Urinary Incontinence

Normal mechanisms of female continence

Types of incontinence

• Stress

  • intravesical pressure exceeds maximal urethral closure pressure

• Urge

  • sensation of urge to urinate

  • overactive bladder

  • increased frequency often indicates infection
  • in absence of infection may be due to detrusor instability

• Mixed

• Overflow

• Reflex

• Extra-urethral

History

• Onset and timing

• frequency

• urgency

• nocturia

• dysuria

• volume passed

• incomplete emptying

• enuresis

• haematuria

• fluid intake

• associated symptoms

  • abdominal pain / swelling

  • dragging sensation

  • sensation of genital prolapse

  • vaginal lumps / interference with sex

  • faecal incontinence

• PMHx

  • previous surgery

  • systemic illness

  • recent and current medications

• Past O&G Hx

  • inc. epidural

• Family and social history

  • occupation

  • personal circumstances

  • consequences of incontinence

Examination

• General

• CNS

• Abdominal

• Pelvic

  • vulval excoriation

  • perineal soiling

  • genital prolapse

  • demonstrable stress incontinence

  • bladder neck descent

  • pelvic masses

Investigation

• Urinalysis

• micturition chart

• pad test

• Basic urodynamics

  • flow rate

  • cystometrography / videocystometrography

• Urethral pressure profile

• micturating cytogram

• (sacral evoked responses / urethral electrical conductance)

• IVU

• ultrasound

• cystoscopy

• MRI

Treatment

Medical

• fluid restriction

• bladder training

• Stress

  • physiotherapy

  • pessaries

  • oestrogen cream

• Urge

  • Muscarinic Antagonists

    • oxybutinin

    • tricyclic antidepressants

  • Desmopressin (DDAVP)

  • indwelling catheters

Surgical

• Prolapse

  • anterior repair

  • colposacropexy

  • sacrospinous fixation

  • posterior repair

• Incontinence

  • Stress

    • colposuspension

    • tension free vaginal tape

    • sling procedures

    • needle suspensions

    • periurethral injections (Macroplastique)

    • artificial sphincters

    • urinary diversions

  • Urge

    • cystodistension

    • clam ileocystoplasty

    • phenol injections

  • Bowel

    • repair of anal sphincter

    • biofeedback

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