Female urinary incontinence: A review

SA Fam Pract 2007;49(6): 34-39 CPD Article Urinary incontinence affects approximately a quarter of a billion people worldwide. It is associated with high economic costs, psychological morbidity and adverse effects on the quality of life. Despite this, few women seek help for this condition either due to embarrassment and unwillingness to discuss the symptom with their family member or friend or, acceptance of the disorder as a natural part of aging or being unaware that treatment exists. More resources are utilised in maintaining patients with chronic incontinence rather than for diagnosis and treatment of the condition. Urinary incontinence is a complex problem resulting from many different causes and for which many different approaches to treatment exist. The commonest types of incontinence include stress urinary incontinence, urge urinary incontinence and mixed incontinence. Recently, better understanding of the pathophysiology of urinary incontinence has led to the development of numerous nonpharmacological, pharmacological and surgical interventions. Introduction According to the World Health Organisation, urinary incontinence is “a widespread global disease and one of the last medical taboos for many people”.2 In South Africa, urinary incontinence and pelvic floor dysfunction are major health problems. Urinary incontinence affects all ages, both sexes, and all social classes. Its prevalence is underestimated and it is estimated that only one in four symptomatic women will seek help for this problem.3 The annual direct cost in all ages for incontinence is estimated to be over16 billion US dollars (in 1995 dollars), which is more than that of breast, cervical, ovarian and uterine cancers combined.4,5 In 2002, the Standardisation Subcommittee of the International Continence Society (ICS) changed the original ICS definition of incontinence, from ‘urinary incontinence is the involuntary loss of urine that is a social or hygienic problem,’ since it relates the complaint to the quality of life, to ‘urinary incontinence is the complaint of any involuntary loss of urine’.6 Standardisation thus facilitates comparison of results and effective communication between clinicians. Types of Urinary Incontinence There are three main types of urinary incontinence (UI), stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence. According to the ICS, the definitions are as follows: • Stress UI is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. • Urge UI is the complaint of involuntary leakage accompanied by or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to defer). • Mixed UI is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing. Stress UI (SUI) is a very common condition affecting approximately half of incontinent women between 18 and 90 years of age. In stress UI there are two main mechanisms for urinary leakage: • Insufficient urethral support from the endopelvic fascia and muscles. Periods of increased intra-abdominal pressure causes descent of the urethra-vesical junction. Increased urethral mobility forces urine from the bladder into the urethra • Intrinsic sphincter deficiency (ISD) occurs when there is failure of the urethral sphincter due to mucosal and muscular atrophy and denervation, occurring alone or in combination with inadequate urethral support. It is commonly due to aging, neurologic disorders, obstetric/surgical trauma and lack of estrogen. Urge incontinence, together with other symptoms such as urgency, frequency, and nocturia forms part of the overactive bladder (OAB) symptom syndrome. Urgency is the ‘driving’ symptom in OAB, with the patient experiencing urgency at URGENCY NOCTURIA INCREASED FRQUENCY IN INCONTINENCE AND REDUCED INTERVOID INTERVAL REDUCED VOLUME VOIDED PER MICTURITION Figure 1: Urgency drives the other symptoms of the overactive bladder syndrome. Adapted from Chapple, et al. The role of urinary urgency and its measurement in the overactive bladder symptom syndrome: current concepts and future prospects. BJU Int 2005; 95: 335-340.7