Urinary incontinence

What it is

Chronic urinary incontinence is divided into five types, and the type decides the treatment.

• Stress: sphincter weakness, that is urethral sphincter and/or pelvic floor weakness, with urethral hypermobility.
• Urge: detrusor overactivity, meaning uninhibited bladder contractions, caused by irritation within the bladder or by loss of inhibitory neurologic control of bladder contractions.
• Mixed: a combination of stress and urge incontinence.
• Overflow: overdistention of the bladder caused by impaired detrusor contractility or bladder outlet obstruction, which causes urine leakage by overflow.
• Functional: variable leakage of urine, usually caused by environmental or physical barriers to toileting.

Causes and risk

• Stress: childbirth and obesity in women, and it may occur after prostatectomy in men.
• Urge: bladder irritation caused by cystitis, prostatitis, atrophic vaginitis, bladder diverticuli or prior pelvic radiation therapy, and loss of neurologic control caused by stroke, dementia, spinal cord injury or Parkinson disease. Detrusor overactivity may also be due to UTI, neurologic disease or diabetic neuropathy.
• Overflow: anticholinergic medications, benign prostatic hyperplasia, pelvic organ prolapse, diabetes mellitus, multiple sclerosis and spinal cord injuries.
• Functional: severe dementia, physical frailty or inability to ambulate, and mental health disorder such as depression, with impaired physical function and impaired cognition.

Medications are a cause in their own right, which is why they are reviewed first. Alpha-adrenergic antagonists decrease sphincter tone and angiotensin-converting enzyme inhibitors may increase coughing, both causing stress incontinence. Diuretics give a high urine flow that leads to bladder contractions and urge incontinence, and alcohol acts the same way while it depresses central inhibition. Calcium channel blockers, opioids, skeletal muscle relaxants, antihistamines and anticholinergics relax the bladder or inhibit bladder contractions, causing retention and overflow incontinence, and antidepressants, antiparkinsonian agents and antipsychotics inhibit bladder contractions in the same way, as do medications for urinary urgency. Cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs increase fluid retention, causing nocturnal diuresis and functional incontinence. Sedatives and hypnotics lead to sedation and impaired cognition, causing functional or overflow incontinence, and thiazolidinediones increase fluid retention, causing nocturnal diuresis and functional incontinence.