Lebanese University, Urology
Department
4th year Medical student course
2022
DR. HUSSEIN ISSA,MD,UROLOGIST
Urinary Incontinence
Urinary incontinence
Urinary incontinence is the involuntary leakage of urine.
This medical condition is common in the elderly, especially in
nursing homes, but it can affect younger adult males and females
as well.
Urinary incontinence can impact both patient health and quality
of life.
Several different types of urinary incontinence exist, including
stress urinary incontinence, urge urinary incontinence, functional
incontinence, mixed incontinence, and overflow incontinence.
Stress Urinary
incontinence
Etiology
Stress urinary incontinence
The involuntary leakage of urine that occurs with increases in
intraabdominal pressure (e.g., with exertion, effort, sneezing,
or coughing) due to urethral sphincter and/or pelvic floor
weakness.
Young women active in sports may experience this type of
incontinence.
In addition, pregnant women and women who have
experienced childbirth may be prone to stress urinary
incontinence.
SUI
Stress urinary incontinence
Loss of support from pelvic floor musculature
and connective tissue
Neuromuscular damage from previous pelvic
surgeries
Epidemiology
Stress urinary incontinence affects 15 % of adult women.
77 % of women report the symptoms to be bothersome.
30% report the symptoms to be moderate to severe.
Prevalence of stress urinary incontinence will increase
with age particularly with menopause.
One study found that 41% of women older than 40 years
old will have urinary incontinence.
History and PE
Detailed history, particularly the genitourinary
review of systems
Voiding diary
Physical examination with the demonstration of
stress incontinence and assessment of urethral
hypermobility
Urinalysis with or without a urine culture
Measurement of postvoid residual urine volume
(PVR)
Urodynamic testing is not initially indicated in
uncomplicated stress urinary incontinence
History
• Precipitating events
• Fluid intake pattern
• Nocturia
• Type of protective devices used (tampons/pads/diapers)
• Past medical/surgical history
• Transient causes (UTIs, hypoestrogenism, cholinergic
medications, diabetes, diuretics, psychological stress)
Voiding diary
A diary of voiding should document at least
two days and include the number of accidents
with the time of day, amount of fluid intake,
amount voided versus leakage, and association
of activity
Voiding diary
PE
The pelvic examination should take place with
a full and empty bladder, both standing and
supine.
The degree of uterine and bladder prolapse
should be assessed.
Evaluation
Indications for urodynamic testing
include:
Complicated SUI
Failed surgical treatment
Patients over 60 years old
Continuous/unpredictable leakage
History of radical pelvic surgery or pelvic irradiation
Urodynamics
Treatment / Management
Treatment of stress urinary incontinence
subdivides into behavioral, pharmacological,
and surgical management.
Bladder irritants to avoid include caffeinated
beverages (coffee, tea, sodas) alcohol, citrus
fruits, chocolate, tomato, spicy foods, and
tobacco.
Behavioral therapy
Pelvic muscle exercises such as Kegel exercises –
three sets of ten pelvic musculature contractions held
for ten seconds three times a day
Bladder retraining (timed voiding) - regularly
scheduling urination leading to an empty bladder for
longer periods throughout the day
Biofeedback - visual or audio signals can provide
feedback to properly contract pelvic floor muscles
Electrostimulation - via acupuncture needles for 30
minutes weekly for 12 weeks followed by monthly
maintenance sessions
Pharmacological options
Surgery
The goals of surgery for stress incontinence
include reinforcing the pubourethral ligaments
and the paraurethral connective tissue at the
mid-urethral.
Surgical treatment generally divides into
abdominal procedures (open or laparoscopic),
vaginal procedures, and urethral bulking agents.
Abdominal procedures
Burch colposuspension
Pubovaginal sling
Burch urethropexy
The bladder neck is supported with a few stitches placed on either side of
the urethra and the iliopectineal (Cooper's) ligament
Pubovaginal sling - a strip of rectus fascia or fascia lata is placed
directly under the bladder neck via the retropubic space and
secured at the level of the rectus abdominis fascia
Vaginal procedures
Mid-urethral sling procedures
TVT- retropubic
TVT-O - "inside-out" placement of the mesh from
the vagina through the obturator foramen out
through the skin of the groin
Urge Urinary
Incontinence
UUI
Urge urinary incontinence is the involuntary leakage of
urine that may be preceded or accompanied by a sense
of urinary urgency (but can be asymptomatic as well)
due to detrusor overactivity.
The contractions may be caused by bladder irritation or
loss of neurologic control.
Etiology
Detrusor overactivity is believed to be the uninhibited
(involuntary) contractions of the smooth muscle during bladder
filling.
Significant causes leading to this overactivity could be neurologic
disorders (spinal cord injury), abnormalities in the urinary
bladder, and an increase or alteration in the bladder
microbiome.
This may also be completely idiopathic.
Etiology
History and PE
Patient’s typical voiding pattern.
Onset, and duration of incontinence symptoms.
Whether or not the patient is bothered by symptoms and any
associated factors that can affect incontinence.
Other factors requiring assessment should include urinary
frequency (>7 micturition episodes in a day), urgency, pain
with a full bladder, obstetric history (number and mode of
deliveries), gynecological history (history of pelvic organ
prolapse, anal incompetence, menopause, sexual dysfunction),
any previous pelvic surgery
The 3 incontinence questions (3IQ)
Brief questionnaire that may be useful to
distinguish among stress, urge, mixed urinary
incontinence, and other causes
UDS
Indications for these urodynamic studies are:
Significant inconsistencies between symptom scale,
history, and voiding diary
Planned or previous surgery
Hematuria
The presence of neurological diagnoses such as
multiple sclerosis
Associated prolapse of pelvic organs
Previous history of correction surgery for incontinence
Elevated volume of post-void residual urine.
Treatment / Management
The first-line treatment includes teaching the patient some
behavioral therapies such as bladder training and toileting
habits, lifestyle modifications, voiding diary, dietary changes, and
avoiding bladder irritants (such as caffeine, smoking), pelvic floor
muscle training (PFMT), and biofeedback.
Treatment / Management
Some antimuscarinic agents currently available for the
treatment of urge incontinence include oxybutynin,
tolterodine, fesoterodine, trospium, darifenacin, and
solifenacin.
The beta-3 adrenoreceptor agonists cause direct relaxation of
detrusor muscles
Antimuscarinic drug
Extended-release versions have been found to cause lesser side
effects compared to immediate-release versions.
The common side effects related to these drugs are dry mouth,
blurred vision, tachycardia, constipation, impaired cognition,
and urinary retention. These side effect profiles have often
culminated in high discontinuation rates and less than standard
compliance rates.
Medicines like darifenacin and solifenacin (selective
antimuscarinic agents) are sometimes preferred over non-
selective agents to control cognitive side effects better
beta-3 adrenoreceptor agonists
They achieve inhibition of spontaneous contractile activity in the bladder and
reduction in bladder afferent activity.
Mirabegron is the first of its class and the only beta-3 adrenoceptor agonist
that is used as a second-line treatment for those who either poorly tolerate
antimuscarinic agents or cannot tolerate them at all.
Daily doses of mirabegron 25, 50, and 100 mg demonstrated significant
efficacy in treating symptoms of urge incontinence in phase three clinical
trials.
In some cases, combining an anticholinergic medication with mirabegron
may result in increased efficacy and minimized side effect load.
This medication can theoretically lead to an increase in cardiovascular events,
particularly hypertension and headache.
Treatment / Management
If patients with urge incontinence meet the following criteria,
they are eligible for third-line treatment (refractory cases): 1)
They demonstrate a failure of response to behavioral therapy,
and 2) They have either intolerance to or inadequate
response to at least two second-line treatments.
Third-line treatment includes Percutaneous stimulation of
tibial nerve (PTNS), temporary chemical denervation of the
bladder detrusor muscle, and sacral neuromodulation.
PTNS
Treatment / Management
Third-line treatment includes also Intravesical onabotulinum
toxin A injection requires delivery via cystoscopy every six
months if symptoms recur.
It results in flaccid paralysis of the detrusor muscle with
consistent improvement in urge incontinence symptoms and
quality of life.
Intradetrusor Botox Injection
Overflow incontinence
Overflow urinary incontinence is the involuntary leakage of
urine from an overdistended bladder due to impaired
detrusor contractility and/or bladder outlet obstruction.
Etiology
Neurologic diseases such as spinal cord injuries,
multiple sclerosis, and diabetes can impair detrusor
function.
Bladder outlet obstruction can be caused by external
compression by abdominal or pelvic masses and
pelvic organ prolapse, among other causes.
A common cause in men is benign prostatic
hyperplasia.
Management
Conservative management
- clean intermittent catheterization,
indwelling urethral catheter, relief of
obstruction
Pharmacologic management - alpha-
adrenergic antagonists (e.g. terazosin,
tamsulosin)
Surgical management - suprapubic catheter,
TURP
Questions???
Thank you