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Types of incontinence

Urge incontinence (most common in elderly)

  • Incontinence accompanied by sudden urge to urinate
  • I couldn’t make it to the bathroom in time!
  • Increased bladder sensitivity and overactivity of the detrusor muscle
  • Most common cause is idiopathic
    • However, anything that irritates the muscular wall of the bladder can lead to urge incontinence
      • Inflammation of the bladder
      • Bladder cancer
      • Renal stones
    • Neurological conditions in the brain can also result in urge incontinence
  • Treatment
    • Lifestyle changes
      • Weight loss
      • Less alcohol and caffeine
      • Smoking cessation
    • Medication
      • Anticholinergic medication
        • Oxybutynin
        • Tolterodine
        • Trospium
        • Scopolamine (also useful for nausea_
      • TCA (with anticholinergic effect)
        • Side effect of imipramine

Stress incontinence

  • Incontinence accompanied by any activity that increases the intra-abdominal pressure
    • Laughing
    • Coughing
    • Sneezing
    • In clinic: Valsalva maneuver
  • Due to weakened pelvic floor muscles that occurs with age/multiple pregnancies
    • Normally, any intraabdominal pressure is exerted to both the bladder and the proximal urethra – since the pressure is applied equally to both, there is no pressure difference between the bladder and the proximal urethra and therefore no urine passes
    • As the pelvic diaphragm becomes weak, the proximal urehtra slips under the pelvic diaphragm, so that any intraabdominal pressure is now exerted to only the bladder and not the proximal urethra
    • Because pressure in the bladder > pressure in the proximal urethra, urine flows from the bladder into the urethra with no delay during episodes of increased intraabdominal pressure
  • To differentiate from urge incontinence, on history there is no urge to go to th washroom
  • Treatment
    • Kegel exercises to strengthen pelvic floor
    • Weight loss
    • Less alcohol and caffeine
    • Smoking cessation
    • Insertion of a pessary – a disc that is inserted into the vagina to provide support to the pelvic floor and possibly also provide compression to the urethra
    • Medication
      • Duloxetine (cymbalta)
      • Anticholinergic medication
        • E.g. oxybutynin
    • Surgery if medication doesn’t work
      • Midurethral sling procedure – procedure to support the mid urethra with a hammock-like effect
      • Urethropexy – replacement of the proximal urethra to its correct intra-abdominal position

Overflow incontinence

  • Caused by conditions or medications that
    • Impair the ability of the detrusor muscle to contract (hypotonic bladder)
      • Neurological conditions such as diabetes, spinal cord injury
    • Blocks urine from leaving the bladder
  • Eventually as urine builds up in the bladder, the intravesical pressure builds to a point where urine starts to dribble from the bladder through the urethra resulting in incontinence
  • Patients with overflow incontinence may also have leakage with increased intraabdominal pressure due to the pressure induces a detrusor muscle spasm
    • However, it is different than stress incontinence because there is a delay between the cough or sneeze, and the resulting spasm
  • Diagnose with large post-residual volume
  • Treatment
    • Catherization in the acute setting (intermittent catherization)
    • Scheduled visits to the washroom
    • Stopping anticholinergics and treating any underlying conditions

Fistula related incontinence

  • Typically seen after surgery or labor
  • Patient reports leakage of fluid from the vagina or rectum
  • Diagnose with dye into the vagina and look for leakage of dye colored fluid from vagina (or discoloration of tampon in vagina if leakage is slow)
  • Treatment with surgery to fix fistula

Functional incontinence

  • Awareness of urge to urinate is present, but the patient is unable to get to the washroom (no physiological basis for the incontinence)
  • Any barriers that make it difficult for a person to reach a washroom in time
    • Dementia
    • Confusion
    • Vision
    • Psychiatric issues