Urinary incontinence is defined as the involuntary loss of urine, through the urethra, which creates a social and hygienic problem. It can produce, when not corrected, an important personal devaluation, affecting the self-esteem and favoring the social separation and the difficulties of relation.
Incidence of urinary incontinence in the population
The incidence of urinary incontinence is difficult to know exactly. Epidemiological studies show that the occurrence of urine leakage at least once in the last 12 months affects 5-69% of women and 1-39% of men. In general, incontinence is twice as common in women as in men.
Risk Factors for Urinary Incontinence
The risk factors that determine the occurrence of urinary incontinence between men and women should be differentiated:• Women. In relation to women, pregnancy and vaginal delivery (obstetric causes) are the most important risk factors, causing an alteration of the musculature of the floor of the pelvis, which causes an increase in the fall of the organs located there (prolapses of the pelvic organs), and that is accentuated with the number of deliveries:1) bladder (Cystocele)2) rectocele3) uterine prolapseOn the other hand, hysterectomy or removal of the uterus and other pelvic surgeries on the rectum also favor the risk of prolapse of the pelvic organs. Also, among other factors involved, are also:- functional or cognitive impairment- neurological disorders- infections- Mellitus diabetes- advanced age, by decreasing the mass of muscle tissue- constitutional factors, since there is a lower proportion of collagen fibers in the support structure
• Male. Risk factors for men include:- advanced age- infections- Mellitus diabetes- functional and cognitive impairment- neurological disorders- history of surgery of the prostate, urethra or rectum, especially prostatectomy (more frequent cause of incontinence in the elderly male)
Classification of urinary incontinence
Urinary incontinence can be classified into:• Urge incontinence , also called "overactive bladder". Its origin is in the involuntary contractions of the bladder muscle (detrusor), when the bladder is in the filling phase. They are shown in the urodynamic study.• Stress incontinence. This type is characterized by loss of urine with increases in intra-abdominal pressure (for example with cough, sneezing and laughing). In some women, it may appear when standing, walking or picking up weights. Obesity and chronic cough can also contribute to its onset.• Mixed incontinence (effort and urgency). Incontinence that mixes the previous two. There may be predominance of one over the other.• Incontinence without perception of voiding desire. Sometimes the voiding desire is not perceived, reason why they suffer escapes of urine without being able to relate them to a concrete situation. This type of urinary incontinence is related to a situation of bladder overdistension and, although it accounts for less than 10% of cases of incontinence in the geriatric population, it is important to recognize it, since chronic urinary retention can lead to recurrent infections and upper urinary tract. This type of urinary incontinence occurs only with large volumes of urine within the bladder, and occurs when the intravesical pressure exceeds the urethral, regardless of any increase in intra-abdominal pressure (overflow incontinence). The latter differentiates it from stress urinary incontinence.
Diagnosis of urinary incontinence
The main objective in the diagnosis of urinary incontinence, in order to perform a correct treatment, is to establish the type of urinary incontinence. For this we rely on:1) General medical history. Personal history: medical, surgical, obstetrical, pharmacological, history of infections.2) Directed medical history. Questions about the type of incontinence:- duration: always, temporary, referred to some event- loss: continuous, drop by drop, standing alone, with cough, postural changesloss with effort- loss preceded by irresistible imperiousness- there is awareness of the loss of urine or does not exist, but underwear or diapers appear wet- There is loss of urine as the only symptom or, on the contrary, there are others such as voiding pain, painful sensation during bladder filling, which forces frequent urination and possibly relieves with emptying of the void frequency (polaquiuria).
3) Functional evaluation of the patient. Carry out a study of the patient's motor capacity.4) Physical examination. Abdominal and pelvic floor: evaluation of prolapses, reproduction of incontinence.5) Analytical study. Hematology and biochemistry, and urine: sediment and / or culture.6) Further explorations:-Radiographic study. The radiography and ultrasound of the urinary apparatus inform us of the morphology of the kidneys and the bladder, as well as the presence or absence of urine after urination (post-motile residue).-Urodynamic study, in certain cases. It allows to reproduce the act of micturition of the most physiological forms in their different studies: flowmetry, cystomanometry and pressure / flow study.
Treatment of urinary incontinence
In the therapeutic management of urinary incontinence, several alternatives are included, which should not be considered as mutually exclusive. On the contrary, they can and should be used in a complementary way to obtain the best therapeutic results. Therefore, in order to decide the most appropriate treatment in each patient, the Urologist should evaluate the type of incontinence, the associated medical conditions, the impact of incontinence, the patient's preference, the applicability of the treatment and the balance between the benefits / risks of each treatment.1) General measures- Hygienic-dietary measures. Reduce the consumption of exciting substances (alcohol, coffee or tea), since they can cause urinary urgency episodes. In cases of nocturia (urinating many times at night) and nocturnal incontinence, one can limit the intake of fluids from the snack, thus avoiding some nocturnal exhausts.- Modification of drugs that alter urinary continence, such as diuretics, psychoactive drugs, anticholinergics, calcium antagonists, etc., trying to replace them with other pharmacological groups or, at least, reduce their doses.2) Behavior modification techniquesThe aim of these techniques is to try to restore a normal bladder emptying pattern, thus promoting urinary continence. They are considered highly effective techniques, achieving a decrease in the frequency and severity of urinary incontinence in 50% of the patients and in a smaller percentage (about 30-40%),. It is possible to regain urinary continence.Behavior modification techniques include: bladder retraining, pelvic floor exercises, behavioral training, and biofeedback.3) Treatment of urinary incontinence of urgency or overactive bladdera) Pharmacological treatment:In order to make detrusor hyperactivity disappear, multiple drugs have been used and with different actions, all aimed at suppressing the involuntary contractions of the detrusor. Pharmacological treatment is effective in 50-70% of cases. The most commonly used are anticholinergics, since these drugs inhibit bladder contractility by selectively blocking acetylcholine at postsynaptic receptors.b) Electrical stimulation:By administering faradic or interferential current through an intraanal (male) or intravaginal (female) electrode, involuntary contractions of the detrusor can be suppressed and the bladder can be relaxed and voiding control restored.c) Other options:Injection of botulinum toxin type A (Botox). In situations of poor therapeutic response to anticholinergics injection of Botox into the bladder is gaining control of overactive bladders, by relaxing muscles and allowing more urine to be stored. These injections could reduce urinary incontinence episodes over a period of 7-9 months and a 75-80% effectiveness, with minimal side effects.4) Treatment of stress urinary incontinenceSurgery is considered the treatment of choice, achieving the fixation of the pelvic muscles and recovery of the physiological mechanism of continence. There are many techniques to correct stress urinary incontinence using one or other of the factors based on previous factors (existence of vesical-urethral neck anomaly, existence of pure urethral dysfunction, characteristics of each patient, age, presence of associated prolapses such as rectocele, cystocele, or uterine prolapse). The incorporation of the techniques with adjustable meshes has meant a control of 85-90%, since they allow to manipulate the mesh and to adjust the continence.In exceptional cases, when the urinary sphincter has been injured, usually after prostate, rectum and urethral surgery, the placement of a urinary artificial sphincter. In recent years this surgical technique has been developed, giving good overall results in both women and men with alteration or incompetence of the urethral sphincter.5) Treatment of overflow incontinencea) Treatment of obstruction. Whenever possible, a surgical correction of the cause of the obstruction (prostatic hyperplasia, urethral stricture, lithiasis, etc.). In cases of urethral obstruction or of the bladder neck dilations can be performed with probes or under endoscopic vision.b) Treatment of bladder dysflexia. The goal in this situation is to achieve bladder emptying, for which one can resort to pharmacological measures or bladder catheterization techniques. In this case, the technique of choice is intermittent bladder catheterization, resorting to permanent catheterization only when the patient's functional situation or lack of family or social support prevents this technique from being performed.