Dr Alex Carachi

The incidence of urinary incontinence (UI) is on the increase worldwide, prevailing mostly among women (25-45%) but also affecting men (1-9%). Over the past years awareness on this condition has been on the rise and more patients have been willing to disclose their complaints and seek medical advice in order to combat, more effectively, a disorder which causes significant morbidity, both physically and psychologically. Multiple studies have shown that quality of life is poorer in patients suffering from UI and in some, it may be a marker of poor health status, especially in the elderly population.

The aetiologies of UI are multiple and can be transient or long-standing. The incidence increases with age, parity, history of pelvic surgery, smoking, increased BMI, menopause, diabetes mellitus, caffeine/alcohol intake, as well as cognitive and functional impairment. Initial investigations aim at identifying causes for lower urinary tract symptoms (LUTS) – which include UI symptoms namely stress UI; urgency UI; mixed UI; nocturnal enuresis; postural incontinence; continuous, insensible and coital incontinence   – and other conditions affecting the bladder and urethra.

A thorough history is taken in order to evaluate and identify the source of the client’s complaint followed by a physical examination of the cardiorespiratory, neurological and gastrointestinal systems. In women a pelvic examination is performed to rule out organ prolapse or lower tract pathology and in males a digital rectal examination, in order to rule out prostate pathology. The patient is assessed for storage and voiding symptoms and any suspicious signs, such as haematuria, bacteriuria and dysuria are addressed with appropriate investigations including urine microscopy, sensitivity and cytology, imaging and endoscopy accordingly.

Most patients suffering from UI are treated according to their symptoms, history and clinical examination – after any other possible pathology has been ruled out. These treatments mainly include behavioural therapy such as bladder training and pelvic floor physiotherapy, anti-muscarinics and other pharmacological treatments including alpha-blockers and 5-alpha-reductase-inhibitors. However, cases can be more complex and the latter investigations and treatments might prove insufficient.

The International Continence Society (ICS) suggests further assessment through internationally validated tools, including bladder diaries and questionnaires which aid in assessing more closely the clients’ symptom frequency and severity, also providing a baseline for evaluating the condition after treatment. Some of these tools assist the clinician in evaluating the impact of the patients’ complaints on the quality of life, sexual and social function. Furthermore, these questionnaires, help the clinician better identify the possible need for more specific investigations, such as Urodynamics.

Urodynamics incorporates a set of tests which are carried out as an adjunct to clinical diagnosis in order to support the latter with objective measurements that can be reproduced and quantifiable. One of the main aims of urodynamics is that of identifying and measuring the complaints of the patients and thus providing a pathophysiological rationale for their symptoms, whilst corroborating them with the urodynamic findings.

Complex cases which fail to be resolved with non-invasive measures require further investigations. The latter are also indicated in those patients which have already undergone previous surgery, especially if related to their symptoms and even in those patients, for whom surgery might be potentially complicated. In the past, procedures done for LUTS/UI were mainly based on LUTS, however, over the last decades, the use of Urodynamics has showed that most of the symptoms were of poor diagnostic value and at times, the surgery yielded no clinical benefit.

Urodynamic studies encompass an array of tests that vary in complexity. Uroflowmetry together with voiding assessment can be used in conjunction with ultrasonography. This is a non-invasive test that can help identify a voiding pathology and can also be used as a follow-up to assess response to treatment or to plan for possible more invasive treatment options.

Pressure studies, which include cystometry, provide information on the patient’s bladder filling function. It is another test which is used to assess storage symptoms in various types of UI whilst aiding to distinguish the latter from overactive bladder (OAB) symptoms. In conjunction with flow studies, these tests help to distinguish between intrinsic bladder pathologies such as underactive detrusor (UD) muscle or bladder outlet obstruction (BOO). Thus, these tests reproduce and record the coordination between the urinary bladder detrusor muscle and the urethra or pelvic floor during the voiding phase. Furthermore, if there is the need to assess the anatomy together with the function of the lower urinary tract, video-urodynamics can be utilized for such an assessment.

Other possible tests which can be offered at Urodynamics are Electromyography (EMG) studies, which reflect the external urethral sphincter, the peri-urethral striated musculature, the anal sphincter and the striated pelvic floor muscles. Lastly, urethral pressures can also be evaluated, an investigation which is selectively used in neuro-urological cases.

Nowadays, with the aid of novel investigations and a better understanding of the functional physiology of the lower urinary tract, UI can be better understood and better treated. The urinary bladder, which was once considered as an “unreliable witness”, has become, with the aid of medical advances, a precious ally.

 

Bibliography

Abrams P, Cardozo L, Khoury S, Wein A (eds). Incontinence. 5th ed. . Proceedings of the 5th International Consultation in Incontinence, Paris 2012. 2013.

Abrams P. Urodynamics. 3rd ed.  Springer London Ltd. 2006.

EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3.

G.H. Badlani, Davila GW, Michel MC, Rosette JJ (eds). . Continence – Current

Concepts and Treatment Strategies. Springer-Verlag London Ltd. 2009.

The International Consultation on Incontinence Questionnaire. Available from: https://iciq.net/