Incontinence

=Incontinence=

What it is
Incontinence is the lack of voluntary control of excretory functions. Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life.

Symptoms
There are 3 main types of urinary incontinence, which may occur separately or in combination:
 * //urge//, storage failure due to uninhibited contraction of the bladder (detrusor instability/overactive bladder)
 * //stress//, impaired urethral support and/or poor urethral closure fails to prevent urine loss due to increases in intra-abdominal pressure (eg during coughing)
 * //overflow//, emptying failure caused by outlet obstruction (eg prostatic hyperplasia), or inability to contract the detrusor (eg neurogenic bladder), resulting in urinary retention and bladder distension.

How to Treat
Tests (including urinalysis and, if appropriate, urodynamic evaluation) are necessary to identify type of incontinence and possible aetiology. Ask the patient to keep a simple fluid balance diary for two 24-hour periods; this may help in assessment. Treat contributing factors, eg UTI, faecal loading, excessive fluid intake, unstable diabetes. Consider drugs as a cause of incontinence, eg alpha-blockers (eg prazosin), diuretics, sedatives, calcium channel blockers, sympathomimetic decongestants (eg pseudoephedrine), anticholinergics. Drug-induced incontinence is particularly common in the elderly. Consider non-drug measures to help bladder control including pelvic floor exercises and bladder training (particularly useful for stress and urge incontinence); protective pads and other appliances; and reduced intake of caffeinated or alcoholic drinks.
 * Before starting treatment**

//Anticholinergics// Help relax the bladder and increase its capacity, and are mainly used for urge incontinence. They may increase voiding dysfunction, causing hesitancy and retention in susceptible people. TCAs, particularly imipramine, have also been used. The extent of benefit varies between individuals; on average there is one fewer episode of incontinence per 48 hours compared with placebo. Stop if there is no benefit after 4 weeks of treatment. Elderly people are more sensitive to anticholinergic adverse effects such as blurred vision, dry mouth, constipation and confusion. Avoid using in people with dementia as such drugs impair cognition. //Selective alpha-blockers// Block receptors in bladder neck and urethra, which may help to reduce outflow obstruction and overflow incontinence in males but may precipitate or worsen incontinence in women. //Oestrogens// Increasing evidence suggests that oestrogens should not be used to treat incontinence in postmenopausal women as they may worsen the condition. On the basis of a recent study of estrogen’s effect on connective tissues, the investigators suggested that estrogen might actually alter collagen metabolism, which would result in damage to the periurethral connective tissues essential for effective urethral closure. //Other drug treatments// Bethanechol increases bladder contraction by parasympathetic stimulation. It has been used to treat urinary retention and overflow incontinence but is of questionable efficacy and not recommended. //Neurogenic bladder// This is a complex condition that may change with time, and varies according to the pathology (neurological and urological); it is best managed by a specialist. Mainstays of treatment are intermittent self-catheterisation, behavioural modification, anticholinergics and selective alpha-blockers. Surgery and the use of urinary appliances may be useful.
 * Drug choice**
 * Special cases**

Other advice

 * pelvic floor exercises, bladder training and other behavioural techniques are effective first line treatments in stress and urge incontinence; these strategies avoid adverse effects associated with drug treatment but require patient motivation and adequate cognitive function
 * surgery is often successful if conservative measures (drug and non-drug) fail
 * intermittent catheterisation is preferred in most cases of overflow incontinence occurring postoperatively, postpartum or after neurological damage when improvement with time can be expected
 * newer anticholinergic agents (eg solifenacin, darifenacin) that are more selective for muscarinic receptors in the bladder have not significantly improved efficacy, and patients may still experience adverse effects (eg dry mouth)
 * there are few trials directly comparing efficacy and safety of currently available anticholinergic drugs

Additional Resources
[|AMH] [|Is Oestrogen Good for Urinary Incontinence?] Urinary Incontinence
 * Lecture Notes**