Medihub - Medical Information - Urology

URINARY_INCONTINENCE is the uncontrolled leakage of urine from the bladder. There are many types of incontinence and before treatment can be advised, one must determine which type of incontinence is affecting the patient and its underlying cause. Incontinence affects the quality of life. Even though it tends to be age-relate, it can still be treated in most cases.

Evaluation
This is assessed from the history, physical examination and relevant lab or xray investigations. Sometimes, urodynamic tests may be needed [Fig 1]. This is the study of the bladder and urethra function by means of a machine with tubes inserted into the bladder and rectum to measure the pressures within

Fig 1. Urodynamics is sometimes needed determine the type of incontinence, especially in complicated cases.

Types & Treatment

There are 5 types of incontinence:
1. Stress incontinence. [Fig 2]. This type of incontinence affects mostly women and occurs upon any form of physical exertion, especially on carrying loads, coughing, and sneezing. It is due to weakened pelvic floor muscles, which tend to occur during difficult childbirth, after menopause and following pelvic surgery. It can also occur in men following prostate surgery. The treatment is initially physiotherapy, eg. pelvic floor exercises which consist of squeezing these muscles frequently and repeatedly. However, up to one-third of sufferers cannot do this exercise. In such a case, surgery to restore the bladder support is recommended. There are many ways of doing this, ranging from open surgery (colposuspension) to minimally-invasive sling surgery to bulking agent injection. The most popular surgical method currently is sling surgery because of its good cure rates that are durable and has minimal complications. Because it is also minimally-invasive, it can be done as a day case and therefore, quicker return to normal activities. The most popular sling is the TVT (tension-free vaginal tape) and it is made of prolene material which is placed under the middle part of the urethra. [Fig 3]. The surgery takes less than 30 mins and the cure rate is on average 81% at 7 years follow-up. Complications include bladder injury and voiding difficulty if the tape is placed too tight. A variant of the TVT surgery is the TVT-O in which the tape exits through the side rather than through the top, thus avoiding bladder injury. Bulking agent injection into the urethra and bladder neck is an alternative method to control stress incontinence, especially in frail elderly women. These agents range from collagen to silicon particles. The advantage is that this is a simple procedure with minimal risks that can be done under local anaesthesia in less than 15 mins. The disadvantage is that these agents may not last enough and repeat injections are then needed.

Fig 2. Stress incontinence occurs when the weak pelvic floor is unable to support the bladder during physical exertion.

Fig 3. TVT corrects stress incontinence through support of the mid-urethra

2. Urge incontinence [Fig 4]. This is the leakage of urine as a result of an overactive bladder. The overactive bladder is a condition which occurs in up to 15% of the population, especially in elderly patients. In some patients, the strong sense of urge is difficult to control and if one is unable to reach the toilet in time, leakage occurs. Such incontinence can be controlled by medication in most sufferers. These medications work by inhibiting the unstable bladder waves but can also cause side-effects like dry mouth, dry throat, and dry skin because they also inhibit the salivary and sweat glands. Nevertheless, they work in up to 80% of patients and may need to be given up to 3 months or more to “re-set” the bladder. In patients who do not respond or are unable to tolerate the drugs, then surgical methods may be needed, eg. botox injections into the bladder [Fig 5], or neuromodulation.

Fig 4. Urge incontinence occurs when one leaks due to a strong urge and is unable to reach the toilet in time.

Fig 5. Botox can be injected into the bladder for severe cases of urge incontinence not responding to oral medication

3. Overflow incontinence [Fig 6]. This is the leakage of urine that occurs in those whose bladder are chronically full of urine as a result of persistent blockage eg. enlarged prostate or have weak bladder muscles, eg. elderly, diabetics. The leak occurs upon getting up from a lying position or upon straining and can be difficult to distinguish from stress incontinence. This type of incontinence is suspected when your doctor finds a distended bladder on examining the abdomen. Urodynamics is often needed to confirm this type of incontinence. The treatment is self-catheterisation by means of a soft silicon catheter up to 3 times a day. In men, this can be difficult to do, hence, prostate surgery is recommended if the underlying cause is a huge, enlarged prostate.

Line Callout 2: Distended bladder Fig 6. Overflow incontinence occurs when further physical stress is added to an already full bladder.

4. Total incontinence [Fig 7]. This occurs if surgery severely damages the urethral sphincter muscle, eg. after prostate surgery. Because of this, urine continually leaks out and one has to wear pampers to absorb the urine. The only solution to correct this kind of incontinence is to implant an artificial urinary sphincter. This is a major procedure which can take 4 to 5 hours to do and is expensive because the device is a specially designed one costing a few thousand dollars. A cuff is placed around the bladder outlet and to empty the bladder, the button controlling this cuff is pressed to deflate this cuff. The possible complications relate to the malfunction and infection of the device.

Fig 7. The artificial urinary sphincter is a device to control total incontinence through an inflatable cuff placed around the urethra