Incontinence

Definition | Types | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Example Management | References

Definition

Incontinence refers to the involuntary loss of urine or faeces, which can significantly impact quality of life.

Types

Urinary Incontinence

• Stress Incontinence: Involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or lifting.
• Urge Incontinence: Sudden, intense urge to urinate followed by involuntary leakage of urine. Often associated with overactive bladder syndrome.
• Mixed Incontinence: Combination of stress and urge incontinence.
• Overflow Incontinence: Involuntary leakage of urine due to an overfilled bladder that does not empty properly.

Aetiology

The causes of incontinence vary depending on the type but can include:

• Weakness of pelvic floor muscles.
• Damage to the nerves controlling the bladder or bowel.
• Obstruction or abnormalities in the urinary or gastrointestinal tracts.
• Neurological conditions: Such as multiple sclerosis, Parkinson's disease, or spinal cord injuries.
• Medications: Diuretics, sedatives, and certain blood pressure medications.
• Infections: Urinary tract infections (UTIs) can cause temporary incontinence.
• Chronic conditions: Diabetes, obesity, and respiratory conditions that increase intra-abdominal pressure.

Pathophysiology

Incontinence results from a disruption in the normal storage and voiding functions of the bladder or bowel. This can be due to:

• Weak or damaged pelvic floor muscles, leading to inadequate support for the bladder or bowel.
• Neurological dysfunction, impairing the control of urinary or bowel function.
• Obstructions or abnormalities in the urinary or gastrointestinal tracts, causing retention and overflow incontinence.
• Increased intra-abdominal pressure from conditions such as chronic coughing, obesity, or heavy lifting, leading to stress incontinence.

Risk Factors

• Age: Risk increases with age due to muscle weakening and other age-related changes.
• Gender: Women are more prone to stress incontinence due to childbirth and menopause.
• Obesity: Increased abdominal pressure can weaken pelvic floor muscles.
• Pregnancy and childbirth: Can damage pelvic floor muscles and nerves.
• Chronic conditions: Diabetes, respiratory conditions, and neurological disorders.
• Surgery: Pelvic or prostate surgery can affect bladder control.
• Medications: Certain medications can affect bladder or bowel function.

Signs and Symptoms

• Involuntary leakage of urine or faeces.
• Frequent or urgent need to urinate or defecate.
• Nocturia: Waking up multiple times at night to urinate.
• Feeling of incomplete emptying of the bladder or bowel.
• Recurrent urinary tract infections.
• Discomfort or pain during urination or defecation.

Investigations

• Clinical history and physical examination, including a pelvic exam.
• Urinalysis: To rule out infections or other abnormalities.
• Bladder diary: Recording fluid intake, urination times, and leakage episodes.
• Post-void residual volume (PVR): Measuring the amount of urine left in the bladder after urination.
• Urodynamic studies: Assessing bladder function and pressure.
• Imaging: Ultrasound, MRI, or CT scans to identify structural abnormalities.
• Endoscopy: Cystoscopy or sigmoidoscopy to visualise the urinary tract or bowel.

Management

Stress Incontinence

• Pelvic floor exercises: Strengthening the pelvic floor muscles (e.g., Kegel exercises).
• Medication: Duloxetine may be prescribed to increase urethral sphincter muscle tone.
• Surgery.
• Lifestyle modifications: Weight loss, reducing caffeine and alcohol intake, and managing fluid intake.

Urge Incontinence

• Bladder training: Techniques to increase bladder capacity and control urgency.
• Medications: Anticholinergics (e.g., oxybutynin), beta-3 agonists (e.g., mirabegron), or botulinum toxin injections into the bladder muscle.
• Lifestyle modifications: Avoiding bladder irritants such as caffeine, alcohol, and spicy foods.
• Absorbent products: Pads or protective garments to manage leakage.

Mixed Incontinence

• Combination of treatments used for both stress and urge incontinence.
• Pelvic floor exercises: To strengthen the pelvic floor muscles.
• Bladder training: To control urgency and improve bladder capacity.
• Medications: Appropriate for managing both types of incontinence.
• Surgical options: Considered if conservative treatments are ineffective.

Overflow Incontinence

• Refer to urology.

Example Management for Incontinence

A patient presenting with stress incontinence should undergo a thorough evaluation including a physical examination, urinalysis, and bladder diary. Initial management may involve pelvic floor exercises to strengthen the pelvic floor muscles, lifestyle modifications such as weight loss and reducing caffeine intake. If conservative and medication treatments are ineffective, you should refer to urology.

References

1. NICE. (2024). Urinary Incontinence and Pelvic Organ Prolapse in Women: Management. Retrieved from NICE
2. NHS. (2023). Incontinence. Retrieved from NHS
3. International Continence Society (ICS). (2022). Guidelines on the Management of Urinary Incontinence. Retrieved from ICS
4. European Association of Urology (EAU). (2022). Guidelines on Urinary Incontinence. Retrieved from EAU

Back to Top