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Key Questions - Continence and Urology

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Alison Harris, RGN, BSc, Dip DN, is senior lecturer in primary health care at Middlesex University.

What are the main causes of urinary incontinence?

Urinary incontinence can generally be categorised as either storage problems such as stress urinary incontinence (SUI) and the overactive bladder (OAB), or voiding symptoms such as a slow or interrupted stream, hesitancy, dribbling and a feeling of incomplete emptying. Some people, such as those with neurological disorders, may report both voiding and storage difficulties.

SUI is the complaint of involuntary leakage of urine and it may or may not be accompanied by a prolapse. In women childbirth is the most common cause; in men it may be the result of surgery such as resection of the prostate. SUI involves the inadequate closure of the urethral sphincter so that any rises in intra-abdominal pressure (such as when coughing) causes leakage of urine that stops when the exertion is over.

The OAB is a collection of symptoms that includes urgency, with or without urgency incontinence, frequency and usually nocturia. The person with OAB is unable to inhibit the bladder contraction and complete loss of bladder control can occur. In the presence of a neurological disorder such as MS or Parkinson’s disease, the overactive bladder is termed neurogenic detrusor overactivity.

Voiding symptoms are usually associated with obstructions such as an enlarged prostate or a urethral stricture. People with neurological conditions may have voiding problems associated with the poor coordination of the detrusor contraction and the sphincter relaxation; this is termed detrusor-sphincter dyssynergia. A hypocontractile bladder resulting in incomplete emptying of the bladder may result from a long history of poorly controlled diabetes or a spinal cord injury.

Can urinary incontinence be cured?

As our knowledge of the pathophysiology of the bladder has increased, and as more robust clinical trails have been undertaken, so treatments have improved. Education, empowerment and compliance will contribute to the success of all interventions.

For SUI the first-line treatment is pelvic floor muscle exercises. Electrostimulation and vaginal cones have comparable efficacy. Pharmacological treatment with duloxetine tablets can promote continence when combined with pelvic floor exercises. In overweight individuals weight reduction may improve the condition significantly. Currently the most commonly used surgical procedures are mid-urethral retropubic or trans-obturator tension-free vaginal tape, which have lower morbidity than older procedures such as colposuspension.

To manage OAB, lifestyle intervention (including bladder retraining) fluid modification, prevention of constipation and pelvic floor exercises can be sufficient in promoting acceptable control. Lifestyle modification combined with anticholinergics, such as oxybutynin, tolterodine and solifenacin, may promote further reduction in frequency and urgency.

The enhanced use of intermittent catheterisation has led to the better management of incontinence attributed to non-surgically viable obstructions or neurological disorders.

What are the main causes of faecal incontinence?

Faecal incontinence affects about 5% of adults and can lead to feelings of isolation and despair. History-taking should include childbirth and any sustained trauma; anal conditions such as haemorrhoids; neurological history including congenital disorders such as spina bifida; surgery; and a history of travel or recent activities if a parasitic infection is suspected. A very common cause of faecal incontinence is constipation and impaction, especially in the frail, terminally- ill, the elderly, those with severe learning difficulties and people taking opiates.

Faecal incontinence is very often a management issue and patients require education and support to self-manage their problem. Toilet habits, dietary intake, caffeine and medications can all contribute to faecal incontinence and lifestyle changes can promote a healthy bowel.

What are the main causes of childhood urinary incontinence?

Children are generally expected to be dry by the age of five. When children are wetting after that age, and in the absence of any pathology, they are described as having enuresis. Diurnal enuresis is the more complex problem that may be the result of an overactive bladder or a behavioural problem and requires referral to a practitioner with specialist continence skills. Bladder diaries with or without anticholinergics are the main treatment methods.

Primary nocturnal enuresis (PNE) refers to a child who is bed-wetting, in the absence of any daytime symptoms, and has never been dry. The causes of PNE are polyuria and inability to store urine overnight; an inability to recognise a full bladder and to wake at night; and a combination of both. While PNE is a self-limiting condition for the majority of children, treatment is initiated to reduce the impact on self-esteem that we know enuresis can have. Clinicians should be alert to the possibility of parental intolerance. Treatment includes behavioural techniques that encourage the child to wake to the sensation of a full bladder and reward systems that reinforce their success. Desmopressin can be given when children are passing large volumes of urine and an inability to concentrate the urine overnight is suspected. High levels of support and evaluation of treatment is required.

A child who has been dry for more than six months and then wets again has secondary nocturnal enuresis and the underlying cause may be attributed to an emotional trigger such as starting school, parental divorce or the birth of a sibling.

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