to urinate, use techniques such as deep breathing, distraction, or pelvic floor muscle contractions (quick Kegels) to delay urination.
  • Timed Voiding:
    • Structured Schedule: Adhere to the voiding schedule strictly, even if there’s no urge to urinate at the scheduled time.
  • Fluid Management:
    • Monitor Intake: Distribute fluid intake evenly throughout the day and limit fluids in the evening to reduce nocturia.
    • Avoid Bladder Irritants: Reduce or eliminate caffeine, alcohol, and spicy foods.
  • Best undertaken with the assistance of a continence therapist.

MEDICATIONS

SNRIs –Duloxetine

• May be effective in SUI.
• Mechanism: Relaxes the bladder and increases outlet resistance.
• Common adverse effects: Nausea, fatigue, dry mouth, constipation.

Anticholinergic agents

• Oxybutynin/ditropan – 5mg TDS
  • Start at low dose (2.5 mg at night), increase slowly (up to 5 mg three times daily).
  • SE’s – dry mouth, constipation, blurred vision, drowsiness, delirium
  • Contraindicated glaucoma
  • Can try patches – less systemic side effects – skin can react though
• Solifenacin/Darifenacin:
  • Fewer anticholinergic side effects.
  • Darifenacin is better for patients with cognitive impairment.
• Avoid Anticholinergics (e.g. Oxybutynin) in stress incontinence
• Not effective in Stress Incontinence (and may worsen symptoms)
• can cause confusion
• can interfere with the positive effects of cholinesterase inhibitors used for the treatment of dementia

Alpha or beta adrenoceptor agonists

• without anticholinergic side effects.
• mirabegron
  • Upregulates sympathetic activity – reduces destrusor
  • Monitor blood pressure
    • Caution if HTN or long QT
    • contraindicated in severe uncontrolled hypertension.
  • Can combine with anti-cholinergic

Serotonin–Norepinephrine reuptake inhibitors

• duloxetine

Alpha-Blockers

• for treating possible bladder outlet obstruction related to prostatic enlargement because of benign prostatic hypertrophy
• prazosin or dutasteride–tamsulosin
• Prazosin tends to lower blood pressure, which increases the risk of falls.
• Dutasteride with tamsulosin has become a preferred option for the geriatric cohort.
• Tamsulosin alone is funded under the Department of Veterans’ Affairs and not the PB