Tanta University

Faculty of Medicine

Student Research
Project
Year: One Two Three
Group Number: 67
Course / Module Title: Urinary module
Course/Module Code: URIN 2204
Research Topic: Urinary incontinence is very annoying to the
patient and the cause should be managed promptly
Date of Submission: 2 /6 /2020
Student Names:

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 Student name Student ID National ID
‫ زياد صابر عبد المعطي حسين‬4181351 30005271601359
‫ زياد فوزي محسن شعيب‬4181352 30004091601834
‫ زياد محمد مبروك عبد القادر عالم‬4181353 30011061601631
‫ زياد وليد السيد زكي‬4181354 30001151602895
‫ زينب إبراهيم مسعد الخواجة‬4181355 29912011608769

Student name Role in the research

‫ زياد صابر عبد المعطي حسين‬Writing the research review
‫ زياد فوزي محسن شعيب‬Writing introduction and objectives
‫ زياد محمد مبروك عبد القادر عالم‬Total review of the research
‫ زياد وليد السيد زكي‬Collecting pictures and writing resources
‫ زينب إبراهيم مسعد الخواجة‬Writing summary and conclusion

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 Introduction and Objectives

Introduction:
Urinary incontinence — the loss of bladder control — is a widespread and often
embarrassing illness. The severity ranges from occasionally losing urine when you
sneeze or cough to an urge to micturate, that is so unexpected and intense you do
not go to a bathroom in time. Although it happens more often when people become
older particularly women. Urinary leakage is not a certain result of senility. Urinary
incontinence may also lead to depression. Urinary incontinence may have a great
influence on a person's quality of life. Ignored urinary incontinence can cause, skin
problems, skin wounds and systemic infections. Therefore inserting other great
physical morbidity to patients that are already dealing with many symptoms at old
age. In its various forms, urinary incontinence may limit patients’ mobility and social
interactions, but can be easily got better with right management, treatment and
assessment. Whether urinary incontinence influences your diurnal jobs, do not
hesitate to visit your physician. For many people, natural lifestyle changes or medical
treatment can relieve discomfort or prevent urinary incontinence.

Objectives:

1. To know the medical definition of urinary incontinence.

2. To know the prevalence of urinary incontinence.
3. To know the causes of urinary incontinence.
4. To know the risk factors of urinary incontinence.
5. To know the types of urinary incontinence.
6. To know the investigations of urinary incontinence.
7. To know the treatment of urinary incontinence.

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 Research review
 Definition:
(Becker et al., 2005) defined it uncontrolled leakage of urine which is a very great issue
that embarrasses the patient.

 Prevalence:

(Thomas et al., 1980) states that the spread of urinary incontinence was known by
determining the number of incontinent patients under the auspices of various
medical and health service organizations in two London quarters and by an
enormous study of the 22 431 samples, their age 5 years and over on the practice
lists of 12 general practitioners in various places over the state. The spread of
incontinence determined by the medical and health study organizations was 0.2% in
females and O. 1% in males aged 16-64 and 2.5% in females and 1.3% in males
their age is 65 and over. The postal study, to which 89% of the persons whose right
address was known replied, showed a spread of urinary loss of 8.5% in females and
1.6% in males their age 15- 64 and 11.6% in females and 6.9% in males their age is
65 and over. Nulliparous females had a lower incidence than other females who had
had one, two, three children, but within the equality range of one to three babies,
there were not any difference in prevalence. The prevalence was appreciably high in
women who had had four or more children. Incontinence was average or sharp in a
fifth of those who signed it in the postal study, of whom less than a third were using
medical or health services for the condition. Incontinence is a widespread symptom.

 Etiology: (Cooper, 1997)

Urinary incontinence is not connected with aging. It can occur at any age and can be
resulted from many physical conditions. Many causes of incontinence are temporary
and can be treated with simple treatment. Some reasons of temporary incontinence
are: Infections of Urinary tract, reproductive system infection or irritation, constipation
, effects of urinary Incontinence can be caused by other conditions that are
permanent. These causes of this problem are : Dysfunction of muscles that catch the
bladder in place Weakness of the bladder itself, weakness of the urethral sphincter
muscles , overactive bladder muscle , closed urethra (can be from prostate

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expansion),hormones disturbance in women, nerve disorders, inability of movement
(not be able to move around)

(Dmochowski, Karram and Reynolds, 2013) states that It may also caused by
disturbances to lower urinary system function due to aging, hormone withdrawal, or
bladder outlet obstruction, local hypoxia or partial denervation of the bladder.

 Risk factors:

History of recurrent urinary tract infection, bladder irritation (low fluid intake, caffeine
and possibly alcohol), loss of skills for toileting, age, pregnancy/multiple pregnancies;
childbirth/delivery (vaginal or cesarean section): episiotomy; large gestational weight
cystocele or uterine prolapse, any pelvic surgery including hysterectomy for women,
prostatectomy for men, diabetes mellitus, constipation, fecal impaction, tobacco use,
nerve disorder, cerebral palsy, spinal cord injury, stroke Psychogenic (e.g., childhood
and/or adult sexual trauma for both males and females, Sexual experiences, emotional
stress and Medications e.g. alpha - adrenergic blockers (antihistamines.
decongestants), antiparkinsonian agents, antipsychotics, diuretics, narcotic
analgesics, tranquilizers, Sedative hypnotics.(Goodman and Marshall, 2015)

CLASSIFICATION

 Urge urinary incontinence: This is the involuntary leakage of urine

associated with a strong desire to void (urgency). This is preceded by urgency.
It is either unknown or secondary to urinary bladder outcome obstruction
(instability of detrusor), bladder cancer or urinary tract infection.
 Stress urinary incontinence: This sign indicates uncontrolled leakage of
urine through physical activity. The case is caused by or an overactive
detrusor provoked by physical exertion or sphincter abnormal activity.
 Unconscious Incontinence: Incontinence may occur in the absence of urge
and without conscious recognition of this seen only in the case of a
neuropathic bladder or urethral disorders.
 Continuous incontinence: This means continuous loss of urine, which is
caused by sphincter weakness or extra urethral incontinence.

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 Stress urinary incontinence: This sign indicates uncontrolled leakage of
urine through physical activity. The case is caused by or an overactive
detrusor provoked by physical exertion or sphincter abnormal activity.
 Unconscious urinary incontinence: Incontinence may occur in the absence
of urge and without conscious recognition of this seen only in the case of a
neuropathic bladder or urethral disorders.
 Continuous Leakage: This means continuous loss of urine, which is caused
by sphincter weakness or extra urethral incontinence.
 Nocturnal Enuresis: This urine leakage happens during sleep. It is
uncontrolled disturbance, it sometimes happens because of organic reasons.
 Overflow Incontinence: This refers to any uncontrolled leakage of urine
associated with an over fullness of the bladder. This term has been reviewed
however, and a scientific organization has advised that the term incontinence
should be linked with weak bladder emptying.
 Reflex Incontinence: Involuntary urethral relaxation in the absence of
sensation and is usually associated with the desire to micturate or Loss of
urine due to hyper reflux of detrusor. It is noticed only in the condition of a
urethral disturbances or neuropathic bladder.
 Mixed urinary incontinence: involuntary leakage of urine on effort and
preceded by urgency.(Vasan, 2002)
 Genuine Stress Incontinence: This is the involuntary loss of urine when the
maximal urethral pressure is less than the intravesical pressure in the
absence of detrusor effect. (Jarvis, 1994)

Investigations: (Laycock and Haslam, 2013)

o Pad test: This simple non-invasive investigation enables objective
measurement of urine loss under standard and reproducible conditions. Over
a 1 h period, with a full bladder, a series of standard tests are performed e.g.
coughing, hand- washing walking and jumping, to the patient putting on a pre-
weighed absorbent perianal pad. The time of the activity can be expand to 24
or 48 h when suitable. The quantity of urine lost during the test is quantified by
the rise in weight of the pad in the gram. The weight getting of more than I g
indicates incontinence.

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 o Uroflowmetry: Uroflowmetry qualifies measurement of average flow rate,
maximum flow rate, flow time, volume voided and time to maximum flow. A
rate of flow is only understanded whether the case empties greater than 150
milli and the case feels that the discharge was right of how she or he normally
empties. Nevertheless, uroflowmetry lonely can not distinguish between
outflow block with a natural detrusor creating pressure during empting and
detrusor hypotonia in which the weak rate of flow is because of a disability of
the detrusor to contract. The principle importance of uroflowmetry is the
prognosis of postoperative empting problems in cases of genuine stress
incontinence, by distinguishing females with a weak peak flow rate as shown
in figure1.
uroflowmeter1 Figure

(Wiens, Green and Grecov, 2014)

Cystometry: Cystometry includes the measurement of the intravesical (bladder)

pressure while the bladder is filled and as the bladder empties. if the abdominal
tension, determined in the rectum or inside the vagina, is removed from the
intravesical tension, the outcome tension represents the detrusor tension. There are
two phases:

 Filling Phase: This is the only most important investigation for the
diagnosis of detrusor weakness and permits sorting of detrusor
contractions into, hyperreflexic, hyporeflexic or normal. Through
cystometry the pressure—volume relation of the bladder is

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 determined and bladder sensation, detrusor contractility capacity
and submission are estimated.
 Voiding Phase: At the finish of filling phase, the patient is ordered to
empty in the flowmeter. The maximal voiding tension and rate of
flow are known and blocked voiding (low flow, high pressure) can
be distinguished from detrusor hypotonia (low flow, low pressure).
After emptying, it is normal to calculate the volume of residual urine.
o Videocystourethrography: In Videocystourethrography the lower urinary
tract is radiologically screened, while there is synchronous recording of
urinary bladder function by urodynamic methods i.e. flow rate, cystometry, etc.
though Videocystourethrography is the most important standard' of
urodynamic investigations, it is not necessary to distinguish between detrusor
instability and genuine stress incontinence in simple patients. It is useful in
cases for whose past surgery has gone wrong, as mobility of bladder neck;
the position can be assessed on straining and at rest.
Videocystourethrography readily diagnoses morphological anomalies such as
urethral or bladder diverticulae, vesicoureteric reflux or urethral stenosis.
o Urodynamic Tests: These tests are designed to determine the anatomic
and functional status of the urinary bladder and urethra. Qualified
professionals trained in the specific definitions and procedures perform the
tests. (Panel, 1996)

Treatment: The most popular technique of managing urinary incontinence is

pads and adult diapers. However, many of these products are well prepared and
useful. They are not cheap and specific. Some patients cannot buy these products
and instead design their own unhealthy tissues. There are three methods of
treatment:

 Palliative treatment: (FACP, FAAN and FAAN, 2007)

 Behavioral therapy: a variety of behavioral therapies has been shown to be
highly effective for targeted patients. Motivated, Functional patients with,
urge, mixed and stress incontinence generally react well to behavioral
therapies. These methods include modifications of fluid intake, education,

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 various bladder-training techniques (e.g., timed voiding and strategies to
manage urgency) and self-monitoring with a voiding diary.
 Urethral tools: catheters and pessary.
 Surgical treatment: (Harding and Thorpe, 2010)
 Peri-urethral bulking agent: The insertion of these agents sub-
mucosaly in the woman urethra is prepared to aid continence through
apposition of the urethral wall.
 Retro pubic suspension procedures: are mainly prepared for therapy of
stress urinary incontinence due to urethral hyper mobility (types 1and 2
in Blaivas classification) and a great variety of different methods are
useful.
 Sling and tape procedures: The first reported kind of surgery still in use
nowadays is the pubo-vaginal sling, and numerous methods had been
prepared using a group of numerous materials ranging from biological
to autologous to synthetic slings to cadaveric.
 Artificial urinary sphincter devices: Artificial urinary sphincter (AUS)
injection comes back to the 1970s. The increase in outlet resistance
supplied by an inflatable cuff around the proximal urethra keeps the
case dry when the cuff is activated and permits bladder evacuation
when it is not. Artificial urinary sphincter insertion is often performed
after failure of the rest surgical treatments.
 Pharmacological treatment:
 Urge urinary incontinence: anticholinergic drugs e.g. oxybutynin,
tolterodine and mirabegron.
 Mixed urinary incontinence: tricyclic antidepressants.
 Stress incontinence: estrogen, pseudoephedrine and antimuscarinic agents
e.g. oxybutynine chloride and tolterodine titrate.

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 Summary and Conclusion
As we saw before, urinary incontinence is loss of urine control. It is a significant
problem which if we do not control it will lead to other complications. It is more
common in old age particularly in women than men. It is more common also in obese
people. There are many causes of it like overactive bladder, neural disorders, urinary
tract infection, obstructed urethra and some drugs. There are also numerous risk
factors as age, multiple pregnancies, diabetes mellitus, tobacco use, hysterectomy
and some medications. There are many types for it including urge urinary
incontinence, stress urinary incontinence, unconscious incontinence, continuous
incontinence, nocturnal enuresis, reflex incontinence, mixed urinary incontinence
and genuine stress incontinence. The two most common types are stress urinary
incontinence and urge urinary incontinence. We should first examine the case by
physical examination. Physical examination includes abdominal examination, pelvic
examination and neurologic examination. We can investigate it by many techniques
including pad test, urofloemetry, cytometry, videocystourethrography,
electromyogram and urodynamic studies. We can treat it in several ways including
palliative treatment, surgical treatment and pharmacological treatment. Palliative
treatment includes behavioral modification, urethral inserts and pelvic floor therapy.
Surgical treatment includes urethral bulking, colposuspentions, pubo-vaginal sling,
artificial urinary sphincter, augmentation cystoplasty and sacral neuro modulation.
pharmacological treatment includes pseudoephedrine, estrogen, antimuscarinic
agents to suppress detrusor over activity.

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