Generality
Urinary incontinence is an involuntary loss of urine. The disorder can result from a variety of conditions, including physical damage, aging, tumors, urinary tract infections and neurological disorders. Some of these causes involve only temporary and easily curable discomforts, while other problems are more serious and persistent.
Urinary incontinence can have a profound impact on the patient's emotional, psychological and social well-being. However, it almost always results from an underlying medical condition, which can be successfully managed or treated.
The clinical picture that characterizes the inability to control bladder emptying is called enuresis .
Often, the term enuresis is used in reference to the urinary incontinence of children, due to a delay in acquiring the full ability to control urination; for example, nocturnal enuresis (bed wetting) is typical. Instead, we tend to talk about urinary incontinence in reference to adults who, for one reason or another, lose this ability to control after having normally acquired it as a child.
Note. Urinary incontinence is a common symptom of many health problems.
what happens under normal conditions?
Urinary function is controlled by a synergistic activity between the urinary tract and the brain. In particular, continence and urination imply a balance between voluntary muscular actions (somatic nervous system) and involuntary ones (regulated by the autonomic nervous system and coordinated by a reflex mechanism).
When the urination is completed, the filling phase begins: the urine is collected in the bladder, where it accumulates until the time of its elimination, which takes place via the urethra. The bladder has a function both as a reservoir (accumulation of urine) and as a pump (urine expulsion).
As soon as the social conditions allow it - with the bladder neck open and the detrusor muscle compressing the bladder - urine flows into the urethra and the person consciously relaxes the muscles of the external urethral sphincter to urinate. This decision is voluntary, so during urination the urinary flow can be interrupted voluntarily with the contraction of the external sphincter. The desire to retain urine has a limit anyway and if the reflection of urination is sufficiently intense (due to an abnormal stretching of the bladder walls) the reflex inhibition of the external sphincter prevails over the voluntary commands that oppose the urination.
Continence, both in men and women, is therefore entrusted to the presence of two main sphincters, one proximal (at the level of the bladder neck, not controlled by the will), and a distal localized at the level of the urethra (under the control of the voluntary nervous system). Pelvic muscles and ligaments that support the bladder neck and the urethra, as well as all the nerve structures involved, also participate in continence.
Incontinence occurs if the closure of the bladder neck is insufficient (stress incontinence) or if the muscles surrounding the bladder are hyperactive and contract involuntarily and suddenly (urgency incontinence).
Causes
The disorder is more common in the female population, both for the anatomy of the urinary tract, and for hormonal implications.
Several scientific studies have found that pregnancy and childbirth (by caesarean section or vaginal delivery) can increase the risk of urinary incontinence. In such cases, there is a weakening of the muscles and ligaments of the pelvic floor, which causes a condition called urethral hypermobility (the urethra does not close properly). Urinary incontinence affects about 20-40% of women after childbirth; most of the time it is transient (it disappears spontaneously within a month or so) and as we shall see later it is mostly "stressful". The prolapse of the uterus can also cause incontinence. This condition occurs in about half of all women who have given birth. During menopause, female subjects may suffer from urine leakage due to decreased estrogen levels and it is interesting to note that estrogen replacement therapy has not been shown to be useful in symptom management.
Men tend to experience urinary incontinence less often than women. Benign prostatic hyperplasia (enlarged prostate gland) is the most common cause of urinary incontinence in men over 40 years. Sometimes, prostate cancer and some medical treatments aimed at its management are associated with the disorder. The outcome of surgery or radiation therapy, for example, can damage or weaken the muscles that control urination.
In men and women, the aging process causes a general weakening of the urethral sphincter muscles and a decrease in bladder capacity.
Some cases of urinary incontinence are temporary and are often caused by lifestyle. Drinking alcohol, caffeinated beverages or any excess fluid can cause loss of bladder control. Even certain drugs can induce a short period of incontinence: diuretics, estrogens, benzodiazepines, antidepressants and laxatives. Furthermore, some health conditions are associated with the disorder: diabetes, high blood pressure, back problems, obesity and Alzheimer's disease. Constipation and urinary tract infections can increase the need to urinate. Also disorders such as multiple sclerosis, spina bifida, Parkinson's disease, stroke and spinal cord injuries can interfere with the nerve function of the bladder.
Possible conditions that contribute and / or cause urinary incontinence
- Vaginal or urinary tract infections;
- Kidney diseases;
- Pregnancy and childbirth;
- Constipation;
- drugs;
- Diabetes;
- Enlarged prostate (benign hyperplasia) and prostatitis (inflammation of the prostate gland);
- Nervous system diseases and neurological disorders (eg: multiple sclerosis, Parkinson's disease, spinal cord injury and stroke);
- Congenital defects (present at birth);
- Some surgical procedures (damage to nerves or muscles);
- Weakness of the muscles that keep the bladder and urethral sphincter in place.
Types of urinary incontinence
Stress urinary incontinence
Also known as urinary stress incontinence, it is essentially caused by the loss of support of the urethra which is usually a consequence of damage to the pelvic floor muscles caused by childbirth or other causes.
Urinary urgency incontinence
This type of incontinence is accompanied by a sudden and strong urge to urinate, which does not leave enough time to reach the bathroom (inability to inhibit, block or postpone the urge to urinate). Urge incontinence is caused by improper (non-inhibited) contractions of the detrusor muscle during the filling phase and is characterized by leakage of large amounts of urine. When this happens, the need to urinate cannot be suppressed voluntarily. Risk factors for urgency incontinence include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet rich in irritants (such as coffee, tea, cola, chocolate and acidic fruit juices).
Mixed urinary incontinence
It is a combination of urgency and stress incontinence.
Urinary incontinence due to regurgitation
It occurs when the bladder does not completely empty, in the presence of an obstacle to the normal flow of urine or if the destrusor muscle cannot contract effectively. It is characterized by post-voiding drip (phenomenon in which the bladder slowly loses urine residues in the urethra after emptying) The causes of urinary incontinence due to regurgitation include: tumors, constipation, benign prostatic hyperplasia and nerve damage. Diabetes, multiple sclerosis and shingles can also cause this problem.
Structural incontinence
Rarely, congenital structural problems can cause incontinence, usually diagnosed during infancy (for example: ectopic ureter, posterior urethral valves, estrofia-epispadias complex). Vesico-vaginal and uretero-vaginal fistulas, caused by traumas or gynecological lesions, can lead to urinary incontinence.
Functional incontinence
It can also occur in the absence of a biological or medical problem. Patients with functional incontinence have mental or physical disabilities, which prevent them from urinating normally, even if the urinary system itself is structurally intact. The person recognizes the need to urinate, but cannot or does not want to reach a toilet. As we have seen, beyond a certain threshold of vesical filling, the involuntary reflection of urination exceeds the voluntary control of the same → the loss of urine can therefore be high. Conditions that can lead to functional incontinence include: Parkinson's disease, Alzheimer's, mobility disorders, drunkenness due to alcohol abuse, reluctance to use toilets due to severe depression or anxiety, mental confusion and dementia.
Transient incontinence
It occurs temporarily and can be triggered by drugs, adrenal insufficiency, mental retardation, reduced mobility and severe constipation.
Diagnosis
As with any health problem, a careful medical history and a thorough physical examination are essential. A urologist, in the first place, can ask the patient questions about individual habits and can collect information related to personal and family medical history. The voiding control loss model suggests the type of incontinence addressed.
The physical exam focuses on finding signs of particular medical conditions that cause incontinence, including constipation, prolapse, hernias, urinary tract obstruction and neurological disorders. Usually, at the first evaluation, blood chemistry and urine tests are performed to check for evidence of infection, urinary stones or other causes that contribute to urinary incontinence. If the results suggest that further evaluation is needed, investigations such as cystoscopy or urodynamics may be recommended, performed to measure bladder capacity, urine flow and post-voiding residue, as well as to establish muscle malfunction pelvic.
Treatment
Treatment for urinary incontinence depends on the type of incontinence, the severity of the problem, the underlying cause and what measures are best suited to the patient's lifestyle. Furthermore, some therapeutic approaches are optimal for men, while others are more suitable for women. The goal of any treatment for urinary incontinence is to improve the patient's quality of life. In most cases, the first line of treatment is conservative or minimally invasive. Medications may be necessary depending on the cause of incontinence. If the symptoms are more severe and all other treatments are not effective, a surgical approach can be recommended. Therapeutic success depends, first of all, on the correct diagnosis. In most cases, great improvements and symptom resolution can be achieved.
Conservative treatments
- Lifestyle changes : significant weight gain can weaken the pelvic floor muscle tone, leading to urinary incontinence. Losing weight through a healthy diet and regular exercise is important. Other useful behavioral measures include: timed emptying of the bladder, prevention of constipation and avoiding lifting heavy objects. Decreasing the volume of ingested liquid and eliminating caffeine and other irritating substances for the bladder can help significantly.
- Pelvic muscle exercises (Kegel exercises) : help to strengthen the pelvic floor, allowing you to improve urinary control. Kegel exercises consist of a series of contractions-relaxations of the pelvic floor muscles, repeated several times a day. To restore muscle tone, alternative behavioral techniques can also be used, which include the use of vaginal cones or electrical stimulation.
drugs
Some therapies can affect the nerves and muscles of the urinary tract in different ways and, in certain situations, a combination of drugs can also be used.
Drugs commonly used to treat incontinence are:
- Anticholinergics: can block nerve signals that cause frequent urination and urgency, helping to relax muscles and prevent bladder spasms. Several drugs fall into this category, including fesoterodine, tolterodine and oxybutynin. Possible side effects include dry mouth, constipation, blurred vision and hot flushes.
- Topical estrogens: the low dose application of estrogen in the form of a vaginal cream, ring or patch can help to tone and rejuvenate the tissues in the urethra and vaginal areas. This can reduce some of the symptoms of incontinence in women.
- Imipramine : is a tricyclic antidepressant that can help patients with mixed incontinence.
Injective therapies
Some treatments for urinary incontinence include the injection of:
- Botulinum toxin type A (especially in the case of overactive bladder);
- Bulking agents (bovine collagen or autologous adipose material, to promote urethral closure and reduce urine leakage).
These treatments can be repeated and sometimes acceptable results are found after multiple injections. The operation is minimally invasive, but the cure rates are lower than in more invasive surgical procedures.
Surgery
Surgery can be used to manage urinary incontinence only after other treatments have failed. Many surgical procedures are available and the choice depends on a number of factors, including the severity of the disorder and the presence of a prolapse of the bladder or uterus. Most of these options are designed to reposition the bladder neck and urethra in their anatomically correct positions. Surgery has high success rates.
Some of the commonly used procedures include:
- Sling procedures : it is the most used procedure for stress urinary incontinence. In this operation, a narrow strip of material, such as a polypropylene tape, is inserted around the neck of the bladder and urethra, to help support them and improve urethral closure. Alternatively, a soft net (synthetic material), a biomaterial (bovine or porcine) or a section of autologous tissue, coming from another part of the body can be used. The operation is minimally invasive and patients recover very quickly.
- Colposuspension : this procedure is intended to provide support for the pelvic structures involved. An incision is made through the abdomen, which exposes the bladder, and, in neighboring tissues, some stitches are positioned. The sutures support the bladder neck and urethra and help control the flow of urine. This procedure can also be performed laparoscopically. The long-term results are positive, but the operation requires longer recovery times. The procedure is recommended especially for patients with stress incontinence.
- Artificial urinary sphincter : this small device can be surgically implanted to restore urination control. An artificial sphincter is particularly useful for men with weakened urinary sphincters, following the treatment of prostate cancer.
Possible adverse outcomes associated with incontinence corrective surgeries include bleeding, infection, pain, urinary retention or urination difficulties and prolapse of the pelvic organs.
Catheterization
Urinary regurgitation incontinence caused by an obstruction must be treated with drugs or surgery to remove the blockage. This may include resection of prostate tissue or urethral stricture or repair of a possible prolapse of the pelvic organs. If no obstruction is found, the best treatment is to instruct the patient to perform self-catheterization, at least a couple of times a day. However, long-term use of a catheter significantly increases the risk of urinary tract infection.
