Urinary Incontinence

Definition and Overview

Image courtesy of Diabetes.co.uk Opens in new window Urinary incontinence (UI) is generally defined as involuntary loss of urine sufficient to be a problem. In a more favored definition offered by the International Continence Society (ICS) Opens in new window, urinary incontinence is defined as a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable.

Urinary incontinence is a highly prevalent condition that has a major impact on the lives of millions of individuals worldwide (Abrams & Wein 1997). It may influence the social, occupational, domestic, physical, sexual and psychological functioning of approximately 15–30% per cent of women of all ages and often leads to the placement of elderly people in nursing homes (Jackson 1997; Kobett 1997; Ouslander et al 1988).

Contrary to popular belief, in which people consider urinary incontinence a natural part of ageing. It is not! The vast majority of older women do not have the disorder. Most people are not aware that young women can also have urinary incontinence.

Since urinary incontinence is so frequently associated with ageing, younger women (perhaps because of embarrassment, or the erroneous belief that incontinence is part of the normal ageing process and that effective therapies are not available) are even less likely to inform a clinician about their condition (Jackson 1997; Ouslander et al 1988). The good news is that there are now many ways to treat individuals who have the disorder.

Types of Urinary Incontinence

Urinary incontinence is of various types; the two most common types are stress incontinence—the loss of urine as a result of laughing, coughing, or sneezing; and urge incontinence—the loss of urine preceded by a strong urge to void. This is sometimes called overactive bladder.

Sometimes an individual has both types of incontinence at the same time. This combination of types of urinary incontinence is called mixed incontinence. The chart below gives brief definitions of the types of urinary incontinence.

Different types of urinary incontinence have different causes, and different treatments solve each type. Since the disorder has major impact on patient’s quality of life hence the evaluation should lead to paths to assist in the diagnosis and treatment of incontinence by types and patient type.

Causes of Urinary Incontinence

Fundamentally, urinary incontinence occurs when intravesical pressure exceeds intraurethral pressure during bladder filling. It may result from an uninhibited detrusor contraction (that is, detrusor overactivitity), incompetence of the urethral sphincter mechanism (for example, stress incontinence), or from other reasons.

Multiple and interacting factors often contribute to UI development, especially in frail, older patients (Ouslander & Bruskewitz, 1989). In such patients, the diagnostic evaluation must be comprehensive, focusing not only on the lower urinary tract but also on the patient’s general medical and functional status.

Several conditions that cause or contribute to urinary incontinence are potentially reversible (see Table X1).

Management of one or more of these conditions can sometimes lead to the resolution of the urinary incontinence. This potentially reversible type of urinary incontinence has been referred to as transient incontinence. In other patients, treatment of these conditions will reduce the severity of urinary incontinence but will not totally resolve it.

Prevalence of Urinary Incontinence

Figure X1 | Urinary incontinence subtypes among men and women: result from detailed assessment of more than twenty epidemiological studies conducted over more than 40 years (Hampel et al 1997).

Urinary incontinence is more prevalent and troublesome in women than in men (Brocklehurst 1993; Bent 1989; A report of the Royal College of Physicians 1995) because various neurological, constitutional, urogynecological and behavioral predisposing factors combine to compound the problem (Hampel et al 1997; Resnick & Yalla 1985; Abrams 1993).

For example, with advancing age, the bladder tends to become overactive and the urethra less competent, with bladder capacity, urinary flow rate and the ability to postpone bladder emptying being reduced (Resnick & Yalla 1985; Abrams 1993).

As a result, the overall prevalence of urinary incontinence increases with age (Abrams 1993). This is not to say that urinary incontinence is an inevitable feature of ageing. Rather, it is a disorder that, if carefully managed, can be treated or even cured, often without the need for extensive testing or surgery (Resnick & Yalla, 1985).

Quality of Life

Urinary incontinence imposes a significant psychosocial impact on affected individuals, their families, and caregivers. UI results in a loss of self-esteem Opens in new window and a decrease in ability to maintain an independent lifestyle.

Dependence on caregivers for activities of daily life increases as incontinence worsens. Consequently, excursions outside the home, social interaction with friends and family, and sexual activity may be restricted or avoided entirely (Grimby, Milsom, Molander, et al., 1993; Noelker, 1987). Quality of life and symptom distress questionnaires for women with UI have been validated for use (Shumaker, Wyman, Uebersax, et al., 1994).

Treatment of Urinary Incontinence

The three major forms of treating UI are

1. Behavioral.
2. Pharmacologic.
3. Surgical

Before implementing behavioral therapy, patients should have the basic evaluation completed. Treatment options including their risks, benefits, and outcomes should be discussed with the patient so that informed choices can be made.

As a general rule, the first choice should be the least invasive treatment with the fewest potential adverse complications that is appropriate for the patient. For many forms of UI, behavioral techniques meet these criteria. However, an informed patient’s preference must be respected.

A combination of surgical, behavioral, and pharmacologic interventions may be appropriate, but more research is required to determine the optimum treatment combinations for specific patient groups.

1. Behavioral techniques

Behavioral techniques are proven to decrease the frequency of UI in most individuals when provided by knowledgeable health care providers, have no reported side effects, and do not limit future treatment options. Behavioral therapies can be divided into

1. caregiver-dependent techniques for patients with cognitive and motor deficitis and
2. those requiring active rehabilitation and education techniques.

These distinctions are arbitrary, however, and any individual’s ability to actively participate varies on a continuum from complete dependence to full participation in the most complex behavioral therapies. For example, physically impaired patients who are cognitively intact may benefit from bladder training, pelvic muscle exercises (PMEs), and biofeedback therapy, but may depend on caregivers for assistance to the toilet.

Behavioral techniques are listed below in the order of those requiring passive involvement to those requiring active participation:

• Toileting assistance—routine/scheduled toileting, habit training, and prompted voiding.
• Bladder retraining.

• Pelvic muscle rehabilitation—PMEs, PMEs and bladder inhibition augmented by biofeedback therapy, PMEs augmented with vaginal weight training, and pelvic floor electrical stimulation.

To effective these behavioral techniques require educating the patient, the caregiver, or both, and provide positive reinforcement for effort and progress. Behavior techniques should be offered to motivated individuals who wish to avoid more invasive procedures or dependence on protective garments, external devices, and medications.

Behavioral therapies have few reported side effects and do not limit future treatment options. Moreover, behavioral techniques can increase patient understanding of lower urinary tract function and the environmental factors affecting symptoms. They can further improve control of detrusor and pelvic muscle function. They generally require patient or caregiver involvement and continued practice. If motivated, most people treated with behavioral techniques show improvement ranging from complete dryness to decreased incontinence episodes. Improved bladder control can occur even in the cognitively impaired individual. Behavioral techniques can also be used in combination with other therapies for UI.

2. Pharmacologic Treatment

Several medication as listed below have proven to be beneficial for treating UI.

• Drugs for incontinence due to detrusor overactivity.
  Anticholinergic/antispasmodic agents.
  The purpose of these drugs is to relax the bladder and increase bladder activity.
  
  Note: All anticholinergic drugs are contraindicated in patients with narrow-angle but not wide angle glaucoma.
  
  Propantheline.
  Recommended at 7.5–30 mg in the fasting state, t.i.d.–q.i.d. (higher dosages may be needed).
  
  Oxybutynin.*
  Recommended at 2.5–5 mg, p.o., t.i.d.
  
  Tricyclic agents.
  Imipramine** and doxepin may be beneficial at 10–100 mg, p.o./d, initially in divided doses.
  
  Dicyclomine hydrochloride.
  Clinical experience suggests that this drug is as effective as other anticholinergic agents in controlling detrusor overactivity. Dose is 10–20 mg, t.i.d., p.o.

• Drugs for incontinence due to urethral sphincter insufficiency.
  
  Alpha-adrenergic agonist agents.
  These drugs increase urethral resistance by stimulation of urethral smooth muscle acting on alpha-adrenergic receptors in the urethra.
  
  Phenylpropanolamine (PPA).
  The recommended dose is 25–75 mg, p.o.,q. 12h.
  Note:These drugs should be used with caution in patients with hypertension, hyperthyroidism, cardiac arrhythmias, and angina.
• Estrogen supplementation therapy.
  Estrogen replacement in postmenopausal woman may restore urethral mucosal coaptation (pp. 45–46 of the guideline text). Estrogen replacement should be given with a progestin when endometrial tissue is present. (Atrophic vaginitis should be treated cyclically with conjugated estrogen, 0.3–1.25 mg/d, p.o., or vaginally, 2 g or fraction/d). Progestin 2.5–10 mg/d continuous or intermittent.
• Combined alpha-adrenergic agonist and estrogen supplementation therapy.
  Based on three well-controlled studies and clinical experience to date, combination therapy may be considered when an initial single drug therapy fails.

• Imipramine.**
  Imipramine may be beneficial in the treatment of stress and urge UI at the recommended dose of 10–100 mg, p.o./d, initially in divided doses.
*Drugs marked with a single asterisk have been officially approved by the FDA for the indicated use. The remainder are not approved but are commonly used.

**Imipramine is officially approved by the FDA for enuresis in children but not for adults.

3. Surgical Treatment

The decision to perform surgery for the treatment of UI should be made only after a precise, focused assessment that includes a comprehensive clinical evaluation with an objective confirmation of the pathophysiologic diagnosis and severity of urinary loss, a correlation of the anatomic and physiologic findings with the surgical plan, an estimation of surgical risk, and an estimation of the impact of the proposed surgery on the patient’s quality of life. See the Table X3 below.