Always check none of the medications are making continence worse.
- Urinary incontinence is defined as the involuntary loss of urine,
sufficiently severe to cause a social or hygiene problem
- It is frequently
precipitated by acute illness in old age and is commonly
- Physical changes to the bladder and pelvic floor with weakness
- Mutifactorial and common with any illnesses with reduced mobility
Types and management
- Stress incontinence: physical causes that cause raises in intravesical pressure and leakage with coughing, laughing, straining. There may be a gynaecological history or obesity. Usually, a mechanical cause and may need surgery. Duloxetine may be used.
- Urge Incontinence: detrusor muscle is unstable and contracts and causes instant overwhelming desire need to pass urine. Can be managed with bladder retraining, pelvic floor exercises and medications such as antimuscarinics which relax bladder smooth muscle. Trial for 4-6 weeks and regular review. Mirabegron is a new agent sometimes used when antimuscarinics have failed.
- Mixed: Both stress and urge can co-exist
- Overflow incontinence: most commonly seen in elderly
men with prostatic enlargement, which obstructs bladder
outflow. Urinary catheterisation and surgery may be needed.
- Take a clear history. May be due to poor communications, mobility, new medications e.g. diuretics, old birthing injuries, gynaecological disease, lack of oestrogen.
- Stress: Stress incontinence usually due to dysfunction of the urethral sphincter, is common in women and uncommon in men. There is urine leakage with coughing and anything that increases intra-abdominal and therefore intravesical pressure. Patients may be obese. Often multiple births and damage to the pelvic floor, menopause and gynaecological surgery. Kegel exercises may be useful, but surgery is considered the most effective intervention.
- Urge: Often unexpected and sudden need to pass urine. Detrusor overactivity. Usually larger amounts of urine. Oxybutynin and bladder training exercises are sometimes effective for urge incontinence, which is more common in men. Alpha-adrenergic blockers and 5-alpha reductase inhibitors are used for
prostate hypertrophy in men.
- Mixed: quite possible that two can coexist
Drugs that worsen Incontinence
- Alcoholic drinks: volume and diuresis of alcohol
- Alpha agonists e.g. nasal decongestants. Can tighten the urinary sphincter; can cause containing urine to be retained in the bladder and pseudoephedrine uncontrollable leakage of small amounts of urine (overflow incontinence)
- Alpha blockers Doxazosin, Prazosin, Relax the urinary sphincter and urethra;
Tamsulosin, Terazosin can cause incontinence when coughing, straining, sneezing, lifting heavy objects, or putting any other pressure
on the abdomen (stress incontinence)
- ACEI: Can cause cough and worsen stress converting incontinence
- Antidepressants Amitriptyline, Interfere with bladder contraction and
Desipramine, worsen constipation; can cause urine to
Nortriptyline be retained in the bladder and overflow
- Antihistamines Chlorpheniramine, Interfere with bladder contraction and
diphenhydramine worsen constipation; can cause urine to
be retained in the bladder and overflow
- Antipsychotics Haloperidol, Can slow mobility and cause abrupt
Risperidone urge to urinate followed by
Thioridazine, uncontrollable loss of urine (urge
- Caffeine Coffee, cola, tea, some Increases urination by increasing urine
- Calcium channel Diltiazem, verapamil Interfere with bladder contraction and
blockers worsen constipation; can cause urine to
be retained in the bladder and overflow
- Diuretics: Furosemide, thiazides Increase urination by increasing urine
- Opioids Morphine Interfere with bladder contraction and
worsen constipation; can cause urine to
be retained in the bladder and overflow
- Sedatives Diazepam, flurazepam, Can slow mobility and worsen urge
- FBC, U&E, Glucose, CRP
- Urine frequency volume chart
- Urinalysis: exclude a UTI
- Abdominal USS may be useful if concerns of structural renal disease
- Urodynamics: may see sudden surges in intravesical pressure with urge incontinence.
Management Urge Incontinence
- Manage any cause of irritation in your bladder which
may be due to infection or medication, diseases of the nervous
system, such as Multiple Sclerosis or Parkinson's Disease, anxiety
or not drinking enough fluids. It can also happen for no obvious
- Pelvic floor exercises. These muscles help to hold your bladder and bowel in position, also the uterus in women. They prevent leakage from your
bladder and bowel, only relaxing when your bladder or bowel is
- Drink adequately 1-2 litres (6 - 8 large cups or glasses). Concentrated urine can irritate the bladder.
- Reduce Caffeine which may be an irritant to your bladder and may increase your
frequency of visits to the toilet.
- Avoid Possible irritants to the bladder include caffeinated drinks, fizzy drinks. grapefruit juice, alcohol. stronger brands of tea that contain more tea and tannins.
, spicy food. tomatoes.
- Try to avoid becoming constipated by eating a healthy diet with
plenty of fruit and vegetables.
- Assessment fill in a 'frequency volume chart' for at least 3
full days (if possible 3 days in a row), to check how often you go to
the toilet and how much urine you pass.
- Bladder retraining: retrain the bladder to hold a greater
amount of urine. This should reduce the number of times you need
the toilet. You should only go to the toilet when you really need to. Regaining
control of your bladder is a gradual process.
- Pelvic floor exercises can help pelvic floor muscles prevent leakage from your bladder and bowel. Simple exercises carried out for 3 - 6 months can improve
your muscle tone (strength) and help you to hold on longer. Your
nurse or continence adviser will explain these exercises and give
you a leaflet, 'How to do pelvic floor exercises.
- Further treatments can include medication to reduce your urgency
and assist with your bladder retraining, nerve stimulation,
physiotherapy or surgery.
Management of Stress Incontinence
- Pelvic floor muscle exercises. Your doctor or physical therapist can help you learn how to do Kegel exercises to strengthen your pelvic floor muscles and urinary sphincter. Just like any other exercise routine, how well Kegel exercises work for you depends on whether you perform them regularly.
- Fluid consumption. Your doctor may recommend how much and when you should consume fluids during the day and evening. However, don't limit what you drink so much that you become dehydrated. Follow as for urge continence.
- Again avoid caffeinated, carbonated and alcoholic beverages, which may irritate and affect bladder function in some people. If you find that using fluid schedules and avoiding certain beverages significantly improve leakage, you'll have to decide whether making these changes in your diet are worth it.
- Quitting smoking, losing excess weight or treating a chronic cough will lessen your risk of stress incontinence and improve your symptoms.
- Bladder training may help if mixed incontinence. More frequent voiding of the bladder may reduce the number or severity of urge incontinence episodes.
- Duloxetine and is used for the treatment of stress incontinence in Europe. Nausea is the most common side effect that makes people stop taking the medication.
- Devices to help control stress incontinence, including:
- Vaginal pessary. A specialized urinary incontinence pessary, shaped like a ring with two bumps that sit on each side of the urethra, is fitted and put into place by your doctor or nurse. It helps support your bladder base to prevent urine leakage during activity, especially if your bladder has dropped (prolapsed).
This is a good choice if you wish to avoid surgery. A pessary will require routine removal and cleaning. Pessaries are used mostly in people who also have pelvic organ prolapse.
- Urethral inserts. This small tampon-like disposable device inserted into the urethra acts as a barrier to prevent leakage. It's usually used to prevent incontinence during a specific activity, but it may be worn throughout the day. Urethral inserts can be worn for up to eight hours a day. Urethral inserts are generally used only for heavy activity, such as repeated lifting, running or playing tennis.
- Surgery: Bladder neck suspension procedure or Sling procedures. Surgical interventions to treat stress incontinence are designed to improve the closure of the sphincter or support the bladder neck. Surgical options include:
- Sling procedure: a common procedure performed in women with stress urinary incontinence. The surgeon creates with the patient's own tissue, synthetic material (mesh), or animal or donor tissue to create a sling or hammock that supports the urethra. Slings are also used for men with mild stress incontinence. The technique may ease symptoms of stress incontinence in some men.
- Injectable bulking agents. Synthetic polysaccharides or gels may be injected into tissues around the upper portion of the urethra. These materials bulk up the area around the urethra, improving the closing ability of the sphincter.
- Retropubic colposuspension. This surgical procedure uses sutures attached to ligaments along the pubic bone to lift and support tissues near the bladder neck and upper portion of the urethra. This surgery can be done laparoscopically or by an incision in the abdomen.
- Inflatable artificial sphincter. This surgically implanted device is used to treat men. A cuff, which fits around the upper portion of the urethra, replaces the function of the sphincter. Tubes connect the cuff to a pressure-regulating balloon in the pelvic region and a manually operated pump in the scrotum.
Overflow incontinence: Prostatectomy and/or Urinary catheterisation