Women between the ages of 20 to 80 year have an overall prevalence for urinary incontinence of 53.2 percent.
Types of Urinary Incontinence
Stress incontinence is the involuntary loss of urine produced by coughing, laughing or exercising. The underlying abnormality is typically urethral hypermobility caused by a failure of the anatomic supports of the bladder neck. Loss of bladder neck support is often attributed to injury occurring during vaginal delivery.
The lack of normal intrinsic pressure within the urethra--known as intrinsic urethral sphincter deficiency--is another factor leading to stress incontinence. Advanced age, inadequate estrogen levels, previous vaginal surgery and certain neurologic lesions are associated with poor urethral sphincter function.
Involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full, is a symptom of the condition commonly referred to as “urge incontinence.” Other
commonly used terms such as detrusor instability and detrusor hyperreflexia refer to involuntary detrusor contractions observed during urodynamic studies.
History and Physical Examination
A preliminary diagnosis of urinary incontinence can be made on the basis of a history, physical examination and a few simple office and laboratory tests.
The medical history should assess diabetes, stroke, lumbar disc disease, chronic lung disease, fecal impaction and cognitive impairment. The obstetric and gynecologic history should include gravity; parity; the number of vaginal, instrument- assisted and cesarean deliveries; the time interval between deliveries; previous hysterectomy and/or vaginal or bladder surgery; pelvic radiotherapy; trauma; and estrogen status.
Because fecal impaction has been linked to urinary incontinence, a history that includes frequency of bowel movements, length of time to evacuate and whether the patient must splint her vagina or perineum during defecation should be obtained. Patients should be questioned about fecal incontinence.
A complete list of all prescription and nonprescription drugs should be obtained. When appropriate, discontinuation of these medications associated with incontinence or substitution of appropriate alternative medications will often cure or significantly improve urinary incontinence.
Key Questions in Evaluating Patients for Urinary Incontinence
Do you leak urine when you cough, laugh, lift something or sneeze? How often?
Do you ever leak urine when you have a strong urge on the way to the bathroom? How often?
How frequently do you empty your bladder during the day?
How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?
Do you ever leak urine during sex?
Do you wear pads that protect you from leaking urine? How often do you have to change them?
Do you ever find urine on your pads or clothes and were unaware of when the leakage occurred?
Does it hurt when you urinate?
Do you ever feel that you are unable to completely empty your bladder?
Immediately before the physical examination, the patient should void as normally and completely as possible. The voided volume should be recorded. A post-void residual volume can then be determined within 10 minutes by catheterization or ultrasound examination. Post-void residual volumes more than 100 mL are considered abnormal.
A clean urine sample can be sent for culture and urinalysis.
Determining post-void residual volume and urinalysis allows screening for overflow incontinence, chronic urinary tract infections, hematuria, diabetes, kidney disease and metabolic abnormalities.
The abdominal examination should rule out diastasis recti, masses, ascites and
organomegaly. Pulmonary and cardiovascular assessment may be indicated to assess control of cough or the need for medications such as diuretics.
The lumbosacral nerve roots should be assessed by checking deep tendon reflexes, lower
extremity strength, sharp/dull sensation and the bulbocavernosus and clitoral sacral reflexes.
The pelvic examination should include an evaluation for inflammation, infection and atrophy.
Signs of inadequate estrogen levels are thinning and paleness of the vaginal epithelium, loss of rugae, disappearance of the labia minora and presence of a urethral caruncle.
A urethral diverticula is usually identified as a distal bulge under the urethra. Gentle massage of the area will frequently produce a purulent discharge from the urethral meatus.
Testing for stress incontinence is performed by asking the patient to cough vigorously while the examiner watches for leakage of urine.
Treatment of urinary incontinence
Rehabilitation of the pelvic floor muscles is the common goal of treatments through the use of pelvic muscle exercises (Kegel's exercises), weighted vaginal cones and pelvic floor electrical stimulation.
A set of specially designed vaginal weights can be used as mechanical biofeedback to augment pelvic muscle exercises. The weights are held inside the vagina by contracting the pelvic muscles for 15 minutes at a time.
Pelvic floor electrical stimulation with a vaginal or anal probe produces a contraction of the levator ani muscle. Cure or improvement in 48 percent of treated patients, compared with 13 percent of control subjects.
Occlusive devices, such as pessaries, can mimic the effects of a retropubic urethropexy. A properly fitted pessary prevents urine loss during vigorous coughing in the standing position with a full bladder.
Medications such as estrogens and alpha- adrenergic drugs may also be effective in
treating women with stress incontinence. Stress incontinence may be treated with localized estrogen replacement therapy (ERT). Localized ERT can be given in the form of estrogen cream or an estradiol-impregnated vaginal ring (Estring).
Behavioral therapy, in the form of bladder retraining and biofeedback, seeks to reestablish cortical control of the bladder by having the patient ignore urgency and void only in response to cortical signals during waking hours.
Pharmacologic agents may be given empirically to women with symptoms of overactive bladder.
ERT is also an effective treatment for women with overactive bladder. Even in patients taking systemic estrogen, localized ERT (ie, estradiol-impregnated vaginal ring) may increase inadequate estrogen levels and decrease the symptoms associated with overactive bladder.
Pelvic floor electrical stimulation is also effective in treating women with overactive bladder. Pelvic floor electrical stimulation results in a 50 percent cure rate of detrusor instability.
Neuromodulation of the sacral nerve roots through electrodes implanted in the sacral
foramina is a promising new surgical treatment that has been found to be effective in the treatment of urge incontinence.