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Urinary Incontinence

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Urinary incontinence is a condition characterized by loss of voluntary control over urination. Under normal conditions, urine passes from the urinary bladder to the outside through a tube-like organ called the urethra. Sphincter muscles around the urethra prevent leakage of urine from the bladder. This sphincter is under voluntary control from around the age of three. Loss of this voluntary control in adults leads to unintentional or uncontrolled urination. Due to many unreported cases, statistical data is unavailable; however, it is estimated that around 423 million adults globally experience urinary incontinence to varying degrees. Apart from being a medical dysfunction, urinary incontinence can disturb one's emotional, psychological, and social well-being. Considering Urinary incontinence as a part of old age is a misconception, as it can be treated or managed with medical support.

Types


  • Overactive bladder incontinence: It is also known as 'Urge incontinence' and is characterized by a sudden and urgent need to urinate immediately. This can be due to loss of nerve control, weak sphincter muscles, or menopause. OAB can also occur as a side effect of certain medications and caffeinated beverages.

  • Stress incontinence: This happens when the person involuntarily leaks urine while sneezing, lifting heavyweight, sudden movements like sneezing, etc. Stress incontinence occurs due to weakened muscles on the floor of the pelvis. 

  • Mixed incontinence: This happens when the reason for urinary leakage is both an overactive bladder and stress incontinence. 

  • Overflow incontinence: This occurs when the bladder does not empty fully while urinating, therefore causing frequent leakage of urine in small amounts. This is more common in men with an enlarged prostate. 

  • Functional urinary incontinence: This happens due to physical or environmental barriers to urination. In this case, the urinary system is healthy. Still, disorders like mental illness, dementia, arthritis, etc., can cause difficulty to locate a toilet or undressing on time, thereby causing leakage of urine.

Symptoms

Urine leakage due to urinary incontinence occurs as a result of sudden movements that exert pressure on the urinary bladder. This includes exercising, laughing, etc. Common symptoms experienced in most types of Urinary incontinence are:


  • Sudden leakage of urine can be due to activity. The amount of leakage can be a few drops or in large volume, depending on the intensity of pressure exerted. 

  • Sometimes, urine leakage can be due to a change in orientation during sexual intercourse, or other external stimuli. The urge to urinate can occur frequently at any time.

  • Symptoms of lower urinary tract muscles such as an extremely slow passage of urine, straining while urination, and feeling dissatisfied after urination, can also occur. 

Causes And Risk Factors

Causes


Short-term Urinary incontinence can be caused due to the following reasons:

  • Constipation: This is a cause mainly in cases of chronic constipation.

  • Pregnancy: Pressure exerted on the bladder, especially during pregnancy or vaginal childbirth, can lead to Urinary incontinence that can last for a few weeks postpartum.

  • Beverages: Caffeinated beverages such as tea or coffee, alcohol, etc., can stimulate urination and increase the frequency of incontinence.

  • Medications: Many prescribed drugs can increase the chances of experiencing Urinary incontinence. These include diuretics that increase the bulk of urine production, taken usually for hypertension to reduce the total blood volume. Other drugs include antidepressants, sedatives, Angiotensin-converting enzyme inhibitors, or Hormone Replacement Therapy.

  • Urinary incontinence after surgeries

  • Urinary tract infections


Long-term Urinary incontinence can be caused due to the following reasons:

  • Menopause- There is a lower incidence of Urinary incontinence among young women and the highest during menopause and old age. This can be due to rapid changes in hormonal levels and weakened muscles of the urinary bladder and urethra.

  • Stroke

  • Diabetes- Both Diabetes mellitus (type I and II) and Diabetes insipidus can produce large volumes of urine, frequently leading to Urinary incontinence.

  • Neurological disorders- These include Parkinson’s disease and Multiple sclerosis, where a person cannot control voluntary motor activities.

  • Ehlers-Danlos syndrome- It is a connective tissue disorder that weakens the strength and elasticity of many organs, including the urinary bladder.

  • Tumours in the urinary tract

  • Disorders of the pelvic floor


Risk factors


Several factors are known to increase the risk of urinary incontinence. These include:

  • Age (Risk increases with age)

  • Gender (Higher prevalence of Urinary incontinence seen in women)

  • Genetics

  • Obesity

  • Smoking

  • Neural injuries

  • Alcoholism


Apart from this, urinary incontinence in women is mainly found due to gynaecological factors like pregnancy, childbirth and pelvic surgery.

Prevention

Prevention


Although it is not always possible to prevent urinary incontinence, you can lower its risk with the following measures:

  • Practice Kegel exercises, especially during pregnancy

  • Eat a healthy diet, especially more fibre-rich foods.

  • Maintain a healthy weight

  • Avoid caffeine and acidic foods as they irritate the bladder

Diagnosis

The following comprise diagnosis for Urinary Incontinence:


  • Physical examination-With a thorough physical examination followed by a brief history of your clinical health, your doctor might detect the condition. You may be asked to perform a simple test that involves closing your mouth and nose and exhaling hard to check urinary incontinence.

  • Urine analysis

  • Ultrasound of the bladder

  • Cystoscopy- To view the urinary tract internally.

  • Urodynamic testing- To determine the volume holding capacity of one’s bladder.

  • Pad test- To evaluate the leakage.

  • Dipstick test- This test evaluates the presence of bacteria, proteins or traces of blood in the urine to determine the chances of Urinary tract infections.

  • Residual volume test- This determines the amount of urine left in the bladder after urination.

Treatment

Treatment for Urinary incontinence is planned according to your age, severity and type of the condition, presence of a co-existing disease, etc. Following are some of the treatment approaches for Urinary incontinence:

Behavioural therapy:


  • Toileting assistance- This includes planning routine toilet visits and attempting to ensure complete bladder emptying to prevent frequent incontinence.

  • Bladder training- This involves training an individual to reduce the frequency of voiding the bladder by resisting the urge to urinate.


Medications: Different drugs can be used depending on the type of Urinary incontinence. For SUI, an antidepressant called Duloxetine is often prescribed. Antimuscarinics like darifenacin and Oxybutynin are used for Urge incontinence. In the case of antimuscarinic intolerance, Mirabegron is used. For relief from nocturia, Desmopressin is prescribed. However, these medications have various adverse effects and should be taken only if prescribed by a registered physician.

Diet changes: Food that stimulates urination, such as caffeine, alcohol and citrus fruits, should be controlled in the diet.

Pelvic muscle rehabilitation: This involves enhancing the muscle tone of the pelvic cavity organs and comprises the following-

  • Kegel or vagina weight training- This involves placing small smooth-surfaced weights in the vagina that strengthens the muscles of the vagina.

  • Biofeedback- Small probes are used to review the strength of muscle contraction, thereby determining the impact of weight training on the patient.

  • Electric Stimulation of the pelvic muscles- This helps to stimulate contraction of the pelvic muscles.


Urine collection devices: There is a wide range of urine collection and storage devices, which can be chosen according to the type of incontinence and patient compliance. These include:

  • Absorbent pads or adult diapers

  • Urine drainage bags

  • Indwelling catheters

  • Toilet substitutes

  • External collection systems: For men, these are Texas catheters or a special type of condoms that drain urine into a collecting bag. For women, funnel-like tubes are available but are rarely used.


Surgery- This is done mostly for stress incontinence by placing a sling below the urethra to prevent leakage during activities.
Apart from these, Botox injections, peripheral nerve stimulation, etc., can be used.

Lifestyle Management

This can include losing weight, changes in diet and controlling the amount of fluid intake, as both high and low amounts of fluid in the body affect incontinence.

Prognosis And Complications

Prognosis


Effects of treatment of Urinary incontinence are variable. Generally, favourable cure rates are seen in patients after surgical interventions. In most cases, significant improvement is seen, if not cured.

Complications


If left untreated, urinary incontinence might lead to urinary tract infections. Apart from this, this condition also impacts your personal as well as social life and increases your risk of suffering from skin infection. Other complications include:

  • Renal dysfunction due to obstruction in the urinary tract

  • Cellulitis

  • Pressure ulcers

  • Medication side effect

  • Infections due to catheter insertion

  • Sexual dysfunction

  • Depression

Alternative Treatments

The use of herbal medicines is an alternative to antimuscarinics that are widely used for Urinary incontinence. These are not only cheaper but they can also be free of side effects. Examples include Chinese herbal medicines like Gosha-jinki-gan and Hachi-mi-jio-gan, Capsaicin from chilli seeds and Buchu, which is a medicinal herb with antispasmodic activity are found to show improvement in Urinary incontinence. However, there is a lack of research proving their efficacy.

Reference:


  1. Incontinence: Symptoms & Treatment - Urology Care Foundation. (2021). Retrieved 23 June 2021, from https://www.urologyhealth.org/urology-a-z/u/urinary-incontinence

  2. Tran LN, Puckett Y. Urinary Incontinence. [Updated 2021 Apr 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559095/

  3. Incontinence: Leakage, Causes, Diagnosis, Treatment & Prevention. (2021). Retrieved 24 June 2021, from https://my.clevelandclinic.org/health/diseases/17596-urinary-incontinence#symptoms-and-causes
    Urinary incontinence - Symptoms. (2021). Retrieved 24 June 2021, from https://www.nhs.uk/conditions/urinary-incontinence/symptoms/

  4. Urinary incontinence - Causes. (2021). Retrieved 24 June 2021, from https://www.nhs.uk/conditions/urinary-incontinence/causes/

  5. Stress Urinary Incontinence (SUI): Symptoms, Diagnosis & Treatment - Urology Care Foundation. (2021). Retrieved 24 June 2021, from https://www.urologyhealth.org/urology-a-z/s/stress-urinary-incontinence-(sui)#Diagnosis
    Urinary incontinence - Diagnosis. (2021). Retrieved 24 June 2021, from https://www.nhs.uk/conditions/urinary-incontinence/diagnosis/

  6. Urinary Incontinence in Women. (2021). Retrieved 24 June 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/urinary-incontinence/urinary-incontinence-in-women

  7. Stress Urinary Incontinence (SUI): Symptoms, Diagnosis & Treatment - Urology Care Foundation. (2021). Retrieved 24 June 2021, from https://www.urologyhealth.org/urology-a-z/s/stress-urinary-incontinence-(sui)#Treatment
    Chughtai, B., Kavaler, E., Lee, R., Te, A., Kaplan, S. A., & Lowe, F. (2013). Use of herbal supplements for overactive bladder. Reviews in urology, 15(3), 93–96.

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