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Incontinence – overview & assessment

Urinary incontinence

  • Complaint of involuntary loss of urine

Stress urinary incontinence

  • Complaint of involuntary loss of urine on effort or physical exertion including sporting activities, or on sneezing or coughing

Urge urinary incontinence

  • Complaint of involuntary loss of urine associated with urgency

Mixed urinary incontinence

  • Complaints of both stress and urge incontinence

 

Incidence:

  • Up to 10 % of men and up to 38 % of women affected by UI
  • 65 % of women in a GP waiting room report some type of UI
  • 70 % of people with ‘leakage’ do not seek help
  • Annualised incidence in middle aged women 40 – 60 years range from 1 – 10 %, with estimated 3 % / year for SUI, UUI and MUI

 

Pathophysiology of incontinence – principles

Factors affecting the bladder:

  • Any neurological process affecting the normal inhibition of the pontine micturition centre can lead to UUI
    • CVA, MS, Parkinson’s, dementia
  • Anything causing detrusor overactivity at the level of the bladder leads to UUI
    • Obstruction, DM, neurogenic DO, radiation
  • Overflow incontinence can occur from underactive bladder or detrusor areflexia
    • DM, alcoholism, SCI spinal shock, pelvic surgeries

 

Factors affecting sphincteric function:

  • Iatrogenic sphincteric injury i.e. RRP, TURP, prolapse surgery
  • Spinal cord injuries or neuropathic conditions can cause DSD
  • Labour, delivery, any number of risk factors for SUI in women

 

Consider causes of transient incontinence – DIAPPERS.

 

History

  • Is this SUI, UUI or mixed
  • Other symptoms – UTIs, haematuria, nocturia
  • Quantify the leakage if possible – number of pads etc
  • Degree of bother
  • Inciting events
  • O+G history
  • Previous surgeries or other pelvic treatments, radiation etc
  • Neurological conditions

“The bladder is an unreliable witness” – history is often not enough to guide management.

 

Examination

  • General examination – age, frailty, mobility
  • Habitus
  • Pelvic examination – atrophic post-menopausal changes
  • Objective demonstration of SUI – cough/Valsalva, supine (+/- standing?)
  • Assessment for prolapse, supine and standing
  • Q-tip test for objective urethral mobility assessment
  • Neurological examination
  • Pad weights

 

Investigations

  • Urine MCS
  • Post void residual and flow rate
  • Bladder diary
  • Standardised questionnaire – ICIQ etc

 

  • Cystoscopy, if indicated
    • Any haematuria, storage symptoms possibly CIS, recurrent UTIs, pelvic surgery and potential foreign body
  • Urodynamics

 

Rare causes of ‘insensible’ incontinence should be considered – overflow (SUI, nocturnal leak), urethral diverticulum (post micturition), ectopic ureter (continuous), fistula (continuous).

 

ICIQ