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264 Chapter 6: Genitourinary system

Incidence/prevalence washing hands or even prematurely, e.g. on arriving
Even in young patients it is relatively common (up to home. This is mainly due to detrusor instability/over-
30% of women <65 years but only up to 5% of men <65 activity.
years).Inolderpatientstheageratiosapproach1–2F:1M. Mixedstress and urge incontinence is also common.
Rates are much higher in certain settings such as care of Overflow incontinence is continual or unprecipitated
the elderly institutions (up to 45%) and psychiatric care leakage without urge. This may result from either the
of the elderly (90%). lack of sensation of a full bladder or sphincter in-
competence. Bladder outflow obstruction may lead
Age to overflow incontinence due to bladder decompen-
Increases with age. sation. Rare causes include spinal cord compression
affecting the sacral segments (S2, 3 and 4) or the conus
medullaris. Patients may empty the bladder by strain-
Sex
ing or manual compression.
F > M
Acomprehensive examination is important and can
avoid the need for specialist tests. It is important to as-
Aetiology
sess fluid balance, mobility, cognitive ability and relevant
Incontinence has been associated with many conditions
neurology. Rectal examination for constipation, rectal
and risk factors such as chronic cough, depression, de-
masses and vaginal speculum examination for atrophy,
mentia, pregnancy, vaginal delivery (particularly with
masses, cystocele or rectocele.
episiotomy, forceps delivery), impaired mobility, drugs
and chronic medical conditions such as heart failure,
Complications
chronic lung disease, stroke, multiple sclerosis and dia-
Increased risk of urinary tract infections (UTI’s) and
betes.
stones. Hydronephrosis, reflux damage to kidneys.
Pathophysiology Investigations
Incontinenceismultifactorial.Toremaincontinentthere Avoiding diary is useful to record the time, volume
must be: and relevant events, e.g. beverages, activities, sleeping
The ability to control micturition at the level of the and medications.

urinary tract as well as neurological control. Inallpatientswithpersistentincontinence,U&Es,glu-
The ability to recognise the sensation of bladder fill- cose, calcium, vitamin B 12 and urinalysis should be

ing and to be able to respond appropriately and suffi- performed (with culture if indicated).
ciently quickly to this. Padtest (weighing a pad before and after various ex-
The ability to mobilise safely or the manual dexterity ercises).

to use a container. Post-void bladder volume should be assessed. Urody-
The motivation to maintain dryness and hygiene. namic investigations are rarely required.

Occasionally, depending on the history and examina-

Clinical features tion, other tests include X-rays, ultrasound renal tract
Symptoms of incontinence may be grouped into those and neurological testing for sacral evoked response.
of specific syndromes:
Stress incontinence occurs when intra-abdominal Management

pressure is increased, e.g. on coughing, bending over, Treatment depends on the class of incontinence and the
or running and jumping. The leak may occur at the underlying cause:
time or just after. This is due to poor sphincter func- Stress incontinence: Initially non-surgical options
tion. (e.g. exercises, medication) can be tried, but surgery is
Urge incontinence is when the patient has an over- the main treatment.

whelming urge to void leading to leakage. This Pelvic floor (Kegel) exercises (with or without weigh-
may be precipitated by the sound of running water, tedcones) may be used but are dependent on the