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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
- 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