TABLE 97 Urinary Incontinence

Problem

Mechanisms

Stress Incontinence

The urethral sphincter is weakened so that transient increases in intraabdominal pressure raise the bladder pressure to levels that exceed urethral resistance.

Urge Incontinence

Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small.

In women, most often a weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra and a change in the angle between the bladder and the urethra. Suggested causes include childbirth and surgery. Local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection, may also contribute.

In men, stress incontinence may follow prostatic surgery.

■ Decreased cortical inhibition of detrusor contractions, as by strokes, brain tumors, dementia, and lesions of the spinal cord above the sacral level

■ Hyperexcitability of sensory pathways, caused by, for example, bladder infections, tumors, and fecal impaction

■ Deconditioning of voiding reflexes, caused by, for example, frequent voluntary voiding at low bladder volumes

Overflow Incontinence

Detrusor contractions are insufficient to overcome urethral resistance. The bladder is typically large, even after an effort to void.

Functional Incontinence

This is a functional inability to get to the toilet in time because of impaired health or environmental conditions.

Incontinence Secondary to Medications

Drugs may contribute to any type of incontinence listed.

■ Obstruction of the bladder outlet, as by benign prostatic hyperplasia or tumor

■ Weakness of the detrusor muscle associated with peripheral nerve disease at the sacral level

■ Impaired bladder sensation that interrupts the reflex arc, as from diabetic neuropathy

Problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Environmental factors such as an unfamiliar setting, distant bathroom facilities, bedrails, or physical restraints

Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics

*Patients may have more than one kind of incontinence.

Symptoms

Physical Signs

Momentary leakage of small amounts of urine concurrent with stresses such as coughing, laughing, and sneezing while the person is in an upright position. A desire to urinate is not associated with pure stress incontinence.

The bladder is not detected on abdominal examination.

Stress incontinence may be demonstrable, especially if the patient is examined before voiding and in a standing position.

Atrophic vaginitis may be evident.

Incontinence preceded by an urge to void. The volume tends to be moderate.

Urgency

Frequency and nocturia with small to moderate volumes

If acute inflammation is present, pain on urination Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a change of position, going up or down stairs, and possibly coughing, laughing, or sneezing

A continuous dripping or dribbling incontinence

Decreased force of the urinary stream

Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present.

Incontinence on the way to the toilet or only in the early morning

The bladder is not detectable on abdominal examination.

When cortical inhibition is decreased, mental deficits or motor signs of central nervous system disease are often, though not necessarily, present.

When sensory pathways are hyperexcitable, signs of local pelvic problems or a fecal impaction may be present.

An enlarged bladder is often found on abdominal examination and may be tender. Other possible signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation including perineal sensation, and diminished to absent reflexes.

The bladder is not detectable on physical examination. Look for physical or environmental clues to the likely cause.

Variable. A careful history and chart review are important. Variable

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