Urinary incontinence

Introduction

Urinary incontinence (UI) is defined as the involuntary leakage of urine. It is a widespread condition affecting both men and women, though more common in women due to anatomical and hormonal factors. UI is not only a physical health concern but also a major cause of psychological distress, social embarrassment, and reduced quality of life.

It is categorized into several types based on underlying pathophysiology, with management tailored accordingly.

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Types of Urinary Incontinence

1. Stress Urinary Incontinence (SUI)

• Leakage occurs with activities that increase intra-abdominal pressure (coughing, sneezing, laughing, exercising).

• Caused by weak pelvic floor muscles or urethral sphincter incompetence.

• Common after childbirth, pelvic surgery, or menopause.

2. Urge Urinary Incontinence (UUI)

• Sudden, intense urge to urinate followed by involuntary leakage.

• Caused by overactive bladder (detrusor overactivity).

• Associated with neurological conditions (Parkinson’s, multiple sclerosis, stroke).

3. Mixed Urinary Incontinence (MUI)

• Combination of stress and urge symptoms.

4. Overflow Incontinence

• Continuous dribbling of urine due to incomplete bladder emptying.

• Causes: bladder outlet obstruction (e.g., enlarged prostate), weak bladder muscle, diabetes-related neuropathy.

5. Functional Incontinence

• Normal urinary tract, but leakage occurs due to physical or cognitive limitations (arthritis, dementia, immobility).

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Risk Factors

• Female gender, vaginal deliveries, pelvic trauma.

• Menopause (estrogen deficiency).

• Obesity (increased intra-abdominal pressure).

• Chronic cough (smoking, COPD).

• Neurological diseases (MS, Parkinson’s).

• Enlarged prostate in men.

• Medications: diuretics, sedatives, α-blockers, ACE inhibitors (cause cough).

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Clinical Presentation

• Involuntary urine leakage (with activity, urgency, or continuously).

• Increased urinary frequency and nocturia.

• Post-void dribbling.

• Associated pelvic organ prolapse (women).

• Symptoms of urinary retention in overflow incontinence.

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Diagnosis

1. History

• Nature, frequency, triggers of leakage.

• Fluid intake, medications, obstetric/gynecological history.

• Neurological symptoms.

2. Examination

• Abdominal and pelvic exam (look for prolapse, pelvic floor weakness).

• Neurological exam if indicated.

• Digital rectal exam (prostate size in men).

3. Investigations

• Urinalysis: Rule out UTI.

• Bladder diary: Frequency, volume, leakage episodes.

• Post-void residual (PVR) volume: via ultrasound or catheter.

• Urodynamic testing: Measures bladder pressure, capacity, detrusor activity.

• Cystoscopy: If hematuria or obstruction suspected.

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Management

General and Lifestyle Measures

• Bladder training: Scheduled voiding, gradually increasing intervals.

• Fluid management: Reduce caffeine, alcohol, excess fluids.

• Weight reduction in obese patients.

• Smoking cessation (reduces chronic cough).

1. Stress Urinary Incontinence (SUI)

• Pelvic floor muscle training (Kegel exercises): First-line treatment.

• Vaginal pessaries: Support devices in women with prolapse.

• Local estrogen therapy (postmenopausal women):

  • Estradiol vaginal cream 0.5 g two to three times weekly.

• Surgical interventions:

  • Mid-urethral sling procedures (TVT, TOT).

  • Colposuspension.

  • Bulking agents (urethral injections).

2. Urge Urinary Incontinence (UUI, Overactive Bladder)

• Bladder training with timed voids.

• Pharmacological therapy:

  • Antimuscarinics:

    • Oxybutynin 5 mg orally 2–3 times daily.

    • Tolterodine 2 mg orally twice daily.

    • Solifenacin 5–10 mg orally once daily.

  • Beta-3 adrenergic agonist:

    • Mirabegron 25–50 mg orally once daily (fewer side effects than antimuscarinics).

• Intradetrusor Botox injections (onabotulinumtoxinA 100 U): For refractory cases.

• Neuromodulation: Sacral nerve stimulation.

3. Overflow Incontinence

• Treat underlying cause:

  • Catheterization (temporary or intermittent self-catheterization).

  • Treat prostate enlargement in men (Tamsulosin 0.4 mg daily, Finasteride 5 mg daily).

  • Surgical interventions (TURP for obstructive prostate).

4. Functional Incontinence

• Address mobility issues, provide bedside commodes, timed voiding.

• Caregiver support in dementia patients.

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Precautions

• Antimuscarinics should be avoided in glaucoma, urinary retention, severe constipation.

• Mirabegron can raise blood pressure; monitor in hypertensive patients.

• Surgical options should only be considered after failure of conservative and pharmacological management.

• Elderly patients are at increased risk of falls due to urgency; fall-prevention strategies should be included.

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Drug Interactions

• Oxybutynin / Tolterodine + CNS depressants (benzodiazepines, alcohol): Additive drowsiness.

• Antimuscarinics + Other anticholinergic drugs (antihistamines, TCAs): Increased risk of constipation, dry mouth, cognitive impairment.

• Mirabegron + Beta-blockers: May reduce beta-blocker efficacy due to receptor competition.

• Alpha-blockers (Tamsulosin) + Antihypertensives: Risk of postural hypotension.

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Red-Flag Features (Require Specialist Referral)

• Gross hematuria.

• Recurrent UTIs with incontinence.

• Neurological symptoms (sudden weakness, numbness, spinal cord compression).

• Pelvic mass or prolapse.

• Incontinence associated with severe pain or rapid progression.