Urinary Incontinence
Urinary incontinence is the involuntary loss of urine from the bladder. Loss of urine occurs at times and places which are inconvenient, inappropriate and socially embarrassing. Stress incontinence is loss of urine during coughing or straining. Urge incontinence is the inability to maintain urinary continence in the presence of frequent and persistent urges to void. Overflow incontinence occurs when the detrusor muscle becomes flaccid and often insensitive to stretch and the bladder distends. Weakness of the sphincter mechanism eventually leads to overflow, when urine leaks out through the urethra.
History
Stress incontinence
History of multiple childbirth. Difficult delivery. Recent prostatectomy. History of loss of urine during coughing and straining.
Urge incontinence
The patient is unable to maintain urinary continence in the presence of frequent and persistent urges to void. Recent prostatectomy. Recurrent attacks of cystitis with dysuria and frequency. Past history of pelvic radiotherapy. History of TB. History of ureteric colic. Persistent suprapubic discomfort and haematuria associated with stone. Haematuria associated with tumour.
Overflow incontinence
History of spinal injury involving lumbar vertebra (sacral centre, cauda equina). History of pelvic surgery, e.g. abdominoperineal resection of rectum with damage to pelvic nerves. History of diabetes. History of prostatism with chronic retention with overflow. The patient may still be able to void reasonably normally but feels the bladder is not emptying and leakage continues.
Neurological
With upper motor neurone lesions, there may be a history of spinal trauma affecting the cord above the sacral centre. History of head injury, CVA, multiple sclerosis or syringomyelia.
Anatomical
Ectopia vesicae will be obvious at birth with an abdominal wall defect and the ureter opening into exposed bladder mucosa on the lower abdominal wall. Duplex ureter may be associated with an ectopic opening of the ureter into the vagina. Vesicovaginal fistula may follow pelvic surgery or pelvic radiotherapy. It may occasionally be the presenting symptom of pelvic malignancy. Rarely, ureterovaginal fistula may occur from an erosion of a ureteric calculus into a vaginal fornix. With duplex ureter, vesicovaginal fistula or ureterovaginal fistula, urine dribbles from the vagina continuously.
Other
Nocturnal enuresis occurs in up to 5% of 10-year-old children. Bed-wetting after puberty usually indicates the presence of an unstable bladder or other pathology.
Examination
Stress incontinence
Observe leakage when patient coughs. A cystocele or complete prolapse may be seen.
Urge incontinence
There may be little to find on examination.
Overflow incontinence
There may be a palpable bladder. Carry out a full neurological examination. Digital rectal examination may reveal prostatic hypertrophy.
Neurological
Reflex emptying of the bladder occurs. Carry out a full neurological examination.
Anatomical
Ectopia vesicae – ureters opening into bladder mucosa on the abdominal wall. With vesicovaginal fistula, examination with a vaginal speculum may indicate the site of the fistula.
General Investigations
Specific Investigations
■ Cystoscopy
Bladder stone. Neoplasia.
■ Cystography
Vesicovaginal fistula.
■ Urodynamics
Uroflowmetry – measures flow rate. Cystometry – detrusor contractions. Videocystometry – leakage of urine on straining in stress incontinence – urethral pressure profiles – sphincter function and outlet obstruction.
■ CT
Cord lesion. Spinal tumour.
■ MRI
Cord lesion. Disc lesion. Spinal tumour. Syringomyelia.
