Urology Conditions
      Back to home
      1. VCT Resource Library
      2. Urology Conditions

      Urinary Incontinence

      Brief Overview: Defined as involuntary loss of urine that presents a social or hygienic condition.
      • Stress incontinence (SUI)-loss of urine with physical exertion-cough/laugh/sneeze/jump/pick up heavy object. Very rare in men unless prostate surgery, neurological disease, or trauma.
      • Urge incontinence-(UI)- loss of urine associated with urgency. “I just couldn’t get there quick enough.”
      • Mixed urinary incontinence (MUI)- multifactorial, urgency and physical effort
      • Overflow incontinence-high residual or chronic retention that causes spillage from bladder overdistention
      • Functional incontinence- loss of urine due to deficits of cognition and mobility

      Prevalence: 3-11% in males. After prostatectomy or TURP can range from 1-57%. 50% more common in women, 30-50%.

      Etiology:

      • SUI- anatomic due to urethral hypermobility from lack of pelvic support, or intrinsic sphincter deficiency that can be caused by surgical scarring, radiation, hormonal, or senile changes.
      • UI- detrusor overactivity
      • Continuous incontinence- constant loss of urine- suspect fistula if pneumaturia, fecaluria, or history of radiation

      Risk Factors: advanced age, cognitive impairment, COPD, menopause, obesity, pelvic organ prolapse, pelvic surgery or radiation, pregnancy, smoking, vaginal childbirth, neurologic disease, prostate surgery, pelvic trauma, prostate surgery

      Commonly Associated Conditions: Parkinson's, MS, BPH, menopause, diabetes. Assess medications that may exacerbate symptoms-diuretics.

      Common Symptoms: Document the amount, frequency, and timing of urine leakage.

      Physical Findings: Pelvic exam- urethral hypermobility with cough/strain. Assess for atrophic vaginitis or pelvic organ prolapse. DRE in men may show an enlarged prostate.

      Common Labs, Imaging, and Tests:

      • UA C&S if symptoms of infection. Glucose may be present if diabetic, protein for decline in renal function.
      • Urodynamics can be helpful to determine detrusor overactivity, emptying, capacity, Valsalva leak point pressure, detrusor leak point pressure
      • Cystoscopy for concern for fistula or malignancy
      Common Medications: Primarily for urge incontinence. Stress incontinence will see minimal-modest benefit with medication.
      • Antimuscarinics/anticholinergics- tolterodine (2-4mg/d), trospium XR (60mg/d), darifenacin (7.5-20mg/d), solifenacin (5-10mg/d), oxybutynin IR/ER(5-20mg/d), fesoterodine (4-8mg/d). these are high-risk medications in the elderly and common side effects are dry mouth, dry eye, and constipation. Risk of cognitive changes with long-term use.
      • Beta-adrenergic agonist-promotes detrusor relaxation- mirabegron/Myrbetriq (25-50mg/d), Gemtesa* no generic (75mg/d). Myrbetriq can cause a rise in BP, not uncommon to see cardiology d/c this medication. Gemtesa is usually very well tolerated but $$$.
      Common Treatments:
      • Lifestyle modification- weight loss, reduce caffeine/alcohol/nicotine, bladder retraining, and toileting schedules
      • keeping bladder diaries for ongoing evaluation and treatment responses.
      • Pelvic floor physiotherapy including biofeedback, vaginal weights, electrical stimulation, and kegel exercises.
      • Vaginal pessary in case of pelvic organ prolapse, some have additional urethral support for SUI.
      • Penile compression clamps, condom catheters.
      • Surgical/procedural intervention:
        • UUI
          • Tibial nerve stimulation, office-based therapy requiring weekly sessions over 3-4mo and periodically thereafter
          • Sacral neuromodulation- Axonics/Interstim- implanted neurostimulator of sacral nerves, modulates activity of bladder, sphincter, pelvic floor muscles. Also indicated for fecal urgency/incontinence. Newer models/operating systems have longer battery life and MRI compatibility. Older models are not MRI compatible, and need to direct to the clinic/rep if questions regarding their personal device. Older models often require recharging their devices. Both systems have devices to make adjustments on their therapy.
          • Intravesical botulinum toxin- Botox. Chemical denervation promoting relaxation of the bladder. Requires retreatment q4-12 mo on average. The biggest risk with this procedure is retention.
        • SUI
          • Urethral bulking agent for intrinsic sphincter deficiency-Bulkamid, Macroplastique.
          • Midurethral sling for urethral hypermobility. Monitor PVR afterwards.
          • Artificial urinary sphincter in males. Consists of a reservoir, an inflatable cuff around the urethra, and a “button” the patient presses to cycle the sphincter to empty the bladder.

       

      Potential Complications and Contraindications: Skin breakdown, dermatitis, candidiasis.
      General Health and Lifestyle Guidance:
      • Expect diuretics to worsen urgency/frequency and sometimes leakage. Do not stop these medications without talking to the prescriber.
      • Hydrate with water. Avoid irritants such as caffeine, alcohol, and sugar.
      • Exercise daily to maintain muscle tone of the core/pelvic floor.
      • Pelvic floor exercises such as Kegels.

      Suggested Questions to Ask Patients:
      • Are you having any UTI symptoms that could cause a worsening in incontinence?

      Suggested Talking Points:
      • Bladder diary to monitor efficacy of treatment, baseline for comparison. See example.
      • Pelvic floor PT referral for SUI.