Incontinence When I was given this topic in urology to discuss with you today I was slightly disappointed. I personally see mostly men for problems such as stones, benign prostatic hyperplasia, prostate cancer and erectile dysfunction. However, as I was putting together this talk I had to stop in the evenings several times to buy adult diapers in three different sizes. Hey, this is a very common problem. Six months ago I had surgery for incontinence. When we are born, if all went well and we are physically and neurologically, normal, the bladder fills and releases urine in a coordinated manner. We are probably not aware of the feeling of a full bladder. The pressure of the full bladder causes the bladder detrusor muscle to contract allowing us to empty completely. As we grow older-say 2-3 years of age-we develop somatic nerve fibers into the basal ganglia, thalamus, hypothalamus, limbic system and the cerebral cortex. This nerve pathway allows us to wait to urinate or to interrupt our urine stream. Only humans and dogs are able to do this. Normally an adult feels the sensation of urine in the bladder at 120ml and is able to hold 400-500ml. The purpose of the bladder is: A. Store ---relax detrusor muscle and contract sphincter muscle B. Empty contract detrusor muscle and relax sphincter muscle.
This diagram will review this process. This is a simplified micturation pathway map. Pathway 1 runs from the motor cortex to the pudendal nucleus in the sacral region of the spinal cord. This controls the external sphincter and allows a person to voluntarily interrupt a voided stream by contracting the external sphincter. Pathway 2 connects between the supraspinal micturation center and the micturation center located in segments S2-S4. This pathway is necessary for a coordinated micturation reflex. Pathway 3 maintains voluntary control of the micturation reflex thru action of suprapontine structures including thalamus, hypothalamus, limbic system, basal ganglia and the cerebral cortex. Pathway 4 involves the sympathetic autonomic nerve supply beginning at T11-T12, innervating the lower urinary tract. The sympathetic detrusor prevents premature detrusor contractions and maintains bladder neck tone. In this next diagram we see that the sympathetic system acts to monitor the status of trigone of the bladder and urethra and keep the bladder detrusor muscle relaxed. The parasympathetic nerves monitor distention and cause the detrusor to contract via cholinergic receptors.
The somatic nerves which innervate the external sphincter and pelvic floor muscles allow contraction and relaxation of these muscles. Incontinence is the involuntary loss of urine, which occurs when the bladder pressure is higher than the urethral pressure. There are 2 basic types of incontinence: A. Failure to store urine B. Failure to empty urine A. First I will list some causes of failure to store urine. 1. Stress incontinence when urine is lost through coughing or lifting, due to a weak pelvic floor, urethral hyper mobility, obesity, and loss of internal sphincter in men thru prostatectomy. 2. Fistula formation a. Vesicovaginal fistula from traumatic childbirth or radiation causes a urine leak into the vagina. b.colovesical fistula from colorectal cancer or diverticulitis can cause urine loss thru the rectum and chronically infected urine and pneumaturia.
3.Urge incontinence may be from 1. a non neurogenic overactive bladder or from 2.a neurogenic injury such as a stroke or brain injury above the brain stem, Parkinsonism, spine injury above S1, multiple sclerosis or from 3. irritating factors such as bladder infection, interstitial cystitis or bladder tumor. 4.Detrusor sphincter dyssynergia occurs in C1 to L2 spine injuries and some cases of multiple sclerosis. In this instance the detrusor empties in a reflex manner but the sphincter muscle does not relax. This can cause a renal failure in time due to translating the pressure from the contracted bladder up the ureters, leading to renal failure. In the past infection and renal failure was the eventual cause of death of spinal cord injured patients. 5.Sensory neurogenic bladder or loss of the feeling of fullness in the bladder occurs in some frontal lobe brain tumors and diabetic neuropathy. Initially in this condition there is a loss of the early sensations of a filling bladder and there is a sudden urge to empty an already full bladder. Later in this condition the bladder may become over stretched and the detrusor muscle is no longer is able to contract.
6.Small capacity bladder may occur due to the pressure of a gravid uterus or obesity, scarring of the bladder after radiation or a space-occupying object such as bladder stones or tumors. 7.over active bladder may be related to ingestion of caffeine, high potassium foods or spicy foods. It may also be due to a bladder tumor or interstitial cystitis. This condition is common in both sexes. 8.Traumatic incontinence may occur after a pelvic fracture or other damage to the external sphincter. B. Incontinence due to failure to deliver urine 1. Overflow incontinence due to an atonic bladder. This may have resulted from constant overfilling from sensory nerve damage from diabetes, surgical damage as from an abdominal perineal resection of rectal cancer, or constant overfilling due to outlet obstruction as from benign prostatic hyperplasia or a urethral cancer. Other causes may be an overly tight pubovaginal sling, urethral stricture, fecal impaction or multiple sclerosis, including detrusor sphincter dyssynergia or any other cause of initial acute retention such as anesthesia from surgery.
Now, what do we do when the patient comes in and complains of incontinence? First it is necessary to ask if this is a problem. Most people will not report having incontinence unless asked, due to feeling shame. Of course it is always necessary to get a good history from the patient. This would include the usual questions involved in a history of present illness. I want to know if there is urinary hesitancy, urgency, urgency with incontinence, is there leaking with cough, how strong the voiding pressure is perceived to be, does the person feel completely empty after the void, does the person have to void again within 15 minutes, how many times does the person have to get up to void during the night, is there burning or pain with urination, is there blood in the urine, how many pads does the person wear in a 24 hour period, is the person also incontinent of stool, and what has the patient tried in the past to help this problem? Next it is important to get a good medical history such as illnesses which may cause neurologic problems such as stroke, multiple sclerosis, diabetes, Parkinsonism, urinary tract infections, cancer, or birth defects such as spina bifida or tethered cord, or injuries. Next comes the surgical history to include GYN history in women for pregnancies and include the mode of delivery. Also ask if the person had to have a catheter after any surgery.
Determine which medications the patient may be taking such as anticholinergics, alpha-blockers, and hormones. It is especially important to ask about over the counter medications. Many men have urinary retention after taking decongestants for upper respiratory infections. We have a detailed voiding questionnaire we give to our female patients which includes a voiding diary. Finally comes the exam. In a man, a genital exam always involves checking the foreskin for phimosis, checking the rectum for sphincter tone and masses and checking the prostate for size, consistency and nodules. In a woman with incontinence a pelvic exam is in order. It is important to check for a cystocele enterocele and a rectocele, or urethral diverticulum. Have the woman cough, to see if she leaks urine with a full bladder paying attention to the urethral mobility. It is possible to determine the mobility of the urethra by placing a lidocaine dipped sterile cotton tipped applicator stick in the urethra and having the woman cough or strain. The deflection of the stick should be minimal. Both men and women should have a neurologic exam related to problems which may cause incontinence. When confronted with an incontinent patient the first things I want to know are:
1. Does the bladder empty? 2.Does the urine contain red blood cells, white blood cells, protein or glucose? The first question will tell me if I have failure to store or failure to deliver as a cause of incontinence, the second will tell me if there is possibility of a malignancy, infection or diabetes being a cause of the problem. It is now common in the US to do urodynamic testing on patients whose bladder function is in doubt. This is done in steps: 1.Uroflow is a test whereby the patient urinates in a flow meter to determine the cc per second of urine voided. This is generally 25-30 cc per second for a woman and 20-25cc per second for a man starting with a full bladder. A uroflow machine is fairly inexpensive. A uroflow test can show if the patient is straining to void, voids intermittently or has probable obstructed flow. A simple alternative method of obtaining the peak flow is to have the spouse with a second hand watch stand behind the person voiding. When the person voiding feels he has reached his maximum flow he is to place a measuring cup under the stream and the partner counts off the 5 seconds he is to void in the cup. The ccs in the cup are divided by 5 to get the cc per second peak flow.
2. Post void residual is the determination of the remaining urine in the bladder. This is done by catheterization or by ultrasound. Being able to easily pass a catheter will rule out an obstruction. This residual volume should be quite low in a woman and generally less than 60 cc in a man. 3. Cystometrogram testing. This can be a simple water CMG or a complex computer evaluated CMG with voiding pressure study done with triple lumen catheters, pressure transducers and electrodes at the sphincter, with a flow meter for the voiding portion of the test plus fluoroscopy coupled with x-ray contrast for the filling medium. 4.. I will demonstrate how to do the simple CMG using an irrigating syringe, a catheter, water and a balloon to stand in for the bladder. Now I will tell you how I start to manage these problems as a non-surgeon. 1. Stress incontinence in a woman or man. If the exam is fairly normal with minimal leaking, I first teach Kegel exercises and have him/her avoid caffeine. If she reports more irritative symptoms of overactive bladder, I would also have her try an anticholinergic medication, which she could titrate to a tolerable dose. This can be risky in men
with an intact prostate gland. On return visit I would consider urodynamics. For marked urethral mobility or cystocele in a female patient, she could first be tried with a tampon or a pessary to see if the reduction of the cystocele made the incontinence worse or better. In our facility, if she were a surgical candidate, I would schedule her to see the urologist after urodynamic evaluation. At any time blood is found in the urine I schedule the patients for upper tract imaging such as intravenous pyelogram and cystoscopy. Obese patients should always be counseled to lose weight to take some of the pressure off the bladder. Many of our male incontinent patients used to be those who were post radical prostatectomy for prostate cancer. They were offered the placement of an artificial urinary sphincter. A few have had urinary diversion surgery. With newer techniques for this surgery this is now rarely a problem 2. If fistula is suspected we generally get a 3 phase CT scan of the pelvis. If a vesicovaginal fistula is suspected, place methylene blue solution in the bladder and a tampon in the vagina and look for blue liquid appearing in the tampon. In either colovesical or vesicovaginal fistula the patient needs referral to a urologist for cystoscopy.
3. In patients with recent strokes they should be managed with in indwelling catheter for the first few days, then clean intermittent catheterization four times a day until the bladder function returns. If urge incontinence is later a problem they can be treated with anticholinergics cautiously checking for urinary retention. They can be managed with timed voiding during the day and a diaper at night. 4. Spinal cord injured patients must have urodynamics and regular renal sonograms. They can be managed with high dose anticholinergics and clean intermittent catheterization not allowing bladder volume to go above 500cc to avoid autonomic dysreflexia. Spinal cord patients can also be managed by indwelling catheter, spincterotomy and external catheter for men, or urinary diversion. Remember, dyssynergia is the cause of renal failure in these patients. 5. Atonic bladder has to be drained either by urethral catheter, intermittent clean catheterization or suprapubic catheterization. 6. Obstruction should be evaluated and treated according to the cause. Many men with BPH can void well taking alpha-receptor blockers or even better in combination with 5 alpha reductase inhibitors. Many obstructions can be surgically corrected such as tight phimosis thru circumcision or urethral strictures thru dilation, visual internal
urethrotomy, meatotomy or trans urethral resection of the prostate gland. After discussing all these treatments for incontinence you must wonder why I buy all those diapers. The small/medium diapers are for my 86 year old mother who tragically has end stage Alzheimer s disease and voids as an infant. The large diapers are for my 91 year old father who has a large atonic bladder with a diverticulum. Essentially he would be in overflow incontinence but we drain his bladder with a catheter twice a day. His diaper is actually for bowel incontinence due to spinal stenosis. Remember pathway 1 from the diagram? The extra large diapers are for my brother who has Parkinsonism due to antipsychotic medications. He has a problem getting himself into an upright position at night in time to avoid wetting his bed. Some people are incontinent due to poor mobility. In closing, I have a case history to share with you. Several years ago I had a 29year old patient come to clinic with a history of incontinence. He was a healthy young man who had a closed head injury 3 years before. He was in a coma for 4 weeks and gradually recovered. He was able to function fairly well with his activities of daily living but he was having a problem due to constantly wetting his pants. He described sudden urge to
void followed by voiding a small quantity. He was wearing a diaper. What do you think was the etiology of this young man s problem?