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Incontinence

In This Article

Types of incontinence

This is the involuntary loss of urine, that is serious enough to cause a social or hygiene problem.
It becomes more prevalent with age, with about 15% of women and 10% of men over 60 affected.
  • women are more likely to be affected due to weakened pelvic floor / sphincter muscles, as a result of childbirth
It is very socially restricting. It may also lead to skin damage.
It tends to be undereported, and greatly reduces quality of life.
 
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Risk Factors

 

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Types

It is important to remember that many people will have a combination of more than one of these types (typically, stress and urge are seen together) and thus it can be difficult to see which type is causing the most difficulty and how to treat accordingly.
 
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Normal micturition

Storage - The pressure in the bladder rises gradually as it fills. The sphincter muscle tones also increases with bladder filling. The detrusor muscle remains relaxed the whole time the bladder is filling.
Voiding – the sphincter relaxes and the detrusor muscle contracts. There is a good flow of urine until the bladder is empty.
 
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Stress incontinence

This is leakage of urine due to an incompetent sphincter. It typically occurs when intra-abdominal pressure rises such as in coughing, laughing or exercise. The proximal 1/3 of the urethra may slip out of the abdominal cavity.
Two major risk factors are age and obesity. It essentially results from pelvic floor damage (e.g. as seen in childbirth, or even in trauma). In men, it may result from a prostatectomy.
It is particularly common in pregnant women, and women just after birth. About 50% of post-menopausal women will suffer to some degree.
It involves small but frequent losses of urine particularly when coughing or laughing.
 
The patterns seen on urodynamics will be the same as those seen in normal micturition, except that there will be a passive (i.e. not caused by detrusor muscle contraction, but instead by increased intra-abdominal pressure) increase in vesicular pressure when the patient coughs.
 
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Treatment

Pelvic floor exercises - improves symptoms in 50% of cases
Intravaginal electrical stimulation may help, but many women find this unacceptable.
Ring pessary – this is rubber/metal/plastic ring in which the cervix of the uterus sits. It is usually used to prevent prolapse of the uterus. A prolapsed uterus is basically where the uterus slips downwards – it may move so far that is protrudes out of the vaginal orifice. This occurs due to dysfunction of the muscles that usually hold the uterus in place.
Duloxetine – is a SNRI (serotonin-norepinephrine reuptake inhibitor) that is usually used to treat depression. It will not cure the condition, but will relieve symptoms in about 50% of cases, but has significant side effects, including nausea, vomiting and abdominal pain
Surgery – if pelvic floor exercises are unsuccessful, another option is surgery. You can surgically alter the position of the bladder or the urethra to relieve symptoms of this condition:

  • Sling procedure – this is about 85% effective and is the procedure of choice for most women. A sling is created, either from native body tissue (such as fibrous connective tissue from the rectum) or man-made materials (such as telfon – although these are not as effective as natural body tissue). The sling is attached to the abdominal wall, and lifts up the top part of the urethra thus increasing pressure around this region and reducing incontinence.
    • The procedure involves open surgery, and thus there is a recovery period of 2-4weeks, although patients may return home after 3-4 days.
    • There is a chance that the procedure will have to be redone within 10 years
  • Tension-free vaginal tape (TVT)– this is a more modern procedure, and basically has fwere side-effects, and higher success rate than a sling procedure. It is does via the vagina under local anaesthetic, and can be done as an outpatient procedure.
  • Cholposuspension – this is a large operation in which the bladder is attached to the posterior abdominal wall. It is more effective than a sling procedure, but is a much more serious operation. It also means you can’t have children after you have had it done. This has an 85% success rate. There is a 5% risk of incontinence or difficulty passing urine afterwards.
 
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Urge Incontinence

Some people refer to this as an over reactive bladder, or Detrussor overactivity. The urge to empty to bladder is soon followed by uncontrollable and sometimes complete emptying of the bladder.
It occurs in 17% of those over 65, and 50% of those requiring nursing home care.
This is caused by involuntary contractions of the detrusor muscle. This can be due to detrusor instability(as a result of local irritation of the bladder, perhaps due to inflammation and/or infection) or brain damage(as often seen in the elderly as a result of e.g. stroke, Parkinson’s, dementia).
It can also be caused by; UTI,