Urinary incontinence

Definition
Urinary incontinence is the involuntary leakage of urine. It can range from occasional small leaks to complete inability to control urination and is common in women but also occurs in men, especially after prostate surgery.

---

Types

1. Stress incontinence

   • Leakage with increased intra-abdominal pressure (e.g., coughing, sneezing, laughing, exercise)

   • Cause: Weakness of pelvic floor muscles and/or urethral sphincter

   • Common in women after childbirth, menopause, or pelvic surgery

2. Urge incontinence

   • Sudden, intense urge to urinate followed by involuntary leakage

   • Cause: Overactive bladder due to involuntary detrusor muscle contractions (may be idiopathic or secondary to neurological disease)

3. Mixed incontinence

   • Combination of stress and urge symptoms

4. Overflow incontinence

   • Continuous dribbling or leakage due to bladder overdistension

   • Cause: Bladder outlet obstruction (e.g., enlarged prostate), underactive detrusor muscle (neuropathy)

5. Functional incontinence

   • Inability to reach toilet in time due to physical or cognitive impairments (e.g., severe arthritis, dementia) despite normal urinary tract function

---

Risk Factors

• Female sex, especially postmenopausal

• Vaginal childbirth (especially multiple or instrumental deliveries)

• Pelvic surgery or radiation

• Ageing

• Obesity

• Chronic cough (COPD, smoking)

• Neurological diseases (stroke, multiple sclerosis, Parkinson’s disease, spinal cord injury)

• Prostate enlargement or surgery in men

---

Clinical Features

• History of urine leakage: timing, triggers, associated urgency, frequency, nocturia

• Assess volume, severity, and impact on quality of life

• Associated symptoms: hesitancy, weak stream, dysuria

• Physical exam: pelvic examination in women (look for prolapse), prostate exam in men, neurological assessment

---

Diagnosis

• Bladder diary (fluid intake, voiding frequency, leakage episodes)

• Urinalysis to exclude infection or haematuria

• Post-void residual volume (bladder scan or catheterisation) to detect incomplete emptying

• Urodynamic studies if diagnosis uncertain or before surgery

• Cystoscopy if haematuria, suspected structural abnormality, or bladder pathology

---

Treatment

1. General measures (all types)

• Lifestyle: weight loss, reduce caffeine/alcohol, fluid management

• Bladder training: scheduled voiding, gradually increasing intervals

• Pelvic floor muscle exercises (Kegel exercises) – especially for stress incontinence

2. Stress incontinence

• Pelvic floor physiotherapy

• Vaginal pessaries in women with prolapse

• Surgical options:

  • Mid-urethral sling procedure

  • Colposuspension

  • Urethral bulking agents

3. Urge incontinence / Overactive bladder

• Bladder training, timed voiding

• Antimuscarinic drugs (oxybutynin, tolterodine, solifenacin)

• Beta-3 agonist (mirabegron)

• In refractory cases: intradetrusor botulinum toxin injections, sacral nerve stimulation

4. Overflow incontinence

• Treat underlying cause (relieve obstruction, manage neuropathy)

• Intermittent self-catheterisation if necessary

5. Functional incontinence

• Address mobility issues, cognitive support

• Easy toilet access, timed voiding assistance

---

Prognosis

• Many cases improve with conservative measures and targeted therapy

• Surgical and minimally invasive options are available for resistant cases

• Early management prevents complications such as skin breakdown, urinary infections, and reduced quality of life