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Urinary Incontinence

Urinary incontinence is the uncontrolled leakage of urine from the bladder. There are many types of incontinence and before treatment can be advised, one must determine which type of incontinence is affecting the patient and its underlying cause. Incontinence affects the quality of life. Even though it tends to be age-relate, it can still be treated in most cases.

Urinary Incontinence

This is assessed from the history, physical examination and relevant lab or xray investigations. Sometimes, urodynamic tests may be needed [Fig 1]. This is the study of the bladder and urethra function by means of a machine with tubes inserted into the bladder and rectum to measure the pressures within

Types & Treatment

There are 5 types of incontinence:

1. Stress incontinence

This type of incontinence affects mostly women and occurs upon any form of physical exertion, especially on carrying loads, coughing, and sneezing. It is due to weakened pelvic floor muscles, which tend to occur during difficult childbirth, after menopause and following pelvic surgery. It can also occur in men following prostate surgery. The treatment is initially physiotherapy, eg. pelvic floor exercises which consist of squeezing these muscles frequently and repeatedly. However, up to one-third of sufferers cannot do this exercise. In such a case, surgery to restore the bladder support is recommended. There are many ways of doing this, ranging from open surgery (colposuspension) to minimally-invasive sling surgery to bulking agent injection. The most popular surgical method currently is sling surgery because of its good cure rates that are durable with minimal complications. Because it is also minimally-invasive, it can be done as a day case with quicker return to normal activities. The most popular sling is the TVT (tension-free vaginal tape) which is placed under the middle part of the urethra.

The surgery takes less than 30 mins and the cure rate is on average 81% at 7 years follow-up. Complications include bladder injury and voiding difficulty if the tape is placed too tight. A variant of the TVT surgery is the TVT-O in which the tape exits through the side rather than through the top, thus avoiding bladder injury. Bulking agent injection into the urethra and bladder neck is an alternative method to control stress incontinence, especially in frail elderly women. These agents range from collagen to silicon particles. The advantage is that this is a simple procedure with minimal risks that can be done under local anaesthesia in less than 15 mins. The disadvantage is that these agents may not last enough and repeat injections are then needed.

2. Urge incontinence

This is the leakage of urine as a result of an overactive bladder. The overactive bladder is a condition which occurs in up to 15% of the population, more so in elderly patients. In some patients, the strong sense of urge is difficult to control and if one is unable to reach the toilet in time, leakage occurs. Urge incontinence can be controlled by medication. The medication work by inhibiting the unstable bladder waves but can also cause side-effects like dry mouth, dry throat, and dry skin because they also inhibit the salivary and sweat glands. Nevertheless, they work in up to 80% of patients and may need to be given up to 3 months or more to "re-set" the bladder. In patients who do not respond or are unable to tolerate the drugs, then surgical methods can be considered, eg. botox injections into the bladder, or neuromodulation.

3. Overflow incontinence

This is the leakage of urine that occurs in those whose bladder are chronically full of urine as a result of persistent blockage eg. enlarged prostate or have weak bladder muscles, eg. elderly, diabetics. The leak occurs upon getting up from a lying position or upon straining and can be difficult to distinguish from stress incontinence. This type of incontinence is suspected when one finds a distended bladder on examining the abdomen. Urodynamics is often needed to confirm this type of incontinence. The treatment is self-catheterisation by means of a soft silicon catheter up to 3 times a day. In men, this can be difficult to do, hence, prostate surgery is recommended if the underlying cause is a huge, enlarged prostate.

4. Total incontinence

This occurs if surgery severely damages the urethral sphincter muscle, eg. after prostate surgery. Because of this, urine continually leaks out and one has to wear pampers to absorb the urine. The only solution to correct this kind of incontinence is to implant an artificial urinary sphincter. This is a major procedure which takes 4 to 5 hours and is expensive because the device is a specially designed one. A cuff is placed around the bladder outlet and to empty the bladder, the button controlling this cuff is pressed to deflate this cuff. The possible complications relate to the malfunction and infection of the device.

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