Urinary incontinence (aka enuresis) is any leakage of urine. It is especially problematic if it occurs repeatedly, and in Pt's old enough expected to exercise such control.
Patient information
What is urinary incontinence?
Number one's are a bit like a tap. So it's where your tap leaks - that is, when urine leaks.
Physiology
Urine is produced in the kidney and stored in the bladder
Urination is the emptying of urine through the urethra, and is controlled by relaxation of the internal and external urethral sphincters, which are supported by the pelvic floor muscles
When the bladder is full, stretch receptors send a signal to the brain. When it is not time to urinate, the brain returns an inhibitory signal to keep the urethral sphincters shut. When it is time to urinate, the inhibition is removed, and the detrusor muscle which empties the bladder contracts
Patient information
Before we get into urinary incontinence, how does normal urination exactly occur?
Urine is produced by the kidney. It's stored in the bladder. The storage usually doesn't "leak" because a set of muscles ("urethral sphincters" and "pelvic floor muscles" - keeps it from doing so. However, when storage is full, and you want to pee, the brain tells those muscles - "you can relax now". At the same time, another set of muscles ("detrusor muscles" contract to empty the bladder.
Types
In adults:
Mixed incontinence, which is a combination of urge and stress incontinence. It is not uncommon in elderly females, and can sometimes be complicated by urinary retention
I've heard of "stress" and "urgence" incontinence - in short, what's the difference ?
"Urge". That's just just as it sounds. You have overwhelming "urge" to pee. It's usually because you constantly need to go to the toilet. As compared with "stress". Again, that's just as it sounds. Whenever you face any "stress", you pee. That can be anything from coughing, jumping, bouncing ... well, anything . Without wanting to. That's more so to do with the fact that the muscles controlling having-to-pee, are weak.
"Mixed incontinence". I know in skateboarding, you have "combo" tricks like a 360 shove it+double heel flip. So is this like any "combo" of the urinary incontinences?
Not entirely. It involves only 2 of the most common ones. And we've chosen this "combo" because it's common in women. That is - the "stress". And "urgence" types.
I see. How about the other 2 types of incontinence? Overflow? And functional?
Overflow is like the opposite of urge incontinence. Whereas urge incontinence was too much contraction of the bladder-emptying muscles - usually caused by constant urges to pee. Overflow incontinence is too little contraction of the bladder. Causing retention of urine. Functional on the other hand, just means you simply can't be bothered going to the toilet. Or because of some medical condition, you can't get there.
Other classifications in adults:
Transient incontinence, which is temporary incontinence. It can be triggered by medication, adrenal insufficiency, mental impairment, restricted mobility, stool impaction (severe constipation)
Double incontinence, combining both urinary and fetal incontinence. Due to involvement of the same muscle group (levator ani) in bladder and bowel continence, Pt's are likely to have both → can be caused by damage from childbirth, complications from surgery especially involving the anal sphincters
Post-void dribbling, where urine remains in the urethra after voiding the bladder, and slowly leaks out after urination → common and usually benign, but can indicate prostatitis, or post-prostate cancer surgery
Coital incontinence, an urinary leakage that occurs during either penetration or orgasm, and can occur with a sexual partner or with masturbation → can be caused by pelvic floor disorders
How about in kids?
We divide this into wetting during night time, and day time. The stuff during day time is very similar to that in adults - so urge incontinence caused by an UTI, stress incontinence caused by giggling, or functional incontinence caused by not being bothered going to the toilet. So it's the same stuff in adults, but because for kid-related reasons.
So night time wetting. Why does it occur?
It can be normal. Kid's normally wet the bed if they're not toilet trained. This is usually under 6yo for girls, and boys tend ot be 1 year later - at 7yo. Because not all kids are the same, some kids may just have slower physical development - that is, their bladder - which stores pee - the size of that organ, is still growing. They might have slower neurological development - not enough chemicals signalling "stop producing pee" is produced at night time. Kids can be anxious. It may be genetic. And rarely - although parents usually worry about this one - there is a structural abnormality causing urine to back up.
Hx
HPC of voiding:
How often do you go to the toilet? → Urinary frequency
Do you have to pee at night? → Nocturia
When you have to go, do you have to go suddenly? → Urge incontinence
Or can you not make it because something is stopping you? → Functional incontinence
Do you ever leak urine? → Incontinence
Do you use pads? And if so, how often do you change them? → Polyuria/urge incontinence
Do you leak urine when you're giggling, laughing? → Stress incontinence
Do you ever feel like, when you go to the toilet, you can't empty your bladder? → Overflow incontinence
Do you have to strain when taking a pee? → Overflow incontinence
Drug use → Diuretics/Urge incontinence
Recent surgery? → Stress incontinence
Physical exam:
Tumors blocking the urinary tract → Overflow incontinence
Stool impaction → Fecal incontinence
Poor reflexes or sensations → Neurological cause/Overflow incontinence
Ix
Measurement of bladder capacity and post-void residual urine → inadequate bladder emptying/Overflow incontinence
Stress test, where the Pt relaxes, then coughs vigorously as the Dr watches for loss of urine → Stress incontinence
Urinalysis, for evidence of:
Bacterial infection → UTI → Urinary frequency/Urge incontinence
Urinary stones → Overflow incontinence
Glucose → DM → Polyuria/Urge incontinence
Other contributing causes
Blood tests, examined for substances related to causes of incontinence
U/S, to visualize the kidneys, ureters, bladder, and urethra → Overflow incontinence
Urodynamic testing, which are techniques used to measure pressure in the bladder and the flow of urine → Overflow incontinence
Cystoscopy, where a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder
Keep a bladder diary from 1 day-1 week, to record the pattern of voiding, noting times and amounts of urine produced
Mx
Patient information
What can be done about urinary incontinence?
That entirely depends on the type of urinary incontinence.
I see . So let's say stress incontinence. What can you do about it?
Remember that this type is related to the pelvic floor muscles causing urination "on stress". So we want to do things to help those muscles. Pelvic floor exercises is at the top of the list, any muscle that you exercise is going to build up. You can also build those muscles by practising waiting to go to the toilet. Just like how there are electrical stimulation devices to build your abs - there's also this available for the pelvic floor muscles. Where none of that works, we can do surgery. The idea behind surgery is to give support to those pelvic floor muscles. Also, there's weight loss, that always helps to reduces abdominal pressure.
How about urge incontinence. What can you do about that?
Remember that this type is related to producing too much urine and an overactive bladder causing the "urge" to pee. So there are common things we do that cause us to urinate. Drinking caffeine, drinking close to bed time, that's all behavioral things. Because urge is also related to an overactive bladder that involves spasms of the bladder muscles, we can also use drugs known as "anticholinergics" and "antimuscarinics". These block "parasympathetics", which in short, is the "rest and digest" system, including the urinary tract. So we prevent the process involved in urination from doing it's thing!
Epidemiology
Stress incontinence and urge incontinence are the most common types of urinary incontinence in women
Stress incontinence is more common than urge incontinence
Urinary incontinence affects 4% of the population, and 10% in those 65yo+
Affects less as age progresses, including 33% of 5yo, 25% of 7yo, 15% of 9yo, 8% of 11yo, 4% of 13yo, 3% of 16yo
Diurnal/day enuresis, is much less common [than noctural/night enuresis]
In childhood, 60% are male, but this ratio increases such that by 11yo there are 2x as many boys [as girls]. In adulthood, women suffer from urinary incontinence 4x more than men
Incidence is greater amongst those of lower socioeconomic status
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