Doctors Revision

Renal & Urinary System

Urinary Incontinence

Involuntary leakage of urine. Common types include stress incontinence, urge incontinence (overactive bladder), mixed incontinence, and overflow incontinence.

Also known as: Incontinence, Leaking Urine, Bladder Leakage

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Referral and warning signs

When to refer

Refer to specialist (Urogynaecologist/Urologist/Geriatrician) if: Diagnosis uncertain. Haematuria present. Associated pain, recurrent UTIs, voiding difficulty, neurological disease. Suspected significant pelvic organ prolapse or fistula. Failed conservative/behavioural therapies. Considering pharmacological therapy beyond basics or interventional/surgical management.

Red flags

  • Haematuria
  • Pelvic pain
  • Neurological symptoms/signs
  • Significant pelvic organ prolapse
  • Suspected fistula (continuous leakage)
  • High post-void residual volume

Signs and symptoms

  • Stress Incontinence: Leakage of small amounts of urine with activities that increase intra-abdominal pressure (coughing, sneezing, laughing, lifting, exercising).
  • Urge Incontinence: Leakage preceded by or occurring simultaneously with urgency (sudden, compelling desire to void that is difficult to defer). Associated with urinary frequency and nocturia. (Part of Overactive Bladder - OAB syndrome).
  • Mixed Incontinence: Combination of stress and urge incontinence symptoms.
  • Overflow Incontinence: Continuous dribbling or leakage associated with incomplete bladder emptying. Often due to bladder outlet obstruction or underactive detrusor muscle.
  • Functional Incontinence: Leakage due to inability to reach toilet in time because of physical or cognitive impairment (e.g., mobility issues, dementia), despite normal urinary tract function.
  • Continuous Incontinence: Constant leakage suggests urinary fistula (e.g., vesicovaginal fistula - VVF) or ectopic ureter.

Risk factors

  • Stress UI: Pregnancy, childbirth (vaginal delivery), menopause (oestrogen deficiency), obesity, chronic cough, constipation, pelvic surgery, pelvic organ prolapse.
  • Urge UI/OAB: Increasing age, neurological conditions (stroke, Parkinson's, MS, spinal cord injury), diabetes, UTIs, bladder irritants (caffeine, alcohol), certain medications, idiopathic.
  • Overflow UI: Bladder outlet obstruction (BPH, stricture, prolapse), diabetic neuropathy, spinal cord injury, medications (anticholinergics, opioids).
  • Functional UI: Immobility, dementia, severe arthritis, environmental barriers.
  • Fistula: Obstructed labour, pelvic surgery, radiation.

Diagnosis

Clinical assessment

History is key to determine type of incontinence (stress vs urge vs mixed vs overflow vs continuous), frequency, severity, triggers, impact on quality of life. Assess fluid intake, bowel function, medications, medical/surgical/obstetric history. Physical exam: Abdominal (palpable bladder), Pelvic (assess prolapse, atrophy, pelvic floor muscle strength - Kegel test), Neurological (assess perineal sensation, reflexes), Rectal (sphincter tone, prostate in men). Observe leakage during cough stress test.

Investigations

  • Urinalysis: Rule out UTI, haematuria.
  • Post-Void Residual (PVR) Volume Measurement (Ultrasound/Catheter): Assess bladder emptying (high PVR suggests overflow/obstruction).
  • Bladder Diary: Patient records fluid intake, voiding times, incontinence episodes, triggers over 2-3 days.
  • Urodynamic Studies: Specialist tests to assess bladder and urethral function (pressure/flow studies). Indicated if diagnosis unclear, considering surgery, neurological cause suspected, or failed conservative therapy.
  • Cystoscopy: If haematuria, recurrent UTIs, suspected bladder pathology.
  • Imaging (Ultrasound/MRI): Assess urinary tract anatomy, rule out obstruction/masses.

Diagnostic criteria

Clinical diagnosis based on symptom pattern, supported by physical exam and basic investigations (Urinalysis, PVR).

Management

Non-pharmacological management

  • Lifestyle Modifications (Applicable to most types):
  • - Fluid management (avoid excessive intake, limit evening fluids, avoid bladder irritants like caffeine/alcohol).
  • - Weight loss (if overweight/obese).
  • - Treat constipation.
  • - Smoking cessation (reduces cough).
  • Behavioural Therapies:
  • - Pelvic Floor Muscle Exercises (Kegel exercises): First-line for stress incontinence, can help urge incontinence. Requires proper technique and regular practice.
  • - Bladder Training (for Urge UI/OAB): Scheduled voiding, gradually increasing interval between voids, urge suppression techniques.
  • Prompted Voiding / Timed Toileting (for Functional/Cognitive impairment).
  • Supportive Devices:
  • - Absorbent pads/products.
  • - Vaginal pessaries (for stress incontinence associated with prolapse).
  • - Continence devices (e.g., urethral inserts, external clamps - less common).
  • Interventional/Surgical (Specialist):
  • - Stress UI: Mid-urethral slings (TVT, TOT), Burch colposuspension, bulking agent injections.
  • - Urge UI/OAB: Botulinum toxin A injection into bladder, Sacral neuromodulation, Augmentation cystoplasty.
  • - Overflow UI: Treat underlying obstruction (e.g., TURP), Intermittent self-catheterization.
  • - Fistula: Surgical repair.

Pharmacological treatment

  • Urge Incontinence / Overactive Bladder (OAB):
  • - Antimuscarinics (Anticholinergics): Reduce detrusor overactivity. Examples: Oxybutynin, Tolterodine, Solifenacin. Side effects common (dry mouth, constipation, cognitive effects - caution in elderly).
  • - Beta-3 Adrenergic Agonists: Relax detrusor muscle. Example: Mirabegron. Fewer anticholinergic side effects, can increase BP.
  • Stress Incontinence: Limited pharmacological options. Duloxetine (SNRI) has modest effect but significant side effects, not widely used for this indication.
  • Atrophic Vaginitis (Postmenopausal women): Topical vaginal oestrogen cream/pessary can improve urethral/vaginal tissue health and associated storage symptoms/recurrent UTIs.
  • Overflow Incontinence: Treat underlying cause (e.g., alpha-blockers for BPH). Bethanechol (cholinergic agonist) rarely used for detrusor underactivity.

Monitoring

Monitor symptom frequency/severity (bladder diary useful). Assess quality of life impact. Monitor for side effects of medications. Monitor PVR if relevant.

Complications

  • Skin irritation / breakdown
  • Urinary Tract Infections (UTIs)
  • Falls (rushing to toilet)
  • Social isolation, embarrassment, depression
  • Sexual dysfunction
  • Complications of underlying cause or treatment (e.g., urinary retention with anticholinergics, surgical complications)

Prevention

  • Pelvic floor exercises (especially peri/post-partum).
  • Maintain healthy weight.
  • Avoid bladder irritants.
  • Treat constipation.
  • Timely management of BPH/obstruction.

Patient education

  • Explain type of incontinence.
  • Reassurance that it's common and treatable.
  • Lifestyle and behavioural strategies (fluid management, Kegels, bladder training).
  • Correct use of medications and potential side effects.
  • Use of continence products.
  • When to seek further help.

Uganda-specific notes

Vesicovaginal fistula (VVF) due to obstructed labour is a major cause of continuous incontinence in women. Pelvic floor exercises and bladder training are key conservative measures. Access to urodynamics, specialist medications (beyond basic anticholinergics), and surgical interventions is limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 7, Section 7.2.7

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