Urinary incontinence, patient management

By Cristiano Antonino On May 23, 2023

Urinary incontinence is a very common problem: typical of ageing, it is more frequent in women than in men

When we speak of urinary incontinence, we refer only to adults

In the case of children, one speaks of enuresis, referring to the inability to control urination.

Usually due to ageing or benign and easily treatable pathological conditions, in rare cases incontinence is a symptom of more serious pathologies (tumours, neurological disorders).

By resolving the underlying cause, urine loss is also resolved, resulting in an improvement in the individual’s physical, psychological and social well-being.

Urinary incontinence is the involuntary loss of urine

In some individuals it manifests itself with the sudden urge to urinate, in others leakage occurs as a result of sneezing or coughing.

There are three main types of incontinence

Stress incontinence, when the cause is a stimulus (sneezing, coughing fit, sudden laughter).
Urge incontinence, when the cause is a sudden and uncontrollable urge to urinate.
regurgitation incontinence, when you are unable to empty your bladder completely during urination.

Urinary capacity depends on the cooperation between the brain and the structures that make up the urinary tract and, more specifically, on the balance between voluntary and involuntary muscle actions.

The bladder acts as a ‘reservoir’ for urine, and when it is about ⅓ full, the person feels the urinary urge: the bladder walls are stretched, and nerve impulses are sent to the brain and spinal cord.

At this point the emptying reflex arises: the detrusor muscle receives the stimulus from the spinal cord to contract and the internal sphincter to relax.

The person contracts the muscles of the external sphincter to hold back urine: if he cannot urinate, emptying is postponed; if he can urinate, he relaxes the external detrusor muscle to let the urine flow out.

There are thus two sphincters that make continence possible: one is located at the level of the bladder neck and cannot be controlled voluntarily, the other is located at the level of the urethra and is controlled by the voluntary nervous system.

When the bladder neck does not close completely, or the muscles around the bladder contract incorrectly, incontinence can occur.

The causes of urinary incontinence are numerous

In the case of women, who are most affected by the problem, pregnancy and childbirth play a key role.
The pelvic floor muscles, which are involved in continence, weaken, leading to a condition known as ‘urethral hypermobility’ (the urethra is not completely closed): present in 20-40% of women who give birth, incontinence due to this cause usually resolves spontaneously within a few weeks after delivery.

Other causes of urinary incontinence are

prolapse of the uterus, usually caused by childbirth;
menopause, a period when urine loss is due to muscle weakening caused by the drop in oestrogen;
enlargement of the prostate gland;
prostate cancer;
radiotherapy or surgery that weakens the pelvic floor;
ageing;
lifestyle: excess alcohol, caffeine or liquids in general;
intake of diuretics, laxatives, oestrogens, antidepressants, benzodiazepines;
hypertension;
diabetes;
Alzheimer’s disease;
obesity;
back problems;
Parkinson’s disease;
spina bifida;
multiple sclerosis;
stroke;
spinal cord injuries;
urinary tract infections;
kidney disease.

Depending on the cause, different types of urinary incontinence can be identified

Stress incontinence or stress incontinence is due to increased abdominal pressure from activities such as lifting weights, bending over, a cough, a laugh, a jump or a sneeze.

All conditions that lead to pelvic floor damage contribute to the clinical picture.

Urinary leakage is minimal.

Urge incontinence manifests itself as an urgent need to urinate, and is due to involuntary contractions of the detrusor muscle in the filling phase.

The loss of urine is considerable.

Mixed incontinence occurs when the causes of urge incontinence are added to the causes of stress incontinence.

Regurgitation incontinence consists of incomplete emptying of the bladder, and is due to constipation, diabetes, multiple sclerosis, shingles, benign prostatic hyperplasia.

Urine loss occurs in drops, after urination.

Structural incontinence is due to congenital structural problems, but also to fistulas caused by injuries or gynaecological trauma.

Functional incontinence is typical of the physically or mentally disabled, but also from alcohol abuse, and consists of the inability to reach the toilet to urinate even in the absence of physical problems.

Transient incontinence resolves in a short time, and is generally caused by taking certain drugs.

The symptoms

The typical symptom of urinary incontinence is the loss of urine, which can manifest itself as the uncontrolled release of a few drops or be very copious.

Usually there are no other symptoms, except for pain on urination (in some cases) and the discomfort the person feels (incontinence creates embarrassment and discomfort for the person).

Diagnosis

The diagnosis of incontinence is made by the urologist, based on the anamnesis and objective test.

The doctor will obtain information about the patient’s medical history, his general health condition and lifestyle, as well as his symptoms.

He or she will then carry out a physical test, to look for the presence of hernias, uterine prolapse, constipation, neurological or urinary tract disorders.

Next, the specialist will prescribe blood and urine tests to detect any infections, urinary tract stones or other causes.

If he/she considers it appropriate, he/she may ask for a cystoscopy (endoscopy of the bladder through the urethra) or a urodynamic test (diagnostic investigation to study the function of the bladder and urethral tract) to be performed.

Therapies

The therapies for urinary incontinence are different, and depend on the severity of the problem and its causes.

Treatment must be customised to the individual patient and must take into account gender, age and general health conditions.

It is generally conservative, pharmacological or otherwise minimally invasive.

However, in a small percentage of cases, surgery may be necessary.

Lifestyle, medication and injection therapies

As a first therapeutic strategy, it is advisable to intervene in the patient’s lifestyle.

It is important to keep body weight under control, exercising regularly and following a low-calorie diet to lose the extra kilos.

Being overweight weakens the pelvic floor.

If necessary, the doctor will provide guidance to prevent constipation, and will ask that excessive exertion and caffeine abuse be avoided.

If the cause of constipation is a weakening of the pelvic muscles, he will also teach the patient Kegel exercises.

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Mainly intended for women but also useful for men, they consist of simple exercises to be performed several times during the day.

If deemed appropriate, the specialist may prescribe drug therapy

Anticholinergic drugs block the nerve impulses underlying urge incontinence, but can cause constipation, dry mouth, blurred vision and hot flashes; topical oestrogens (creams, patches, rings) are reserved for women and serve to tone the vaginal and urethral areas.

Finally, those suffering from mixed incontinence may find benefit from taking imipramine.

Sometimes, the injection of botulinum toxin type A or bulking agents proves useful in the treatment of urinary incontinence: the former is indicated in the case of an overactive bladder, the latter serve to help close the urethra.

However, with minimal invasiveness, they are less effective than surgical treatments.

Surgery

Should conservative treatments fail to produce an effect, surgery can solve the problem.

The specialist chooses the most suitable technique based on the problem presented by the patient.

The most commonly used technique for those suffering from stress incontinence is the ‘tape’ technique.

The Tot (trans obturator tape) consists of making three small incisions to pass the tape through the pelvis.

The operation lasts about three quarters of an hour, is performed under local or loco-regional anaesthesia, and the patient can return to his or her life immediately after discharge (with a few precautions).

An alternative technique is the Sis (Sling single incision), which involves inserting the webbing through a single incision in the wall of the vagina.

This is a very delicate procedure, which only specialised incontinence treatment centres can perform, and is reserved for young patients with mild to moderate incontinence and who are not obese.

Colposuspension, also indicated for stress incontinence, is used to support the pelvic floor.

The incision is made in the abdomen so that the surgeon can suture the nearby tissues supporting the bladder neck and urethra, but the operation can also be performed laparoscopically.

In order for the patient to regain control of urination, an artificial urinary sphincter can be implanted (a procedure usually performed in men with prostate cancer), while in cases of severe incontinence, silicone or resorbable fillers can be injected.

These are useful for narrowing the urethra duct, and are used when urine leakage occurs even in the absence of effort or stimulation.

While silicone is ‘permanent’, resorbable fillers need to be repeated every one to two years.

Other surgical options are catheterisation and electrical stimulation.

Catheterisation is indicated in the case of regurgitant incontinence, when there is an obstruction that needs to be removed and the prolapse of the pelvic organs needs to be repaired, the urethra stenosed, or the prostate tissue resected.

If an obstruction is not present, however, it is advisable to teach the patient self-catheterisation.

The risk of a urinary tract infection, however, increases significantly with this technique.

Electrical stimulation, on the other hand, is an innovative technique that consists of inserting a small pacemaker connected to the sacral nerves under the skin of the buttocks to stimulate the nerve roots of the bladder and pelvic floor.

The efficacy rate is about 70%, and the procedure has few contraindications.

The prognosis of incontinence depends on the severity of the problem, the underlying causes, and the patient’s general health condition.

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