Urinary incontinence is loss of urine objectified, involuntary and having a social impact. It is a symptom covering many entities. Schematically, we can differentiate stress urinary incontinence, overactive bladder and mixed incontinence.
DIAGNOSTIC:
Examination:
The interrogation theoretically allows to differentiate the different types of incontinence. The limits thereof are however numerous.
The description of symptoms is not always accurate. The fear of leakage may induce urinary frequency precautionary behavior. A pure stress urinary incontinence can then take the mask of an overactive bladder.
The number of urination during the day is often misjudged by the patient and depends on many drinks. It is therefore recommended to ask patients a voiding diary on 24 or 48 hours. The systematic collection of urine and measuring the volume urinated used to check for leaks, frequency and circumstances of occurrence, measure urine output, sometimes too much, to have an idea of the functional bladder capacity.
Reviews:
The clinical examination is local and general. It allows for women to view an incontinence, to assess the vaginal health, especially after menopause, to verify the absence of prolapse, quantify the strength of the levator ani muscles (accessory muscles of continence ), possibly visualize a leak.
The orientation of the rest of the review depends on the type of flight and its impact.
A urine culture (urine culture) is almost always required.
ETIOLOGY:
The main types of incontinence are presented in Box 1.
Box 1. Different types of incontinence
urinary incontinence: leakage without needing to urinate a contemporary effort proportional to the effort. No other urinary disorders.
Overactive bladder: urinary frequency, urge incontinence with or without incontinence.
Mixed urinary incontinence: a combination of stress incontinence and urge incontinence a.
Overflow incontinence: dysuria, urinary frequency, sometimes incontinence or urge incontinence.
Urinary incontinence:
This is incontinence occurring outside an urge to urinate, a contemporary effort all the more important that the effort is prolonged, intensive and full bladder. This is the most common urinary incontinence. It occurs mainly in women. Its risk factors are known: gender, age, menopause, obesity, pregnancy, childbirth, prolapse, etc. In humans, this type of incontinence is very rare and occurs almost only after prostate surgery. Its diagnosis is clinical: visualization during a cough or abdominal thrust leakage of urine from the urethral meatus. The urinary incontinence mechanism effort based on a unique concept: failure of urethral sphincters to ensure their role in the effort.
This malfunction has multiple causes: sphincter deficiency, loss of reflex contraction of the striated urethral sphincter, urethral hypermobility, loss of urethral support mechanisms.
If urinary incontinence isolated effort in young women or perimenopausal, pelvic floor muscle training is the first line treatment. This is a pelvic floor muscle training with an average of 10 to 12 sessions, conducted by a midwife after childbirth or physiotherapist used to this type of treatment. This rehabilitation using mostly a vaginal probe, combining the techniques of awareness, electrical stimulation, biofeedback improves or cured 30% of women. This perineal rehabilitation should not be continued beyond 20 sessions if there is no efficiency. No further investigation is necessary before a pelvic floor muscle training for isolated SUI. If unsuccessful rehabilitation specialist advice should be taken that lead most often in cases of troublesome urinary incontinence surgery. In this context, additional tests are required: usually balance urodynamics, pelvic ultrasound, to find more cons-indications or elements of poorer prognosis of surgery than to ask the indication is clinical. The increasing number of surgical techniques and their “mini-invasive” nature induce greater ease of access to these techniques. However the best indication of surgical techniques such TVT [tension-free vaginal tape] or TOT [trans-obturator tape] remains isolated stress urinary incontinence. It is for patients with urinary incontinence secondary to sphincter incompetence, in case of failure of conventional surgery the artificial urinary sphincter can be offered.
OAB:
It is the present definition of a clinical symptom involving urinary frequency, urge incontinence, urgency, with or without leakage on uncontrollable pressing need. It can occur in women (mostly) in humans also. Its incidence increases with age.
His diagnosis is a diagnostic examination that covers the mechanisms and multiple etiologies. Indeed, this symptomatology
frequent, may be the only sign of infection
urinary, pathology of the lower urinary tract (prostate adenoma, bladder tumor, etc.), neurological disease (multiple sclerosis, Parkinson’s disease, etc.), to reflect the unit’s aging vésicosphinctérien or be a functional symptoms without defined etiology.
The mechanisms of overactive bladder are multiple: detrusor overactivity defined by the existence uninhibited detrusor contraction during the urodynamic assessment, hyperesthesia bladder, sphincter insufficiency, etc.
However, it may be only clinical symptom.
A minimum balance is required. It must include a urinalysis looking for a urinary tract infection. The neurological examination looks for signs for a debutante neurological disease, especially if there are associated anorectal disorders. A pelvic ultrasound and the slightest doubt a urinary tract endoscopy and finding abnormal cells must be requested.
The voiding diary is always performed to detect a rather frequent excessive diuresis in young women. The urodynamics can search detrusor overactivity challenge denies the existence of uninhibited detrusor contraction, bladder hyperesthesia, a compliance disorder. Sometimes no abnormality is found or only low urethral pressure.
Other types of incontinence:
Mixed incontinence combines both types defined above. It is a frequent association making it harder to support.
In part, but can take the mask of each of, these e incontinence, the chronic urinary retention must be considered systematically especially in the elderly.
Transient incontinence:
It is mainly observed in the elderly. The causes of transient incontinence is most often found in areas that are not directly on the lower urinary tract. Incontinence can be caused by an infection with a challenge cit autonomy or other elements. The causes of transient incontinence were identified by Resnick in 1984. Named in English “DIAPPERS” they include:
– Delirium;
– Symptomatic infections or lower urinary tract;
– Vaginal or urethral Atrophies;
– Psychological causes;
– Pharmacological causes (Box 2);
– Excess diuresis;
– Restrictions on mobility, constipation (S).
And urinary incontinence in the elderly is most often a multidisciplinary assessment that includes a geriatric assessment.
Pharmacological causes:
The different contested pharmacological classes are given in Box 2.
Box 2. Key pharmacological classes incriminated in the genesis of transient urinary incontinence
Anticholinergics (outside the treatment of bladder, antispasmodic, some antihistamines, antidepressants, anti-Parkinson): urinary retention, constipation, confusion, hypotension, etc.
Analgesics, opioids: constipation
Antihypertensive hypotension resulting in decreased mobility
Diuretics: urinary frequency, urgency
Calcium channel blockers: constipation, urinary retention
Angiotensin converting enzyme cough
Alpha: decreased urethral resistance (women)
Sedatives: excessive sleepiness
Other (alcohol, caffeine): urinary frequency, urgency
TREATMENT:
The management depends on the etiology.
Medical treatment:
If functional pathology, anticholinergics
remain the first line treatment. Three molecules are currently on sale in France: oxybutynin (Ditropan, Driptane®) the oldest, trospium chloride (Ceris®) and tolterodine (Detrusitol®). Only the first two are covered by the regime of Medicare.
The recommended dose of oxybutynin is 5 mg three times daily. In fact the 2.5 mg four times a day is often better tolerated.
The side effects of these treatments often lead to poor adherence. These side effects are multiple with the leading dry mouth and constipation.
Other side effects are less common: disturbance of accommodation, dysphagia.
Oxybutynin may induce delirium and is against-indicated in cases of intellectual deterioration. Its use should be cautious in the elderly because of the risk of urinary retention as anticholinergic.
Trospium chloride, newest administered at a dose of 20 mg 2 times per day. Its side effects are less pronounced particularly dry mouth. His brain penetration is low and it causes less delirium. Its use should therefore be preferred in the elderly. However, the risk of retention remains the same with oxybutynin.
Tolterodine is marketed as stamp 1 mg and 2 mg. The maximum dose used was 2 mg 2 times daily.
Anticholinergic therapies have proven their effectiveness in unquestionable way the hyperactivity of the detrusor particularly in neurological diseases. Their efficacy in functional overactive bladder symptom exists but remains modest.
Taking functional load:
Taking rehabilitative and behavioral management has its place in the functional management of this symptom. Indeed, understanding the mechanisms involved, triggering elements (cold, the sound of water, the fact of coming home: a sign of the key or the mat, etc.), helps to control symptoms . This support, more developed in the Anglo-Saxon countries has demonstrated its effectiveness. It requires a patient’s adherence to the care program and a self-rehabilitation. In case of failure of this type of treatment and mainly in case of detrusor overactivity (uninhibited detrusor contraction during cystometry), neuromodulation of the sacral roots can be offered with variable efficacy in different individuals. This neuromodulation is rarely tested in case OAB without detrusor overactivity.
In case of mixed incontinence, you have to specify the main discomfort of the patient: incontinence or urgency, search the largest assumed mechanism disorders. The management therefore depends on the prevailing disorder.
It is in any significant way to list all the symptoms and prevent the patient well as the management will usually only set one symptom. In case of urinary incontinence, treatment is usually surgical preventing the significant risk of persistent post-micturition urgency.
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