Summary
Urinary incontinence is a common condition characterized by uncontrollable leakage of urine. Causes and presentations are variable. Stress incontinence, urge incontinence, and mixed incontinence are the most frequent forms. Urinary incontinence remains a grossly underreported condition in the US, affecting approximately 30–40% of the adults older than 65 years of age. The condition is twice as common in women as men. Diagnosis involves a detailed medical history, a voiding diary, physical examination, and diagnostic testing such as measurement of the bladder pressure (urodynamic examination). Treatment is determined based on the type of incontinence and its etiology, and usually involves measures such as pelvic floor physiotherapy, anti-incontinence devices, anticholinergics, or collecting devices. The prognosis in adequately treated cases is usually excellent, but, if left untreated, constant contact with leaked urine can cause urinary tract infections, dermatitis, and psychological distress.
Epidemiology
-
Prevalence [1]
- Increases with age
- Up to 50% of women and up to 25% of men older than 65 years are affected.
-
Sex: ♀ > ♂ (2:1) [2]
- Stress incontinence and mixed incontinence are the most common types of incontinence in female patients.
- Urge incontinence is the most common type in male patients.
Epidemiological data refers to the US, unless otherwise specified.
Etiology
- Idiopathic
- Neurological causes
-
Genitourinary causes
- Trauma to the pelvic floor
- Intrinsic sphincter deficiency
- Urethral hypermobility in women
- Impaired detrusor contractility
- Bladder outlet obstruction
- Pelvic floor weakness
- Urogenital fistula
-
Potentially reversible causes
- Drugs (e.g., diuretics)
- Urinary tract infections
- Postmenopausal atrophic urethritis
- Psychiatric causes (especially depression, delirium/confused state)
- Excessive urinary output (in conditions like hyperglycemia, hypercalcemia, CHF)
- Stool impaction
- Impaired mobility
- General risk factors
DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.
Overview
Overview of urinary incontinence | |||
---|---|---|---|
Type of incontinence | Pathophysiological mechanism | Key features [3] | Treatment [4] |
Stress incontinence |
|
|
|
Urge incontinence [5] |
|
|
|
Mixed incontinence |
|
|
|
Total incontinence |
|
|
|
Overflow incontinence (overflow bladder) |
|
|
|
Further causes of urinary incontinence |
|
|
|
Enuresis risoria [10] |
|
|
|
Neural control of micturition: parasympathetic nervous system → S2–S4 ventral root → inferior hypogastric plexus → contraction of the detrusor muscle → voluntary relaxation of the external urethral sphincter muscle via the pudendal nerve → micturition
Diagnostics
Basic diagnostic testing
- Detailed medical history (including medication)
- Voiding diary: to assess the frequency and volume of micturition
- Neurological, vaginal, and rectal examination: to detect local sites of infection (e.g., abscesses, sebaceous cysts), anomalies of local anatomy, neurological deficits, and rectal sphincter flaccidity
-
Laboratory tests
- Urine dipsticks and urine culture to exclude urinary tract infections
- Creatinine and blood urea nitrogen (BUN) to assess kidney function
-
Sonography
- Quantification of residual urine after micturition
- Renal ultrasound
- Quantification of leaked urine: pad test
Additional diagnostic testing
- Micturating cystourethrogram (MCU): to detect morphological abnormalities
- Urodynamic examination: to measure bladder pressure and urethral closure pressure [11]
- Cystoscopy: to rule out tumors and vesicorectal or vesicovaginal fistulae
- MRI: to identify pelvic floor defects
See also “Diagnostics” in “Stress incontinence” and “Urge incontinence” articles for more information.
Treatment
General principles of treatment of urinary incontinence [4][5]
-
Lifestyle modifications
- Weight loss
- Dietary changes (e.g., decrease consumption of alcohol, caffeine, carbonated drinks)
- Smoking cessation
- Modification of other contributing factors (e.g., drugs)
-
Behavioral therapies and exercises
- Bladder training (e.g., timed voiding, relaxation/distraction techniques)
- Kegel exercises: an exercise targeting the pelvic floor in order to strengthen muscles that control urinary flow and bowel movements
- Biofeedback
- Vaginal-weighted cones
-
Physical measures to prevent leakage
- Vaginal pessary (a device inserted into the vagina in order to provide more support for pelvic organs) or penile compression devices
- Absorbent products
- Catheterization
- Urethral occlusion
- Management of reversible causes (e.g., constipation)
- Topical vaginal estrogen (in postmenopausal patients with vaginal atrophy)
Medical treatment
Autonomic drugs used to treat bladder incontinence | |||
---|---|---|---|
Drug group | Example drugs | Mechanism of action | Indication |
Muscarinic antagonists |
|
| |
Muscarinic agonists |
| ||
Sympathomimetics |
| ||
Alpha-1 antagonists |
|
Other treatment options depend on the form of urinary incontinence; see the “Overview” section above as well as “Stress incontinence” and “Urge incontinence” articles.
Complications
- General: depression, psychosocial distress
- From prolonged contact with urine: dermatitis, skin infections, and sores
- Urinary tract: : increased risk of urinary tract infections
We list the most important complications. The selection is not exhaustive.