Incontinence

URINARY
INCONTINENCE

 
Overview
Types
Prevalence
Diagnosis
Management
Treatment

OVERVIEW

Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.

Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g., ALS, spina bifida, multiple sclerosis) eventually cause inadequate urinary storage or control.

Acute and temporary incontinence are commonly caused by the following:

  • Childbirth
  • Limited mobility
  • Medication side effect
  • Urinary tract infection

Chronic incontinence is commonly caused by these factors:

  • Birth defects
  • Bladder muscle weakness
  • Blocked urethra (due to benign prostate hyperplasia, tumor, etc.)
  • Brain or spinal cord injury
  • Nerve disorders
  • Pelvic floor muscle weakness.

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TYPES

Of the several types of urinary incontinence, stress, urge, and mixed incontinence account for more than 90% of cases. Overflow incontinence is more common in people with disorders that affect the nerve supply originating in the upper portion of the spinal cord and older men with benign prostate hyperplasia (BPH). The primary characteristics of these types are as follows:

  • Stress—urine loss during physical activity that increases abdominal pressure (e.g., coughing, sneezing, laughing)
  • Urge—urine loss with urgent need to void and involuntary bladder contraction (also called detrusor instability)
  • Mixed—both stress and urge incontinence
  • Overflow—constant dribbling of urine; bladder never completely empties.

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PREVALENCE

The U.S. Department of Health and Human Services reported in 1996 that approximately 13 million people in the United States suffer from urinary incontinence. The condition is far more prevalent in women than men. In the general population aged 15 to 64 years old, 10-30% of women versus 1.5-5% of men are affected. At least 50% of nursing home residents are affected. Of that number, 70% are women.

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DIAGNOSIS

A complete medical history, which includes a voiding diary and incontinence questionnaire; physical examination; and one or more diagnostic procedures help the physician determine the type of urinary incontinence and an appropriate treatment plan.

Medical History
The medical history provides clues about the type of incontinence. Bowel habits, patterns of urination and leakage (when, how often, how severe), and whether there is pain, discomfort, or straining when voiding are important indicators. The patient's history of illnesses, pelvic surgeries, pregnancies, and medications currently used also supply the physician with information relevant to making a diagnosis. In the elderly, a mental status evaluation and assessment of social and environmental factors may be performed.

Physical Examination
A physical examination includes a neruologic status evaluation and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing indicates a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough indicates urge incontinence.

The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

Urinalysis
Examination of the urine may identify medical conditions associated with urinary incontinence, such as the following:

  • Bacteriuria—presence of bacteria in urine; indicates infection
  • Glycosuria—excess glucose in urine; may indicate diabetes
  • Hematuria—blood in urine; may indicate kidney disease
  • Proteinuria—excess protein in urine; may indicate kidney disease, cardiac disease, blood disease
  • Pyuria—presence of pus in urine; indicates infection

Specialized Testing
If incontinence persists after diagnosis and treatment, additional testing may be needed. Urologists perform urodynamic, endoscopic, and imaging tests to obtain a more extensive evaluation of the lower urinary tract to determine a new treatment plan.

Postvoid residual volume (PRV)
This procedure requires catheterization or pelvic ultrasound. The patient voids just before the PRV is measured. This initial void should be observed for hesitancy, straining, or interrupted flow. A PRV less than 50 mL indicates adequate bladder emptying. Repeated measurements of 100 to 200 mL or higher represent inadequate bladder emptying. The clinical setting and the patient's readiness to void may affect the test result; therefore, repeated measurements may be necessary.

Urodynamic Testing
Cystometry may be used to measure the anatomic and functional status of the bladder and urethra. The cystometer is an instrument that measures the pressure and capacity of the bladder; thus evaluating the function of the detrusor muscle. Simple cystometry detects abnormal detrusor compliance, but abdominal pressure is not included and the results must be evaluated with caution.

The multichannel, or subtracted, cystometrogram simultaneously measures intra-abdominal, total bladder, and true detrusor pressures. This allows involuntary detrusor contractions to be distinguished from increased intra-abdominal pressure. The voiding cystometrogram detects outlet obstruction in patients who are able to void.

Uroflowmetry identifies abnormal voiding patterns. Urethral pressure profilometry measures the resting and dynamic pressures in the urethra.

Endoscopic Tests
Cystoscopy
may be performed when urodynamic testing fails to duplicate symptoms, when the patient experiences new symptoms (e.g., cystitis, pain), or when urinalysis reveals a disease process (e.g., menaturia, pyuria). Cystoscopy identifies the presence of bladder lesions (e.g., cysts) and foreign bodies. Imaging Tests X-rays and ultrasound may be used to evaluate anatomic conditions associated with urinary incontinence. Imaging of the lower urinary tract before, during, and after voiding is helpful in examining the anatomy of the urinary bladder and urethra.

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MANAGEMENT

There are several things patients can do to help improve continence.

  • Avoid overconsumption of diuretics, antidepressants, antihistamines, and cough-cold preparations.
  • Perform Kegel exercises daily.
  • Practice double voiding (urinate, wait a few seconds, urinate again).
  • Eat fruits, vegetables, and whole grains daily to prevent constipation.
  • Retrain the bladder (urinate only every 3 to 6 hours).
  • Stop smoking (nicotine irritates the bladder).

A number of protective devices are available to help manage accidental urination, including the following:

  • Bed pads
  • Combination pad-pant systems
  • Disposable or reusable adult diapers
  • Full-length absorbent undergarments
  • Male incontinence drip collectors
  • Underwear liners (pads, guards, shields, inserts)

Early reliance on absorbent pads may cause the wearer to accept incontinence rather than seek diagnosis and treatment. These products should be applied correctly and changed often to prevent skin irritation and urinary tract infection.

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TREATMENT

Treatment for adrenal cancer depends on the stage of the disease at diagnosis. Options include surgery, chemotherapy, and radiation. Treatment for patients with functioning tumors usually involves using medications to manage symptoms.

Pheochromocytomas require neoadjuvant (before surgery) treatment for high blood pressure, which often includes alpha-blockers (e.g., phenoxybenzamine, prazosin) followed by beta-blockers (e.g., propranolol), and metyrosine.

Surgery
Surgical removal of the adrenal gland (called adrenalectomy) is the only cure for adrenal cancer. It is important to determine if the cancer has spread before surgery, because metastases to lymph nodes or other organs (e.g., liver, lungs, kidneys) often requires extensive surgery. Adrenal tumors that have not spread are sometimes removed using laparoscopic adrenalectomy, which is performed through a smaller incision.

Chemotherapy
Chemotherapy is a systemic treatment (travels throughout the body via the bloodstream) that often uses a combination of drugs to destroy cancer cells. It is used as a palliative treatment for metastatic adrenal cancer and may also be used as adjuvant therapy (in addition) to surgery. Drugs may be administered orally or intravenously (through a vein).

Mitotane (Lysodren®) suppresses adrenal gland function and is the drug of choice to treat inoperable adrenal cancer. Approximately 20% of adrenal cancer patients respond to treatment with mitotane. Side effects include gastrointestinal disturbances (e.g., loss of appetite, nausea, vomiting, diarrhea) and neurological disturbances (e.g., depression, lethargy, sleepiness). When mitotane therapy fails, cisplatin (Platinol®) may be tried, alone or combined with other agents. Drug combinations used include the following:

  • Cyclophosphamide (Cytoxin®, Neosar®), doxorubicin (Adriamycin®), cisplatin
  • Fluorouracil (Adrucil®, Efudex®), doxorubicin, cisplatin® Cisplatin with VP-16

Neuroblastoma may be treated with adjuvant (in addition to surgery) chemotherapy using carboplatin (Paraplatin®), cyclophosphamide, doxorubicin, and etoposide (Vepesid®).

Side effects of chemotherapy are often severe and include gastrointestinal disturbances, low blood count , skin disorders, and neurological disorders.

Radiation Therapy
Radiation therapy uses high energy x-rays to destroy cancer cells. Radiation is not used as a primary treatment for adrenal cancer. It is sometimes used as a palliative (pain relieving) treatment for metastatic adrenal cancer.

Medical Management of Functioning Tumors
Treatment for patients with functioning tumors includes managing symptoms caused by increased hormone production.

Increased cortisol production (Cushing's syndrome) is often treated with aminoglutethimide or ketoconazole (Nizoral®) to inhibit cortisol build-up (synthesis). They may be used alone, or in combination with chemotherapy. Side effects include nausea, vomiting, and abdominal pain.

Excess aldosterone production (Conn’s syndrome) is usually treated using spironolactone (Aldactone®). Spironolactone is an aldosterone antagonist (i.e., counteracts the action of aldosterone). Side effects include ulcers, abnormal breast enlargement in men (gynecomastia), fever, and headache.

Aromatase inhibitors such as anastrozole (Arimidex®) and anti-androgens such as bicalutamide (Casodex®) may be used to treat excessive androgen production.

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