Urinary Incontinence

Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. The etiology of urinary incontinence is multifactorial. Risk factors for women include prior vaginal deliveries and menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause; the main risk factor for men is prior prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. Prostate and other Male Reproductive Glands surgery. Diagnosis is clinical, but more specialized tests are occasionally needed. Successful management is directed to the type of incontinence and the cause. Management includes nonsurgical and surgical approaches. A good prognosis is expected, especially with early detection.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Urinary incontinence is loss of bladder control, leading to involuntary loss of urine or uncontrolled urine leakage, which presents a hygienic or social problem to the individual and impacts quality of life.

Epidemiology

  • Women > men
  • Prevalence ↑ with age
  • Both genders are equally affected after 80 years of age.
  • In the United States, 20 million women and 6 million men experience urinary incontinence (UI) during their lifetime.
  • Globally, approximately 35% of individuals > 60 years of age suffer from UI.
  • Up to 80% of women in nursing homes have UI.
  • Only 25% of individuals affected by UI seek treatment due to the social stigma.

Etiology and risk factors

  • History of multiple pregnancies
  • Current pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
  • Vaginal delivery
  • Damage due to surgery or trauma near/on the bladder or pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor
  • Prostate surgery
  • Menopause
  • Conditions affecting the brain or spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord, such as: 
    • Stroke 
    • Multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis 
    • Parkinson disease
    • Cerebral palsy Cerebral palsy Cerebral palsy (CP) refers to a group of conditions resulting in motor impairment affecting tone and posture and limiting physical activity. Cerebral palsy is the most common cause of childhood disability. It is caused by a nonprogressive CNS injury to the fetal or infant brain. Cerebral Palsy
  • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Chronic renal disease 
  • Obesity
  • Urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections 
  • Medications:
    • Antipsychotics and antidepressants with anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs properties
    • Alpha-adrenergic agonists
    • Alpha antagonists
    • Diuretics
    • Calcium channel blockers Calcium Channel Blockers Calcium channel blockers (CCBs) are a class of medications that inhibit voltage-dependent L-type calcium channels of cardiac and vascular smooth muscle cells. The inhibition of these channels produces vasodilation and myocardial depression. There are 2 major classes of CCBs: dihydropyridines and non-dihydropyridines. Class 4 Antiarrhythmic Drugs (Calcium Channel Blockers) 
    • Sedative hypnotics
    • Angiotensin-converting enzyme inhibitors
    • Medications against Parkinson disease
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • ↑ Alcohol or caffeine intake
  • ↑ Age

Consequences of urinary incontinence

  • Increased: 
    • Rates of depression and social isolation 
    • Hospitalizations 
    • Urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections
    • Pressure ulcers 
    • Admission to long-term residential care 
  • Decreased:
    • Work productivity 
    • General health
    • Quality of life 

Pathophysiology

Normal bladder function

  • The bladder has 2 main functions: 
    • Store urine 
    • Expel urine 
  • Bladder function is controlled by:
    • Detrusor muscle → contracts during voiding 
    • Urethral sphincter → contracts during filling
  • The bladder is innervated by the parasympathetic, sympathetic, and voluntary nervous systems.
  • During filling:
    • Sympathetic stimulation → detrusor muscle relaxation
    • Contraction of the bladder neck
    • Contraction of the external urinary sphincter
  • During voiding:
    • Bladder distention → activation of mechanoreceptors → afferent signals to the pons
    • Inhibition of sympathetic stimulation and relaxation of the bladder neck
    • Parasympathetic activation of the detrusor 
  • ↑ Intra-abdominal pressure is transmitted to the urethra and bladder equally, which results in continence.
  • The urethra is supported by the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor muscles, which help to close the urethral opening.
  • Damage to the balance between the detrusor muscle and the urethral sphincter contributes to UI.

Incontinence pathophysiology

  • Stress incontinence:
    • Leakage of urine due to effort or exertion
    • Intra-abdominal pressure > bladder sphincter pressure
  • Urge incontinence: overactivity of the detrusor muscle
  • Mixed incontinence: combined detrusor muscle and bladder sphincter pathology
  • Overflow incontinence:
    • A bladder outlet obstruction or impaired detrusor contractility cause incomplete bladder emptying.
    • Inability to void the bladder completely → urinary retention → overdistension of the bladder → continuous or frequent loss of urine
  • Functional incontinence:
    • Inability to control urine voiding due to a physical or mental impairment 
    • No organic cause 

Clinical Presentation

General approach

Focus the history on symptoms consistent with incontinence based on the type of circumstance:

  • ↑ Daytime frequency of urination
  • Hesitancy (difficulty to initiate voiding)
  • Urge to void, but leakage before reaching the restroom
  • Disruption in daily activities due to urine leakage 
  • Leakage of urine postsurgery 
  • Feeling of dampness in the undergarment without the feeling of urine leakage
  • Feeling of incomplete voiding 
  • Nocturia 
  • Nocturnal enuresis Enuresis The elimination disorders that most commonly occur in childhood are enuresis (urinary incontinence) and encopresis (fecal incontinence in inappropriate situations). Enuresis is usually diagnosed when children > 5 years of age continue to wet the bed. Enuresis can occur both in the daytime (diurnal) and at night (nocturnal). Elimination Disorders (leakage of urine when asleep)
  • For individuals who have difficulty recalling or quantifying symptoms:
    • Bladder diary:
      • Fluid intake 
      • Frequency of voiding 
      • Urine volume
      • Number of episodes of incontinence
    • Pad test: 
      • The individual is asked to wear a pad.
      • The volume of urine leaked is checked by the weight and the number of pads used per day.

History

  • Stress incontinence:
    • Leakage of urine due to effort or exertion
    • When the event causing ↑ intra-abdominal pressure stops (e.g., coughing), small leakages stop.
    • Associated with pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, childbirth, constipation, and obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
  • Urge incontinence:
    • Sudden and unexpected need to void urine
    • Associated with:
      • Overactive bladder syndrome → urinary urgency occurs with or without incontinence
      • Cystitis
      • Multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis
      • Stroke
      • Parkinson disease
      • Prostate hyperplasia
  • Mixed incontinence: Involuntary leakage is associated with urgency and stress incontinence.
  • Overflow incontinence:
    • Urinary retention or incomplete bladder emptying 
    • Continuous or frequent loss of urine
    • May result from:
      • Pelvic/abdominal surgery 
      • Enlarged prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. Prostate and other Male Reproductive Glands
      • Pressure on the urethra by a tumor
      • Urethral stricture 
      • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
      • Pregnancy
      • Medication 
      • Neurological impairment
  • Functional incontinence:
    • Cognitive or physical factors impairing the individual’s ability to reach or use the restroom.
    • Associated with:
      • Impaired mobility or dexterity
      • Dementia/cognitive impairment 
      • Confusion
      • Poor eyesight 
      • Poor environment or a change in environment (e.g., hospitalization)

Physical examination

  • Pelvic exam to check for: 
    • The integrity of pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor muscles
    • Vaginal atrophy
    • Pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse
    • Digital exam for pelvic/uterine masses
  • Abdominal exam to palpate for pelvic and abdominal masses
  • Rectal exam: 
    • Determine the size and consistency of the prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. Prostate and other Male Reproductive Glands gland.
    • Exclude stool impaction.
    • Examine for rectal mass.

Diagnosis

Laboratories

  • Urinalysis: 
    • To exclude urinary tract infection
    • To exclude the presence of blood in the urine
    • To exclude the pathologic presence of protein or cells requiring further evaluation
  • Blood: 
    • Creatinine 
    • Blood urea nitrogen 
    • Estimated glomerular filtration rate Glomerular filtration rate The volume of water filtered out of plasma through glomerular capillary walls into bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests 

Clinical tests

  • Bladder stress test:
    • Full bladder
    • Ask the individual to cough or bear down while standing.
    • Observe any urine leakage.
  • Measurement of postvoid residual urine: 
    • An assessment of urine left in the bladder after voiding (by ultrasound or straight catheter)
    • Abnormal: > 150 ml or ⅓ of prevoid volume
  • Urodynamic tests measure the pressure the bladder/urinary sphincter muscle can withstand, and the flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure of urine:
    • Cystometry: measures pressure and volume of fluid in the bladder during filling, storage, and voiding
    • Uroflowmetry: measures the rate of urine flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
    • Urethral pressure profile: tests urethral function
    • Leak point pressure: determines the bladder or abdominal pressure when leakage occurs

Radiology

  • Not always necessary
  • Pelvic ultrasound: 
    • To detect tumors 
    • To detect nephrolithiasis Nephrolithiasis Nephrolithiasis is the formation of a stone, or calculus, anywhere along the urinary tract caused by precipitations of solutes in the urine. The most common type of kidney stone is the calcium oxalate stone, but other types include calcium phosphate, struvite (ammonium magnesium phosphate), uric acid, and cystine stones. Nephrolithiasis 
    • To check urine volume before and after voiding
  • Cystoscopy: A thin tube with a camera is passed through the urethra and into the bladder.
  • Abdominal CT: rule out masses/infection (e.g., renal carcinoma, pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess)
  • Spinal MRI: rule out cord compression, cauda equina, and spinal abscess

Management

Management of urinary incontinence is dependent on several factors:

  • Type and severity of incontinence
  • Underlying cause
  • Response to treatment
  • Age
  • General health and mental state 

Lifestyle/behavioral modifications

  • Management of constipation
  • Caffeine control
  • Weight control 
  • Diabetes and hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension management
  • Eliminate the intake of bladder irritants: 
    • Sugar substitutes
    • Citrus fruits
    • Spicy food
  • Smoking cessation
  • Timed voiding before physical or strenuous activities:
    • Urinate every 2–4 hours.
    • Urinate before physical or strenuous activities.
    • Do not wait for the urge to urinate.
  • Double voiding: Avoid overflow incontinence by urinating, and then urinating again after few minutes.
  • Avoid ↑ intra-abdominal pressure maneuvers (e.g., heavy lifting).
  • Kegel exercises:
    • Effective in stress and urge incontinence
    • Similar in both men and women:
      • Contract the muscles to stop the flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure of urine for 5 seconds.
      • Relax the muscles for the next 5 seconds.
    • Effort should be made to gradually progress to 10 seconds per contraction.
    • 3 sets of repetitions per day 
  • Wear pads.
  • Bladder training:
    • The time between trips to the bathroom is progressively delayed.
    • Start with a short gap of time and gradually ↑.
    • Increase the gap until 2.5–3.5 hours is reached.

Medications

  • Topical estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries (in women): 
    • Tones and rejuvenates urethral and vaginal tissues 
    • Postmenopausal use
  • Alpha blockers (in men):
    • Used in men with benign prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. Prostate and other Male Reproductive Glands hyperplasia
    • Relaxes the muscles of the bladder neck
  • Anticholinergics: 
    • Relieves overactive bladder 
    • Helps with urge incontinence
    • Common side effects:
      • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
      • Dry mouth
      • Blurred vision
      • Somnolence
    • Can cause mental status changes in the elderly Changes in the elderly A number of changes normally occur in the aging individual. These changes affect neurocognitive function, organ function, senses, metabolism, sexual function, and sleep patterns. Of particular importance in aging adults, physicians need to understand the difference between normal cognitive decline associated with aging and pathologic decline. Changes in the Elderly
  • Mirabegron:
    • Used in urge incontinence
    • Activates beta-3-adrenoceptors (causes the bladder to relax)
  • Duloxetine: 
    • Used for stress incontinence
    • Serotonin-norepinephrine reuptake inhibitor 
    • Acts mainly in the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord to ↑ the pudendal nerve activity
    • ↑ Closure pressure of the urethral sphincter
  • Botulinum toxin type A:
    • Used for overactive bladder
    • A neurotoxin inhibiting the presynaptic release of acetylcholine
    • ↓ Detrusor muscle contractility
    • Injected directly into the detrusor muscle of the bladder every 6–12 months
    • May lead to bladder paralysis
  • Desmopressin: 
    • Used in nocturia
    • A synthetic analog of vasopressin (antidiuretic hormone)
    • Monitor sodium levels (risk of hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia).

Medical devices

  • Urethral inserts:
    • A tampon-like device is inserted into the urethra before performing a rigorous physical activity to prevent incontinence.
    • Removed before voiding
  • Pessary:
    • Supports the urethra 
    • A flexible, silicone ring inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor 
  • External catheters and collecting systems: 
    • Condom catheters or sheath drainage systems 
    • Preferable to indwelling catheters and pads 
  • Penile clamps:
    • Penile compression devices 
    • Suitable for light-to-moderate cases to prevent leakage of urine 
    • Short-term usage 
  • Indwelling catheters: 
    • A catheter connects the bladder to an external collecting system.
    • Urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections are a common complication.
  • Intermittent catheters:
    • Single-use catheters to address urinary retention
    • Individuals self-catheterize as needed.

Therapies

  • Radiofrequency therapies: 
    • The lower urinary tract tissue is heated to promote collagen and elastin formation.
    • Firmer tissue results, which aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS in bladder control
  • Sacral nerve stimulator:
    • The stimulator is inserted under the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of the buttock; a wire connects the stimulator to the nerve running from the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord to the bladder.
    • Programmed to deliver an electric signal, which stimulates the nerve and aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS in bladder control
  • Bulking material injections:
    • Synthetic bulking material is inserted into the tissue surrounding the urethra.
    • ↑ Mechanical pressure around the urethra prevents leaking
    • Mainly for stress incontinence
  • Electrical stimulation:
    • For stress and urge incontinence
    • Strengthens the muscles of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor
    • Electrodes Electrodes Electric conductors through which electric currents enter or leave a medium, whether it be an electrolytic solution, solid, molten mass, gas, or vacuum. Normal Electrocardiogram (ECG) are temporarily inserted into the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal or vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor to stimulate and strengthen the muscles of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor.
    • Multiple treatments over several months of time

Surgical management

Surgical intervention is considered when other methods of management fail.

  • Sling procedure:
    • Synthetic material or surrounding tissues create a pelvic sling under the urethra at the bladder neck.
    • Mainly for stress incontinence 
  • Prolapse surgery: 
    • Used with pelvic organ prolapse 
    • Many techniques
    • The individual’s tissue or vaginal mesh is used to fix or suspend the sagging pelvic organs.
    • In mixed incontinence, a sling procedure and prolapse correction are performed.
  • Artificial urinary sphincter: 
    • A valve is implanted under the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin and deflates a fluid-filled ring placed around the bladder sphincter when pressed.
    • The deflation allows urine to void.
    • When inflated, the artificial sphincter behaves as a urinary sphincter and prevents incontinence.

References

  1. Bardsley, A. (2016). An overview of urinary incontinence. Br J Nurs. 25(18), S14–S21. https://pubmed.ncbi.nlm.nih.gov/27734727/
  2. Clemens, J.Q. (2019). Urinary incontinence in men. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/urinary-incontinence-in-men
  3. Downey, A., Inman, R.D. (2019). Recent advances in surgical management of urinary incontinence. F1000Res. 8, F1000 Faculty Rev–1294. https://pubmed.ncbi.nlm.nih.gov/31448082/
  4. Irwin, G.M. (2019). Urinary Incontinence. Prim Care Clin Office Pract. 46(2), 233–242. https://pubmed.ncbi.nlm.nih.gov/31030824/
  5. Lukacz, E.S. (2021). Treatment of urinary incontinence in females. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/treatment-of-urinary-incontinence-in-females
  6. Vasavada, S.P., Carmel, M.E. (2021). Urinary incontinence. Emedicine. Retrieved August 2, 2021, from https://emedicine.medscape.com/article/452289-overview

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