URINARY INCONTINENCE
Urinary Incontinence is defined as “the
involuntary loss of urine which is objectively demonstrable and a social or
hygienic problem” (ICS, International
Continence Society definition). The incidence of urinary incontinence varies
according to the gender and the different age groups. It is estimated that for men above the age of
60 years, urinary incontinence occurs in 10 to 15% and for men under the age of
60 years, it is approximately 1 to 5%.
Women have 2 – 3x more incontinence than men. Needless to say, urinary
incontinence has an adverse effect on the quality of life although many
patients do not seem to bring forward this complaint to their healthcare
professionals. Urinary incontinence
affects the quality of life and self-esteem.
A detailed medical history would usually be sufficient for the diagnosis to
be made in the majority of cases. A 3-day bladder diary is important, recording
the input of fluids, time and volume of urination, any incontinence etc. Physical examination of the urinary tract is
carried out to see if the bladder is distended; the prostate is palpated by
digital rectal examination, DRE. Simple urine and blood tests may be done. In specific cases, a detailed assessment of
the voiding function by inserting catheters into the bladder is done by the
urologist, a test known as Urodynamics study, UDS.
The following are the various types of urinary
incontinence:
Stress Urinary
Incontinence, SUI, commonly occurs in middle
age and elderly ladies. The underlying
cause is a weak urinary sphincter which may be contributed by multiple child
births. In stress urinary incontinence,
there is urinary leak when there is physical exercise, including sneezing and
coughing. The urinary incontinence occurs at the same time as the physical straining. The volume
of the urinary leakage may range from a few drops to the patient having to wear
incontinence pads. The urinary sphincter muscles may be improved by pelvic floor exercises, PFX
and also by reducing obesity. A physiotherapist or a continence care nurse can help to supervise and monitor the pelvic floor
exercises. The severity of urinary
leakage may bring the patient forward to seek surgical treatment: the mainstay
surgical procedure is to improve the support of the urinary bladder. There were many procedures used. The gold standard is to do a procedure known
as Burch Colposuspension. If the
patient also requires the uterus to be removed, it can be done at the same
time. Essentially, this consists of
putting sutures to support the proximal urethra and bladder onto the nearby ligaments. The other technique consists of inserting a permanent
tape (a foreign body) around the urethra (known as TVT
or tension free tape) to
improve the support of the urethra; TVT can cause troublesome infection.
Overactive
bladder, OAB,
is defined as “a lower urinary tract disorder characterized by urgency (the sudden
compelling desire to pass urine, which is difficult to defer) with or without
urge incontinence and usually with frequency (> 8x) and nocturia”. [ICS 2002].
It is estimated that 16% of the general population suffers from OAB. The
incidence of OAB is higher in elderly men and women. There are various degrees
of severity of OAB and the treatment depends on this as well as how the patient
perceives its effect on the quality of life.
The initial coping mechanisms for urinary
incontinence involve the restriction of social interaction as well as the
re-arrangement of social activities around the availability of toilets. There may be some restriction of activities
like playing vigorous games or going for a long movie. Some patients re-arrange their intake of
fluids such that they do not have to go to toilet when it is socially inconvenient.
In severe cases, the patient resorts to
the use of diapers and the wearing of dark loose clothing. Physical stress can also bring on the
involuntary contraction of the bladder muscle. Unlike in stress urinary
incontinence where the urinary leakage occurs during the stress, the urinary
incontinence of bladder muscle instability occurs after
the physical stress. Medications can reduce the symptoms of OAB if
it is due to overactivity of the bladder wall muscle, e.g. Vesicare, Detrusitol
or Betmiga. Where the bladder wall muscle is proven by urodynamic study to have
gross hyperactivity, a surgical operation may occasionally be done to divide
the bladder muscle such that the bladder pressure is reduced (operation
called cystoplasty).
SUI and OAB should not be associated with pain nor
blood in the urine. If there is blood in
the urine, one needs to rule out the possibility of a tumour especially if the patient is a smoker or above the
age of 35 years. If there is associated
pain, it is an indication of underlying inflammation. The inflammation may be due to an infection
(UTI, urinary tract infection). UTI can be confirmed with a
urine examination and it can be readily treated by a course of
antibiotics. Malaysia is also endemic
for urinary stones which can cause urinary symptoms, pain and blood
in the urine.
Overflow
urinary incontinence occurs
when the patient suffers from urinary leakage as a result of the inability to
empty the bladder completely. This may
occur if there is an obstruction to the bladder outlet, e.g. by an enlarged prostate or if
the bladder muscle is underactive, UAB e.g. in diabetes. In children, the bladder may not empty well due
to dysfunctional
voiding. Dysfunctional voiding may be due to a
neurological disorder, e.g. a spinal tumour or spina bifida. Prostate enlargement
occurs usually after the age of 60 years and it is diagnosed from the history
as well as a digital rectal examination (DRE) by the doctor. Of course, the treatment for overflow urinary
incontinence due to prostate enlargement is to treat the prostate gland,
sometimes with transurethral resection of the prostate, TURP. If an
underactive bladder muscle is the cause of the overflow, the treatment would be
to empty the bladder intermittently with a clean catheter. This is called CISC, clean intermittent (e.g. 4 – 6 hourly) self
catheterisation. Needless to say, the
underlying medical condition that causes the neuropathic bladder has to be
treated in an appropriate manner, e.g. control of the diabetes, Parkinsonism or neurological disorder.
Urinary
incontinence in
children may sometimes be associated
with a congenital anatomic or urological
problem. This can in turn lead to back
pressure on the kidneys resulting in kidney failure. Therefore, all children with urinary
incontinence should see their doctor and have a full investigations including
x-rays, ultrasounds and occasionally, imaging of the spinal cord. In
children, urinary incontinence may also be due to congenital defects e.g. if
there is an abnormal connection of the urinary tract outside the bladder, e.g.
to the vagina. Such girls would complain of continuous
urinary leakage as well as having a normal voiding pattern.
Children normally achieve night time dryness by the
age of 5 years. If they have bedwetting,
by then, the condition is known as Primary Nocturnal
Enuresis (PNE). This is thought to be due to 2 factors,
namely, the inability of the child to concentrate urine normally at night as
well as the inability to wake up as a response to the sensation of a full
urinary bladder. Enuresis occurs in 8%
of children and 1% can persist till
adulthood. Most children do eventually
grow out of it but they can be assisted in the meantime with behavioural
measures, e.g. reduced fluid intake at night, the use of protective pads, the
use of timed voiding at night and enuresis alarm. If there is significant volume of urine at
night, this may be decreased by using an anti-diuretic hormone (ADH) given at night, e.g.
Minirin 0.1 – 0.2 mg at night.
In adults, urinary leakage from an abnormal passage
(urinary fistula) may occur after surgery near the urinary tract
(e.g. removing the uterus) or prolonged childbirth. If continuous urinary incontinence occurs
after such a procedure, then the fistula needs to be defined by radiology. The treatment would be surgery to close the
fistula.
CONCLUSION:
It is important to recognise that urinary
incontinence is a medical condition that should be discussed with the medical
personnel for appropriate investigations and treatment.
By Dr Clarence Lei Chang Moh,
FRCS Urol, FEBU
Consultant Urologist,
Adjunct Professor,
Universiti Malaysia Sarawak
28th July 2017 at the Malaysian
Enterostomal Therapy Course, Kuching.
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