Incontinence

Urge incontinence is due to Detrusor muscle overactivity, therefore causing symptoms of urgency. Social hx is very important here as the condition can be very embarrassing for patients, having a significant impact on their quality of life.

Stress incontinence is due to weakness of the pelvic floor and sphincter muscles, allowing urine to leak out when there’s increased intra-abdominal pressure e.g. laughing, coughing, sneezing, exercise.

Overflow incontinence is where there are small leaks of urine w/o warning. This occurs when pressure in the bladder overcomes the pressures of the outlet, such as:

• Detrusor underactivity e.g. Anticholinergics, MS, DM, Tumours

• High urinary outlet pressures e.g. BPH, prostatism, constipation

Risk factors:

• Increased age

• Post-menopause

• Obesity

• Previous pregnancies, vaginal deliveries, and perineal tears

• Pelvic organ prolapse e.g. vaginal

• Pelvic floor surgery

• Neurological conditions e.g. MS

• Caffeine, alcohol

Investigations:

• Detailed hx

  • Should distinguish between urge and stress types

  • Ask about Frequency, Urgency, Nocturia

  • Assess modifiable lifestyle factors – Alcohol, Caffeine, Medication, BMI

• Bladder diary

• Urine dip

• Urodynamic testing

Management of Urge Type:

Conservative:

• Bladder retraining - 1st line

• Pelvic floor exercises is another conservative option where the contraction of the pelvic floor relaxes the detrusor, therefore having benefits in this type of incontinence as well

Medical - Anticholinergics e.g. Oxybutynin, Tolterodine – Inhibits parasympathetic activity on the detrusor muscle.

• Side-effects - Dry mouth and eyes, urinary retention, constipation, and postural hypotension (Can't see, Can't pee, Can't sh*t, Can't spit)

If these don't work, other options include:

• Botox injection (Bladder Instillation) to paralyse the detrusor

• Sacral Neuromodulation – Sacral nerve stimulation – Only used if patient fails other treatment options

Management of Stress Type:

Conservative:

• Reduce caffeine, alcohol, and weight

• Pelvic floor exercises

Surgery is an option, but if not suitable, Duloxetine (SNRI) can be given.