QuestionSBA
QuestionChoice
This is an anti-muscarinic agent which is used in the treatment of urge incontinence or overactive bladder.
62116
d
Tolterodine
QuestionChoice
This is an analogue of ADH (vasopressin) used to treat nocturia. It acts on the V2 receptors in the renal collecting ducts to cause re-absorption of water into the blood via aquaporin channels. This leads to reduced urine production.
62117
e
Desmopressin
QuestionChoice
This is an anti-muscarinic agent which is used in the treatment of urge incontinence or overactive bladder.
62115
c
Oxybutynyn
QuestionChoice
This is a sympathomimetic beta-3 adrenergic receptor agonist which relaxes the smooth muscle of the bladder. It is used to treat overactive bladder and urge incontinence.
62114
b
Mirabegron
QuestionChoice
Correct. Duloxetine is a serotonin and noradrenaline re-uptake inhibitor. Its central nervous system effects lead to increased tone of the  external urinary sphincter, thereby acting to reduce stress incontinence.
62113
a
Duloxetine
Concept
Chapter
# Summary

Urinary incontinence refers to the involuntary loss of urine and can be categorised into stress, urge, overflow, functional, and mixed types. Key signs and symptoms vary, ranging from involuntary urine leakage when intra-abdominal pressure is raised in stress incontinence, to an abrupt and uncontrollable urge to urinate in urge incontinence. Essential investigations encompass physical examination, questionnaires, bladder diaries, urinalysis, and occasionally cystometry or cystograms. Management strategies depend on the type and severity of incontinence, encompassing conservative methods (like lifestyle modifications), medical treatment (such as Duloxetine, anticholinergics), and surgical options (for example, incontinence pessaries, mid-urethral slings). Generally, stress incontinence is managed with pelvic floor exercises, whereas urge incontinence is initially managed with bladder re-training exercises.

# Types 

Urinary incontinence can be categorised into:

1. Stress incontinence
2. Urge incontinence
3. Overflow incontinence
3. Functional incontinence
4. Mixed incontinence 

Reversible causes of urinary incontinence can be remembered using the mneumonic **'DIAPPERS':**

D - Delirium

I - Infection

A - Atrophic vaginitis or urethritis

P - Pharmaceutical (medications)

P - Psychiatric disorders

E - Endocrine disorders (e.g. diabetes)

R - Restricted mobility

S - Stool impaction


# Approach to Incontinence

One of the keys is to rule out reversible causes and then try to work out which type of urinary incontinence is. A framework or approach to this is below:

- Physical examination

  - An examination will identify features of pelvic organ prolapse as well as the ability to contract pelvic floor muscles.

- Questionnaires

  - These are recommended in order to quantify the symptoms and assess the severity on patients quality of life which may help when deciding if a patient would benefit from more invasive treatment

- Bladder diary

  - These are also useful for quantifying symptoms and documenting the number and type of episodes of incontinence. They may potentially show a relationship between causes and symptoms.

- Urinalysis

  - This will help to rule out infection as an acute cause

- Cystometry

  - This is an investigation which measures bladder pressure whilst voiding. It is not recommended in patients with clear histories where the diagnosis is clear.

- Cystogram

  - If a fistula is suspected, contrast is instilled into the bladder and a radiological image is obtained in order to see if the contrast travels anywhere else.


# Stress incontinence

This involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence.

## Risk factors 

- Childbirth (especially vaginal).This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor.
- Hysterectomy


## Triggers

Acts such as coughing, laughing, sneezing or exercising can increase abdominal pressure sufficiently.

## Causes

Any abnormality in the anatomy of the bladder, sphincters and urethra can result in stress incontinence.


## Conservative management

General lifestyle advice such as avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake, can go far in helping incontinence.

Pelvic floor exercises when done with good technique and consistently strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment.

## Medical management

Duloxetine can help with stress incontinence, but it's only recommended if conservative measures fail and the patient is not a surgical candidate.

## Surgical management 

- Incontinence pessaries are placed transvaginally and apply pressure to the anterior vaginal wall. This helps to support the urethra and sphincters. However, the evidence for them is poor in individuals without prolapse and isn't recommended by NICE. It would be worth trying if there was a clinical prolapse.
- Bulking agents are injectable materials placed at the bladder neck to improve continence. This procedure is typically reserved for patients who are poor surgical candidates and isn't as efficacious as other methods
- Colposuspension and fascial slings involve suspending the anterior vaginal wall to the iliopectineal ligament of Cooper.
- Mid-urethral slings are the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in the closure of the urethra during increased intra-abdominal pressures. It's minimally invasive and can be performed in the outpatient setting.


# Urge incontinence

## Definition 

This involves the sudden and involuntary loss of urine associated with urgency.

## Risk factors 

Risk factors for urgency include:

- Recurrent urinary tract infections
- High BMI
- Advancing age
- Smoking
- Caffeine


## Conservative management 

General lifestyle advice such as avoiding caffeine, fizzy and sugary drinks as well as avoiding excessive fluid intake can go far in helping incontinence. Chemicals contained in these drinks can irritate the bladder, contributing to urge symptoms.

Pelvic floor exercises when done with good technique and consistently, strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment. In urge incontinence, contraction of the pelvic floor relaxes the detrusor. Bladder training is also helpful.

## Medical/surgical management

- Pharmacological management
	- Anticholinergic medications can help reduce the symptoms of urge and overactive bladder by inhibiting the parasympathetic action on the detrusor muscle.
		- Examples include: **Oxybutynin, Tolterodine, Fesoterodine, Solifenacin**. If one agent has limited impact, it can be combined with another. Use with caution in elderly however due to increased risk of delirium (side-effect).
	- Mirabegron (beta-3 receptor agonist) can be used in older people, but should be used with caution in patients with hypertension.

- Bladder instillation

  - Intravesical injection of Botox can be used to paralyse the detrusor muscle and reduce the symptoms of urge and overactive bladder.

- Sacral neuromodulation

  - Sacral nerve stimulation has been shown to control symptoms of an overactive bladder. This is only done in tertiary centres for patient who have failed or are unsuitable for all other treatments.


# Functional incontinence

## Definition 

This involves an individual having the urge to pass urine, but for whatever reason they're unable to access the necessary facilities and as a result are incontinent.

## Causes 

Functional incontinence associated with:

- Sedating medications
- Alcohol
- Dementias

# Overflow incontinence

## Definition 

This occurs when small amounts of urine leak without warning. When the pressure within the bladder overcomes the pressures of the outlet structures urine leaks.

## Causes 

This occurs either due to underactivity of the detrusor muscle such as from neurological damage, or if the urinary outlet pressures are too high, as in constipation or prostatism.



# NICE Guidelines

[NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management](https://www.nice.org.uk/guidance/ng123)
766
3501
Types of urinary incontinence
Topic
60
General Practice
Condition
697
Urinary incontinence
UkmlaTopic
12
General practice and primary healthcare
Condition
698
Urinary incontinence
UkmlaTopic
14
Medicine of older adult
Condition
699
Urinary incontinence
UkmlaTopic
18
Obstetrics and gynaecology
Condition
700
Urinary incontinence
UkmlaTopic
22
Renal and urology
12484
Presentation
564
Urinary symptoms
UkmlaTopic
10
Endocrine and metabolic
Presentation
565
Urinary symptoms
UkmlaTopic
12
General practice and primary healthcare
Presentation
566
Urinary symptoms
UkmlaTopic
13
Infection
Presentation
567
Urinary symptoms
UkmlaTopic
14
Medicine of older adult
Presentation
568
Urinary symptoms
UkmlaTopic
17
Neurosciences
Presentation
569
Urinary symptoms
UkmlaTopic
18
Obstetrics and gynaecology
Presentation
570
Urinary symptoms
UkmlaTopic
22
Renal and urology
Presentation
571
Urinary symptoms
UkmlaTopic
25
Surgery
A 67 year old female with pure stress urinary incontinence has gained no benefit from conservative management of this condition. She does not want any form of surgical management.

Assuming there are no contra-indications, which of the following pharmacological agent may be offered?
a