Urinary incontinence and neurogenic urinary disorders

URINARY INCONTINENCE

Urinary incontinence is involuntary leakage of urine.

Etiology.
Incontinence can be related to non-urologic or urologic causes. Non-urologic causes of incontinence are usually reversible when the underlying issue is identified and corrected. These transient causes of incontinence are delirium, infection, atrophy of vaginal tissues, depression, polyuria, restrited mobility, stool impaction, use of alcohol, benzodiazepines, diuretics. Urologic causes are urethral and/or bladder dysfunction. Risk factors for incontinence in women are childbirth, aging, abdominal straining such as chronic cough, obesity, and estrogen loss. Less common urologic causes of incontinence include anatomic abnormalities such as urinary fistula or ectopic ureteral orifices.

Types of urinary incontinence: 1.Stress urinary incontinence is due to hypermobility of the bladder neck and proximal urethra or intrinsic sphincter deficiency. Patient (mostly women) complains on urine leak during coughing, exercising or lifting something heavy. 2.Urge incontinence is caused by detrusor overactivity of neurogenic or nonneurogenic origin. Patient has a sudden intense urge to urinate followed by involuntary loss of urine. Overactive bladder (OAB) has become the popularized term for describing patients with frequency and urgency with or without urge urinary incontinence (UUI). 3.Overflow incontinence occurs at extreme bladder volumes or when the bladder volume reaches the limit of the urethral mechanism or the bladder's viscoelastic properties. The loss of urine is driven by an elevation in intravesical pressure which overcomes the outlet resistance but not due to contraction of the detrusor muscle. Patient experiences frequent and constant dribbling of urine. Overflow incontinence is associated with incomplete bladder emptying caused either by bladder outlet obstruction (BOO) or poor bladder contractility. BOO is more common in men and due to enlargement of the prostate (BPH). It is less common in women but can result from severe pelvic prolapse or following any pelvic surgery.

Symptoms.
There are important questions about onset of incontinence, location, duration, characteristics, aggravating factors, previous pelvic surgery, radiation and other treatments. Physician asks about irritative or storage symptoms (i.e. urgency, urgency incontinence, frequency, nocturia), obstructive or emptying symptoms (i.e. hesitancy, straining to void, decrease or interrupted stream, history of retention of urine of incomplete bladder emptying), and symptoms of stress urinary incontinence. Physical examination is performed with emphasis on the abdominal, pelvic and rectal examination. In females, the condition of the vaginal epithelium and the degree of urethral mobility is determined. Simple pelvic examination with the patient supine is sufficient to determine if the urethra moves substantially with straining or coughing. A supine or standing stress test should be performed to demonstrate urinary leakage. The most straightforward for of the stress test is asking the patient to cough during the pelvic exam. The presence of associated pelvic organ prolapse should be noted as it can contribute to the patient's voiding problems and may have an impact on diagnosis and treatment. A rectal exam includes the evaluation of sphincter tone and perineal sensation. Urinalysis is performed to determine if there is any evidence of hematuria, pyuria, glucosuria, or proteinuria. Post void residual urine volume (PVR) is frequently useful to guide treatment and may be measured either with bladder ultrasound or directly with a catheter. Volume less than 50 ml has no clinical efect, volumes in excess of 200 ml should raise concern. A significant PVR urine may reflect either BOO or poor bladder contractility. The only way to distinguish outlet obstruction from poor contractility is with functional urodynamic testing. Voiding diary may be used to quantitate the amount of fluid taken in, the amount of urine per void, the number of voids and the number of incontinent episodes. Pad weight test may be performed in select instances to quantitate the amount of incontinence. Uroflowmetry measure the flow that urine is expelled from the bladder. If abnormal it reflects either BOO or poor bladder contractility but does not always differentiate between the two. Urodynamic testing (UDS) is used to accurately diagnose the etiology of patient’s incontinence. The purpose of urodynamic testing is to examine bladder compliance, detrusor overactivity, urethral function, and to rule out obstruction as a cause of either overflow or urge incontinence. Urodynamics are often performed prior to invasive therapies and are always indicated in patients undergoing repeat procedures following failed treatments. Assessment of the function of the lower urinary tract can be made by a number of investigations, which are listed in Tab. 1.

Tab. 1. Urodynamic investigations • Uroflowmetry (measurement of urinary flow rate during voiding) • Filling cystometry (assessment of bladder capacity, size of the residual urine volume and measurement of bladder pressures with a inserted special urethral catheter during bladder filling) • Voiding cystometry (bladder pressure and urinary flow assessment during voiding with inserted special urethral and rectal catheters). • Profilometry (measurement of urethral and urethral sphincter pressure) (6). The differential diagnosis for urinary urgency, frequency with or without urge urinary incontinence is extensive. There are general conditions such as polydipsia of any cause, constipation, pelvic floor muscle dysfunction, poorly controlled diabetes, use of diuretics, congestive heart failure and primary bladder conditions such as interstitial cystitis, chronic cystitis, bladder outlet obstruction due to BPH, urethral stricture or prior incontinence procedures, decrease bladder compliance in a patient with prior radiation to the pelvis, and foreign body in the bladder. In a patient with irritative bladder symptoms, bladder cancer or carcinoma in situ is a critical diagnosis. Treatment of stress urinary incontinence is tailored to the amount of incontinence and how it affects the patient. The patient who is severely restricted because of severe leakage with minimal movement may opt for surgical treatment, whereas the patient who leaks small amounts infrequently may choose conservative treatment.

Behavioral modification: a variety of strategies to manage fluid and timed voiding, particularly before provocative activities, may assist with the patient’s SUI symptoms. Pelvic floor exercises can improve anatomic stress urinary incontinence by augmenting closure of the external urethral sphincter and by preventing descent and rotation of the bladder neck and urethra. To benefit from the exercises, women must be taught to do them properly and they must do them consistently. Devices - vaginal inserts including continence pessaries or tampon-like devices are options to promote continence by support of the anterior vaginal wall. These are often employed in situations where patients only leak with certain activities (i.e. running) or for women desirous of avoiding more invasive interventions. Surgical treatment for stress incontinence is indicated when a patient doesn’t wish to pursue non- surgical therapy or when other treatments have failed.

In general, interventions are grouped into the following categories: cystoscopic injection of urethral bulking agents, retropubic suspensions, and sling procedures. Choosing a surgical procedure is a complex decision. Patients should be informed of the level of invasiveness, operative risks, and expectations. The most common procedures performed are slings. Pubovaginal slings, often employed in complex situations or for prior failed interventions, most often utilize a patient’s own fascia as a graft. Synthetic mesh mid-urethral slings (tension-free vaginal tape TVT, retropubic or transobturator) are employed in patients with urethral hypermobility. They are often performed due to their low invasiveness and very good results. Treatment of stress urinary incontinence in men. Men who are experiencing symptoms suggestive of SUI will have a history of neurologic condition such as spinal cord injury affecting the bladder neck or more likely will have had a history of surgery for treatment of prostate cancer or BPH. Evaluation would include cough stress test, PVR/Uroflowmetry and when appropriate urodynamic studies and cystoscopy. Male patients with stress incontinence can be treated with an artificial urinary sphincter or a variety of sling procedures. An artificial urinary sphincter provides continence because a cuff compresses the bulbar urethra. Male slings provide compression under the urethra and elevate the urethra to a more retropubic position. Slings are best suited for men with lesser degrees of incontinence as determined by a pad weight test (3,4). Treatment of urge incontinence.

Treatment options include: 1.behavioral modifications: modification of fluid intake, timed or scheduled voiding prior to the feeling the sensation of urge, reduction of bladder irritants, weight loss, urge control techniques (i.e. distractions), electrical stimulation, biofeedback, pelvic floor exercises 2. pharmacological treatment: a.) anti-muscarinic medications, which work by binding the muscarinic receptor on the detrusor muscle and this results in decrease in contractility of the detrusor muscle. There are many different anti-muscarinic medications: oxybutynin, solifenacin, darifenacin, trospium etc. Side effects as dry mouth, dry/itchy eyes, constipation, blurred vision are common. Dyspepsia, urinary retention, UTI, tachycardia, drowsiness, and impaired cognitive function are possible. Use in older individuals should be done with extreme caution as these medications can result in decrease memory recall and altered mentation. Anticholinergic medications may also be linked to development of dementia. Contra-indicated are in patients with narrow or closed-angle glaucoma and should be used with caution in patients with history of impaired gastric emptying or history of urinary retention. b.) β-3 adrenoreceptor agonist: mirabegron works by binding the β-3 adrenergic receptor on the bladder signaling relaxation of the detrusor muscle. Side effects are hypertension, headaches, and UTI. Common side effects reported with anti-muscarinic medications such as dry mouth, dry eyes, urinary retention occur less frequently with mirabegron. Use is contraindicated in patients with uncontrolled hypertension and patients on metoprolol and select antiarrhythmic medications 3. Intradetrusor botulinum toxin (Botox): Botox works by preventing the release of acetylcholine at the nerve terminals, with a decrease in acetylcholine in the nerve terminals the detrusor muscle is not stimulated and remains flaccid. Generally, it is an office-based procedure in with the bladder is anesthetized with intravesical lidocaine and then the Botox is injected into the detrusor muscle via a cystoscopy. 4. neuromodulation – is stimulation of nerve roots in sacral area with efect on bladder function. 5. surgical treatment: augmentation cystoplasty - piece of bowel is separated from the bowel tract and de-tubularized and used to expand the bladder. Both of these types of procedures are highly specialized procedures that are invasive and have considerable associated risks. Urinary diversion - piece of bowel is isolated from the bowel tract and used as a conduit to bring urine to the skin via a stoma. The ureters are inserted directly into the bowel segment. 6. insertion of a chronic indwelling urethral catheter or suprapubic catheter should be considered last resort and reserved for those that are at risk for skin break down or institutionalization due to their urinary incontinence. Urethral catheters carry a risk of irreversible damage to the urethra such as erosion or formation of a patulous incompetent urethra and increased risk for catheter-associated infections. Treatment of overflow incontinence is geared towards emptying the bladder and is dependent on the causes, anatomic or poor detrusor function. Anatomic cause of obstruction in males is from either urethral stricture disease or prostatic obstruction. Depending on the severity of urethral stricture disease the patient may require a urethral dilation, internal urethrotomy, or an urethroplasty. Prostatic obstruction may be treated with medications or surgical intervention. There are many newer approaches to surgical management of BPH, however transurethral resection remains the "gold standard." When a female is obstructed from previous surgery or from pelvic prolapse, she may benefit from an urethrolysis, removal of the prior sling, or surgical correction of the prolapse. The patient with overflow incontinence secondary to poor detrusor contractility is best treated with clean intermittent catheterization as chronic indwelling catheters are not optimum in the long-term. Indwelling catheters are associated with chronic bacteriuria which predisposes them to bladder calculi and ultimately to squamous cell carcinoma of the bladder. Any foreign object in the bladder can cause or exacerbate elevated bladder pressure which then causes hydronephrosis, ureteral obstruction, renal stones and eventually renal failure (5,6).

Neurogenic Bladder
Neurogenic bladder dysfunction is a loss of bladder control caused by damage to the brain, spinal cord, or nerves, resulting in either an overactive (spastic) or underactive (flaccid) bladder. Common causes include stroke, spinal cord injury, multiple sclerosis, Parkinson’s, and diabetes mellitus. Symptoms range from incontinence and frequency to urine retention. Types of Neurogenic Bladder • Overactive (Spastic/Hyperreflexic): The bladder muscle contracts automatically, causing frequency, urgency, and urge incontinence. • Underactive (Flaccid/Hypotonic): The bladder muscle does not contract, leading to urinary retention, overflow incontinence (dribbling), and inability to empty fully. • Mixed: Features of both overactive and underactive. • Detrusor-Sphincter Dyssynergia: The bladder contracts while the sphincter muscle remains closed, preventing emptying. Key Symptoms and Complications • Incontinence: Constant leakage or uncontrollable urge to urinate. • Retention: Inability to empty the bladder, leading to a weak stream or straining. • Infections: Recurrent urinary tract infections (UTIs). • Kidney Issues: Potential for kidney stones, hydronephrosis (urine backing up into kidneys), or renal failure. • Neurogenic Bowel: Often accompanies bladder issues, causing constipation or incontinence. Causes of Damage Neurogenic bladder results from diseases or injuries affecting the nervous system: • Neurological Diseases: Multiple sclerosis (MS), Parkinson’s disease, ALS, dementia. • Injuries: Spinal cord injuries, brain injuries. • Congenital Disorders: Spina bifida. • Other: Diabetic neuropathy, stroke, and nerve damage from pelvic surgery. Diagnosis and Treatment • Diagnosis: Involves neurological exams, imaging (CT/MRI), and urodynamic tests to measure bladder pressure and urine flow. • Management: While often not curable, it is managed with clean intermittent catheterization (CIC), medications, Botox injections into the bladder, or surgery. • Complication Management: Antibiotics for UTIs and specialized care to prevent kidney damage. Diagnosis and Tests • Cystoscopy • Kidney and bladder ultrasound, contrast CT, MRI • Neurological examination • Urodynamic testing Types of neurogenic bladder (fig.1): A B C D Type A: Spinal lesions – detrusor-sphincter dyssynergia High pressure in the bladder, small portions, rezidual urine volume, vesicorenal reflux, kidney damage, renal failure, life threatening. Type B: Cerebral lesions – overactive bladder Frekvent voiding, nycturia, Urgency, Urge incontinence – poor quality of life, not life threatening Type C: Peripheral lesions – underactive bladder low bladder sensation, enlarged capacity, residual urine volume, urination with abdominal stress, reccurent urinary infections, urinary retention. Type D: Peripheral lesions – underactive bladder with underactive sphincter low bladder sensation, enlarged capacity, residual urine volume, urination with abdominal stress, reccurent urinary infections. Treatment options: 1.lifestyle changes (avoiding certain foods or drinks that can irritate bladder, like alcohol, caffeinated drinks like coffee and carbonated drinks like soda pop, treatment of diabetes, treatment of constipation 2. training of the bladder and pelvic floow muscles regulary voiding, Kegels exercises 3. Pharmacological treatment: oxybutynin, propiveron, tolterodine, mirabegron, solifenacin, tamsulosin. 4.Self-catheterization (clean intermittent catheterization) 5.Injection of Botulinum toxin (Botox®) in detrusor muscle reduce symptoms of urgency, frequency and leakage. 6.Continuous catheterization through urethra or lower abdominal wall (suprapubic cystostomy). 7.Augmentation cystoplasty (bladder augmentation) a part of small intestine i sused for increasing the size of bladder 8.Urinary reconstruction and diversion – urostomawhich drains into a plastic bag (urostomy bag) attached to the outside of body. Complications of neurogenic bladder • Bladder damage / urinary retention • Kidney damage (kidney disease) /renal failure • Kidney stones, bladder stones • Vesicoureteral reflux • Recurrent urinary tract infections (UTIs)

Attachment		Date	Size	Availability [?]	Clinically sensitive [?]	Licence
Types of neurogenic bladder		12.2.2026	17.51 KB	faculty member	–

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