Urinary incontinence The International Continence Society de?nes urinary incontinence as an involuntary loss of URINE that is objectively shown and is a social and hygiene problem. The elderly suffer most from this disorder because the e?ectiveness of the sphincter muscles surrounding the URETHRA declines with age. Men are less often affected than women; 20 per cent of women over 40 years of age have problems with continence. It is estimated that around three million people are regularly incontinent in the UK, a prevalence of about 40 per 1,000 adults.
Incontinence can be divided broadly into two groups: stress incontinence and incontinence due to an overactive URINARY BLADDER – also called detrusor instability – which affects one-third of incontinent women, prevalence increasing with age. Bladder symptoms do not necessarily correlate with the underlying diagnosis, and accurate diagnosis may require urodynamic studies – examination of urine within, and the passage of urine through and from, the urinary tract. However, such studies are best deferred until conservative treatment has failed or when surgery is planned.
Incontinence causes embarassment, inconvenience and distress in women, and men are reluctant to seek advice for what remains a social taboo for most people. Su?erers should be encouraged to seek help early and to discuss their anxieties and problems frankly. Often it is a condition which can be managed e?ectively at primary care centres, and quite simple measures can greatly improve the lives of those affected. STRESS INCONTINENCE is the most common cause of urinary incontinence in women. This is the involuntary loss of urine during activities that raise the intra-abdominal pressure, such as sneezing, coughing, laughing, exercise or lifting. The condition is caused by injury or weakness of the urethral sphincter muscle; this weakness may be either congenital or the result of childbirth, PROLAPSE of the VAGINA, MENOPAUSE or previous surgery. A CYSTOCOELE may be present. Urinary infection may cause incontinence or aggravate the symptoms of existing incontinence.
The ?rst step is to diagnose and treat infection, if present. Patients bene?t from simple advice on incontinence pads and garments, and on ?uid intake. Those with a high ?uid intake should restrict this to a litre a day, especially if frequency is a problem. Constipation should be treated and smoking stopped. The use of DIURETICS should be reduced if possible, or stopped entirely. Postmenopausal women may bene?t from oestrogen-replacement therapy; elderly people with chronic incontinence may need an indwelling urethral catheter.
Pelvic-?oor exercises can be successful and the insertion of vaginal cones can be a useful subsidiary treatment, as can electrical stimulation of the pelvic muscles. If these procedures are unsuccessful, then continence surgery may be necessary. The aim of this is to raise the neck of the bladder, support the mid part of the urethra and increase urethral resistance. Several techniques are available. URGE INCONTINENCE An overactive or unstable bladder results in urge incontinence, also known as detrusor incontinence – the result of uninhibited contractions of the detrusor muscle of the bladder. The bladder contracts (spontaneously or on provocation) during the ?lling phase while the patient attempts to stop passing any urine. Hyperexcitability of the muscle or a disorder of its nerve supply are likely causes. The symptoms include urgency (acute wish to pass urine), frequency and stress incontinence. Diagnosis can be con?rmed with CYSTOMETRY. Bladder training is the ?rst step in treatment, with the aim of reducing the frequency of urination to once every three to four hours. BIOFEEDBACK, using visual, auditory or tactile signals to stop bladder contractions, will assist the bladder training. Drug treatments such as CALCIUM-CHANNEL BLOCKERS, antimuscarinic agents (see ANTIMUSCARINE), TRICYCLIC ANTIDEPRESSANT DRUGS, and oestrogen replacement can be e?ective. Surgery is rarely used and is best reserved for di?cult cases. OVERFLOW INCONTINENCE Chronic urinary retention with consequent over?ow – more common in men than in women. The causes include antispasmodic drugs, continence surgery, obstruction from enlargement and post-prostatectomy problems (in men), PSYCHOSIS, and disease or damage to nerve roots arising from the spinal cord. Urethral dilatation or urethrotomy may be required when obstruction is the cause. Management is intermittent selfcatheterisation or a suprapubic catheter and treatment of any underlying cause.
Faecal incontinence is the inability to control bowel movements and may be due to severe CONSTIPATION, especially in the elderly; to local disease; or to injury or disease of the spinal cord or nervous supply to rectum and anal muscles. Those with the symptom require further investigation.
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