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Incontinence
Understanding Urinary Incontinence
Not always a matter of age
Definition
Involuntary urine loss through the urethra due to stress with stable detrusor due to inadequate closure function. Synonyms: Stress incontinence, sphincter incompetence
Urinary incontinence is a functional disorder characterized by the involuntary loss of urine that exceeds the normal extent and control of bladder emptying. This condition can have various causes, including anatomical, neurological, hormonal, or age-related changes in the body. Typical symptoms of urinary incontinence include involuntary loss of urine during physical activity, coughing or sneezing, frequent urination or nocturnal urination, and a general feeling of bladder weakness.
According to the Swiss Society for Urology, about 400,000 people in Switzerland are affected by incontinence, with women being about twice as likely to be affected as men. It is estimated that incontinence causes healthcare costs amounting to several hundred million Swiss francs annually.
Risk Factors
The frequency of urinary incontinence increases with age. Bladder infections are also a common cause of urinary incontinence. During pregnancy, about 30 to 60% of pregnant women suffer from urinary incontinence. Normally, this is temporary incontinence that does not occur after birth. However, urinary incontinence can also be caused by childbirth. Due to the high strain and stretching of the pelvic floor muscles, dysfunction of the sphincters can occur.
Menopause leads to an increased likelihood of bladder infection, as it causes thinning and drying of the genital tissue (genital atrophy).
Overweight can also promote urinary incontinence. The additional weight can strain the pelvic tissue to the point of stretching and weakening the pelvic floor muscles.
Diagnostic
Classification
- Stress Incontinence – uncontrolled urine loss due to increased abdominal pressure, such as heavy lifting, coughing, sneezing, or laughing.
- Causes can include weakening of the bladder sphincter, pelvic floor muscle weakness due to childbirth or surgery, and lack of female sex hormones during menopause.
- Urge Incontinence – characterized by a very strong urge to urinate with involuntary urine loss.
- Causes include overactivity or sensitivity of the bladder. Other possible causes are urinary tract infection, bladder mucosal polyps, or bladder tumors.
- Mixed Incontinence – a combination of both components is possible.
Medical History
The temporal and activity-related assignment of incontinence episodes allows for an initial suspected diagnosis regarding the type of incontinence. Standardized incontinence assessment forms facilitate and complete the history taking. These questionnaires also record urination frequency, nocturia, and daily pad usage – information that is usually provided in a very general manner.
Urine Analysis
Inflammations of the lower urinary tract can mimic the clinical symptoms of an overactive bladder or urge incontinence. Asymptomatic bacteriuria often occurs. Therefore, a urine analysis using test strips should be performed during each initial consultation, and a bacteriological examination should be requested if pathological findings are present.
Genital and Pelvic Floor Status
The genital status serves to exclude a urogenital prolapse (vaginal/uterine prolapse) and provides information about the local hormone status. With a full bladder, the stress test (objectifying involuntary urine loss when coughing) can be performed. If it is negative despite the history indicating stress incontinence, a pad test should be conducted after completing all examinations.
Urogenital Ultrasonography
In addition to assessing the responsiveness of the pelvic floor, an ultrasound examination of the urethra (funneling) when pressing is a typical finding in stress incontinence.
Urodynamics
Before any stress incontinence surgery, an overactive bladder should be excluded. Additionally, the stress incontinence is confirmed by using a resting and stress pressure profile of the urethra.
Urethrocystoscopy
In cases of therapy-resistant urge symptoms, hematuria (blood in the urine), or postoperative dysuria (painful urination), urethrocystoscopy should be generously indicated to exclude possible tumors and chronic inflammatory changes in the bladder wall.
##** Treatment of Urinary Incontinence** Stress, urge, and mixed urinary incontinence are chronic conditions and require permanent therapy following a step-by-step concept.
Treatment of Urge Incontinence
Urge incontinence is treated with medication that relaxes the bladder and facilitates emptying. Organic causes, as described above, must be excluded or treated beforehand.
- Anticholinergics: Anticholinergics should be checked for possible contraindications (e.g., narrow-angle glaucoma, arrhythmias, cerebral sclerosis) and indicated accordingly. During therapy, emerging side effects (e.g., constipation, residual urine formation) must be recognized in time.
- Electrostimulation: This is performed transvaginally with 20 Hz daily for three months initially. Then a decision is made regarding the continuation of therapy.
Treatment of Stress Incontinence
- Pessary Therapy: Pessary therapy for stress incontinence convinces with immediate therapeutic success.
- Pelvic Floor Awareness Training: Pelvic floor training for stress incontinence is individually tailored and oriented to the pelvic floor status. If there is no responsiveness when asked to contract, electrostimulation should be started. Once responsiveness is achieved, various forms of biofeedback training can be recommended.
- Surgical Therapy: The principles of surgical therapy for stress incontinence have not changed despite innovative surgical techniques.
General Therapy
- Fluid and Toilet Training, Nutritional Counseling: By creating a voiding diary, “bad” drinking and voiding patterns can be corrected. Examples include pollakiuria to avoid stress incontinence episodes, which can lead to reduced bladder capacity. In urge incontinence, many patients try to reach the toilet immediately upon feeling the imperative urge to urinate; hasty movements or slow undressing due to musculoskeletal limitations then support involuntary urine leakage.
- Antibiotics: If urinary tract infections are identified as the cause of urge incontinence, they are treated according to the antibiogram.
- Hormones: Local estrogenization (estriol preparations) has infection-preventive as well as urge and stress incontinence episode-reducing properties and should be generously applied postmenopausally.
- BOTOX Applications