Incontinence

ZP301
2010

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Outline and learning objectives
On completion of this section you should be able to:
 Explain what incontinence is
 Describe the different types of incontinence

 Understand and discuss the treatment and

management of incontinence

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What is incontinence?
 Incontinence means “involuntary loss of urine or
faeces in sufficient amount or frequency to
constitute a social or medical problem”
 A heterogeneous condition that ranges in severity
from dribbling small amounts of urine to continuous
urinary incontinence with concomitant fecal
incontinence
 Symptom not a disease
 Can occur and affect any age
 In SA – 2 million people – most > 65
 Woman 4x > Men

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Problems with Incontinence
 Social stigma
 Secrecy – underreported (50-57% of people never
report it)
 Self imposed isolation

 Restricted activities
 Depression
 Family-imposed institutionalisation

 Medical
 Skin breakdown
 Urinary tract infection

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Structure of the urinary
bladder

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Process of micturition

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Process of Micturition (2)
 Frequency
 3-4 hourly during the day
 4-6 times in 24 hours

 Volume of Urine
 Bladder holds 300-500ml of urine
 Adult passes about 1500ml of urine/day

 2 month old infant passes about 400ml/day

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Classification of Incontinence
 CHRONIC
ACUTE
 Urge
Delirium
 Stress
Infection/ Inflamation / Immobility
 Overflow
Atrophic Vaginitis
 Functional
Pharmaceuticals
 Iatrogenic
Psychological
 Mixed
Endocrine (Diabetes) / Epilepsy
 Restricted Mobility / Retention
 Stool Impaction / Shock

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Urge incontinence
 Leakage (usually larger amounts) as inability to
delay voiding after sensation of bladder fullness. 
 Symptoms:
 Frequent abrupt, intense urge to urinate that
cannot be voluntarily suppressed
 moderate to large volumes of urine
 nocturnal wetting
 perineal sensation intact

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Urge incontinence (overactive bladder)

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Urge Incontinence (2)
 Cause:
 Inappropriate contraction of detrusor muscle during
bladder filling
 idiopathic
 related to aging (unclear mechanism)
 decreased cortical inhibition (CVA, Parkinson’s
disease, Alzheimer’s disease, brain tumor)
 bladder irritation (UTI, bladder CA, stones)
 Treatment
 Aim – increase bladder capacity, decrease frequency and
amplitude of detrusor instability
 Drug therapy (55% success)
 Anticholinergics

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Stress Incontinence
 Involuntary leakage of urine when intra-abdominal
pressure increases.  Delay not more than 3 seconds.
 Signs & Symptoms:
 urine leakage triggered by coughing, sneezing,
laughing, lifting, exercising, straining
 usually worse standing than supine
 small to moderate volumes of urine
 infrequent nocturnal leakage

 little post-void residual

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Stress incontinence

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Stress Incontinence (2)
 Causes:
 urethral hypermobility due to pelvic floor laxity

 aging
 difficult or multiple vaginal deliveries
 hysterectomy
 other perineal injury (e.g. radiation)
 intrinsic urethral sphincter deficiency

 autonomic neuropathy
 inadequate estrogen levels
 partial denervation

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Stress Incontinence (3)
 Treatment
 Drug therapy (adrenergics – increase urethral
resistance)
 Oestrogen therapy

 Pelvic floor exercises (Kegel exercises)

 Weight loss

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Overflow Incontinence
 Frequent or continuous leakage (usually small amounts) from
mechanical forces on a over distended /full bladder or from
other effects of urinary retention on bladder and sphincter
function
 Signs & Symptoms:
 Frequent voiding/dribbling (worse after fluid load or
diuretic)
 small volumes
 without warning
 slow or weak flow
 incomplete bladder emptying
 feel need to strain
 nocturnal wetting
 Bladder hypotonic/flaccid and palpably distended
 Large post-void residual (PVR)

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Overflow Incontinence (2)
 Causes:
 long-standing outlet obstruction (eg from prostrate)

 detrusor chronically overstretched

 detrusor insufficiency

 lower motor neuron damage due to peripheral

neuropathy or sacral cord injury
 impaired sensation

 peripheral neuropathy, Vit B12 deficiency, SCI

 medications that reduce detrusor tone

 anticholinergics, antidepressants, antipsychotics, anti-

Parkinsonians, narcotics, Ca-channel blockers,
vincristine

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Overflow incontinence

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Overflow Incontinence (3)
 Treatment
 Facilitate complete bladder drainage
 Correct underlying condition

 Intermittent self-catheterisation

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Mixed Incontinence
 Refers to patients with both stress incontinence and
urge incontinence.
 Helpful to identify the most bothersome symptom
and treat accordingly

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Functional Incompetence
 Inability to void independently due to impairment of
physical and/or cognitive function
 disabling illness, bedridden
 frontal lobe dysfunction, lack of awareness
 deliberate incontinence (rare)
 Patient may have other types of incontinence that
are amenable to treatment
 Pure functional incontinence should be a diagnosis
of exclusion

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Iatrogenic Incontinence
 Drug induced incontinence
 May not be possible to withdraw drug (eg diuretic)
 Other drugs which may be involved

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Drugs causing overflow incontinence
Anticholinergics
Antidepressants Decreased bladder contractions with retention
Antipsychotics
Sedative-hypnotics Decreased bladder contractions with retention
Antihistamines
Nervous system depressants Decreased bladder contractions with retention
Narcotics
Alcohol Decreased bladder contractions with retention
Calcium channel blockers
Alpha-adrenergic agonists Decreased bladder contractions with retention
Beta-adrenergic blockers
Decreased bladder contractions with retention

Decreased bladder contractions with retention

Sphincter contraction with outflow obstruction

Sphincter contraction with outflow obstruction
Drugs causing stress incontinence
Alpha-adrenergic antagonists Sphincter relaxation with urinary leakage
Drugs causing urge incontinence
Diuretics Contractions stimulated by high urine flow
Caffeine Diuretic effect
Sedative-hypnotics Depressed central inhibition of micturition
Alcohol Diuretic effect and depressed central inhibition 25
Enuresis
 Nocturnal enuresis – bedwetting
 Most children by age 5 have night-time bladder control

 10% of 5 yr olds have enuresis and 5% older

 Possible causes:
 Emotional/psychiatric disorder
 UT infection, obstructive lesion of the urethra

 Treatment
 Motivational counselling
 Enuresis alarms
 Pharmacotherapy

 Protective wear

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Enuresis (2)
 Behaviour modification
 Bladder training – pelvic floor muscle exercises
 Habit training

 Prompted voiding
 Scheduled toileting
 Fluid intake – reduce at bedtime and avoid
caffeinated substances and alcohol

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Treatment and Management of
Incontinence
Conservative measures should be tried first
Patient should be involved in choice of treatment
 Behavioural Techniques
 Bladder retraining
 Kegel exercises
 Fluid Intake/ nutrition

 Drugs
 Surgery
 Catheterisation
 Devices / undergarments and shields

 Hygiene / skin care

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Behavioural Techniques
 Bladder Training
 Especially useful in overactive bladder or urge incontinence

 Attempt to defer voiding for a set time (1 hour to start) and

time is gradually extended
 Complete frequency/volume chart
 Lifestyle management
 Reduce or eliminate caffeine

 Reduce or eliminate alcohol

 Drink 6 to 8 glasses of water daily

 Quit smoking
 Weight control

 Follow a healthy diet high in fibre

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Pelvic Floor Exercises
 Pelvic Floor Exercises (Kegel Exercises)
 Useful in stress incontinence
 Muscles that are stretched with pregnancy and
child birth and weakened by straining with
constipation
 To exercise these muscles, pull in or "squeeze"
pelvic muscles (as if trying to stop urine flow).
Hold this squeeze for about 10 seconds, then rest
for 10 seconds. Do 3 to 4 sets of 10 contractions
per day.
 Can use Kegelcones – weighted vaginal cones

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Kegelcones

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Drug Therapy
 Anticholinergic agents (Oxybutynin - Ditropan®) –
 Usually first line for urgency and frequency - stress and
urge incontinence
 Diminish tendency for detrusor muscle to contract – and
increase bladder capacity
 high incidence of side effects
 Tricyclic a’depressants (imipramine and amitriptyline)
 Nocturnal enuresis and detrusor instability
 Oestrogen creams and replacement therapy
 Postmenopausal women
 Improve elasticity of the tissues and organs in the pelvis
 Sympathomimetic agents (phenylpropanolamine and
pseudoephedrine)
 Relax bladder but improve tone of sphincter

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Surgery
 Restores the normal anatomic position of the
bladder neck and urethra
 Bladder neck suspension procedure
 Pubovaginal sling procedure (hammock)

 TVT or Tension-free support (stress incontinence)

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Catheters
 A urinary catheter is a flexible tube system placed in
the body to drain and collect urine from the bladder.
 Simple or standard catheters for intermittent
catheterisation
 Foley catheters – indwelling for short (< 30 days)
and long term catheterisation
 Condom Catheters
 Suprapubic catheters

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Foley Catheters
 Inflatable balloon – anchor the catheter in the
bladder –filled with sterile fluid – 5-30ml
 Sized on a French Scale (Fr number) 6-48Fr - One
French unit = 0.33milimeters
 Drains into bags – overnight or leg bags
 2-way or 3-way catheters
 Catheter valves – used instead of leg bags – press to
drain

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Types of Foley catheters
 Uncoated latex:
Plain latex catheters can be used for up to 7 days.
 Silicone treated latex:
Silicone treated latex should not be confused with silicone
coated latex. Silicone treated latex catheters are usually plain
latex catheters which have been dipped into silicone lubricant.
The silicone lubricant has little or no protective effect, and the
catheters should be treated as uncoated latex catheters.
 Silicone coated latex catheters, hydrogel-coated latex
catheters, all-silicone catheters, 100% silicone catheters,
silicone-elastomer coated catheters:
All of these catheters are classified as long term catheters, and
can usually be used for up to 12 weeks.
 Plastic catheters:
Some Foley (2-way) catheters are made of plastic. However,
they usually have a latex balloon. Depending on the
manufacturer, these may be classed as short term (7 days), or
short to medium term (7-28 days).
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Condom Catheters

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Suprapubic catheters

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Catheter Care
 Long term catheter use (>30 days) – bacteriuria
 30% of patients – symptomatic
 Can cause prostatitis, epididymitis, cystitis,
pyelonephritis, and bacteremia
 Change catheter and treat
 Catheter encrustation - gram-negative organisms
proliferate in alkaline urine (pH >6.5) - form crystals -
calcium oxalate – can lead to bladder stones
 Acetic acid bladder irrigations may reduce
encrustations and acidification of the urine with
ascorbic acid might inhibit bacterial proliferation

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Other devices
 Pessaries
 Mechanical urethral occlusion devices
 Penile Clamps

FemSoft –
Cunningham
urethral plug
Penile
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Pessaries

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Absorbent Devices
Undergarments and shields
 Absorbent products absorb and contain urine to
prevent unwanted leakage
 2 categories
 Bedpads and underpads

 Body worn products

 Inserts
 Briefs

 Pull-ups
 Male guards / drip or dribble collectors
 Disposable or reusable
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 Disposable – usually 3 layers
 Water-permeable cover stock (next to the patient’s
skin)
 Absorbent core

 Fluffed wood pulp

 Super-absorbent polymer
 Absorbent gelling material

 Water-proof poly-ethylene backing

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Skin Care
 Cleaning
 Prompt and gentle
 Moisturising
 Replace last lipids
 Protecting
 Moisture barriers

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Assessment of the Patient
 History
 Physical Examination
 Onset of problem
 Patient’s perception of the problem
 Frequency?
 Leakage on exertion?
 Urgency?
 Volume?
 Marital status
 Mobility
 Medication
 Emotional status
 Environmental – lifestyle
 Constipation
 Finances

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Promotion of Continence
 Public
 Literature
 media coverage
 Support groups
 Availability of products
 Importance of exercise diet
 At all levels – schools – retirement complexes
 Patients
 Comfort/empathy
 Support group
 Explanation of the problem
 Family support
 Pelvic floor / diet
 Health professionals
 Approach and attitude to patients

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