Urinary loss due to abnormal anatomic variations is uncommon but extremely important to consider in the evaluation of the incontinent woman. Bypass incontinence may often mimic other forms of urinary incontinence but usually presents as constant dribbling or dampness. Patients may complain of positional loss of urine without urge or forewarning. Diagnosing this type of incontinence requires a high level of suspicion and an understanding of the underlying anatomic deviation in the lower urinary tract. Genitourinary fistulas (vesicovaginal or ureterovaginal) can be a debilitating cause of incontinence and are formed because of poor wound healing after a traumatic insult (eg, obstetric laceration, pelvic surgery, perineal trauma, or radiation exposure).
Leakage due to fistulas is generally continuous, although it may be elicited by position change or stress-inducing activities. Evaluation should include a careful examination of the vaginal walls for fistulas. This can be facilitated by filling the bladder with milk or dilute indigo carmine dye and looking for pooling in the vaginal canal. Pad testing can be performed by having the patient ingest 200 mg of oral phenazopyridine hydrochloride (Pyridium) several hours before a subsequent examination. By placing a tampon in the vagina and on the perineum, the diagnosis may be confirmed by inspection of the pads after a period of time. Further imaging (intravenous urography) and cystoscopy can identify the exact location of the aberrant communication. If diagnosis is made early, the fistulous tract may heal with prolonged catheterization. However, if this procedure is unsuccessful or if diagnosis is made late, surgical correction is generally the only hope for cure.
Another important but uncommon cause of involuntary urine loss is urethral diverticula. Diverticula are essentially weaknesses or "hernias" in the supportive fascial layer of the bladder or urethra. Urethral diverticulum is most likely to cause symptoms of urinary loss. It has an incidence of 0.3-3% in women and is thought to be largely an acquired condition resulting from obstruction and expansion of the paraurethral Skene's glands. The symptoms of constant small amounts of leakage or urethral discharge are often described. A suburethral mass is visible and palpable on physical examination. Urine or discharge may often be "milked" by palpation of the suburethral mass. Treatment is usually surgical excision of the diverticulum.
A urethral diverticulum is a localized outpouching of the urethral mucosa into the surrounding non-urothelial tissues. This is an uncommon condition that is found mainly in adult women. The possibility of this diagnosis is often overlooked, even in women with presenting symptoms or findings (eg, urinary incontinence, dysuria, dyspareunia, vaginal mass). Delayed or missed diagnosis of this condition can lead to chronic morbidity including urethral calculus formation, chronic or recurrent urinary tract infections (UTIs) or, rarely, malignant transformation.
The epidemiology, diagnosis, evaluation, and treatment of urethral diverticula in women are reviewed here. Diagnosis and management of other etiologies of urinary incontinence or dyspareunia are discussed separately.
The true prevalence of urethral diverticula is difficult to estimate, given the difficulty of accurate and timely diagnosis. The reported prevalence of urethral diverticula in adult females from studies of autopsy specimens or urethrography series ranges from 1 to 5 percent. A population-based study estimated the incidence to be less than 20 per 1,000,000 (<0.02 percent) per year. Urethral diverticula have rarely been reported in men or in children.
Urethral diverticula typically present between the ages of 20 and 60 years.
Risk factors for a urethral diverticulum include female gender, pelvic trauma, and periurethral procedures, but there are no data to quantify these risks. It appears that black women are three-fold more likely than white women to have a urethral diverticulum, based upon data from hospital admissions and surgical procedures related to this diagnosis.
The International Continence Society (ICS) defines SUI as the complaint of involuntary leakage on effort or exertion, or on coughing or sneezing ...
Functional and transient incontinence
"Functional Incontinence" refers to loss of urine that occurs in residents whose urinary tract function is sufficiently intact that they should be able to maintain continence, but who cannot remain continent because of external factors (e.g., inability to utilize the toilet facilities in time)
Any mental and/or physical impediment that delays getting to and/or using the toilet when necessary.
- Delirium, dementia
- Pharmaceuticals: tricylic antidepressants, alcohol, sedatives, hypnotics, anticholinergics, polypharmacy, etc.
- Psychological disorders: stress, anxiety, depression, etc.
- Excessive urine output: (e.g. heart failure or hyperglycemia)
- Restricted mobility: pain, poor dexterity, poor vision, arthritis, Parkinson's disease, multiple sclerosis, deconditioning, obesity, clothing design, toilet access, lighting, etc.
- Urinary Incontinence
- Urinary Incontinence - Overview
L Patient Questionnaires
L Voiding Diary
L Physical Examination
L Cotton Swab Test
L Urinary Cough Stress Test
L Neurologic Examination
L Imaging Tests
- Stress Urinary Incontinence
- Urge Urinary Incontinence
- Mixed Incontinence
- Overflow Incontinence
- Bypass Incontinence
- Functional and transient incontinence
Management of Functional Incontinence
- Raised toilet seats and grab bars to enable an older person with proximal muscle weakness to sit on and stand from the toilet seat;
- Night lights;
- Bedside commodes and/or urinals;
- Wheelchair accessible bathrooms;
- Changes in clothing to eliminate the need for buttons or zippers may help as well, especially for those with urgency;
- Other possible environmental changes include walking aids such as walkers, canes, and gait training to improve mobility;
- Catheters, diapers, pads, and other collecting devices may be used if there is no alternative and behavioral treatment is not possible or not effective.
- Habit training
- Prompted voiding
- Regular toileting
- There is no specific medical treatment for functional incontinence.
- Treat contributing factors as for urge incontinence. Treating urinary tract infections and making dietary changes may be useful. In addition, treating arthritis, neurological disorders, depression, and visual deficits may be useful. Medications that could be contributing, especially psychoactive drugs, should be withdrawn.
Surgical Management - There is no specific surgical treatment for functional incontinence.
Incontinence may be caused by factors outside the lower urinary tract and is particularly significant in the geriatric population, because often a multitude of special circumstances affect the health of the elderly. Physical impairment, cognitive function, medication, systemic illness, and bowel function are all factors that may contribute to incontinence. Many immobile patients are incontinent because of the inability to toilet. Cognitive disturbances limit a patient's ability to respond normally to the sensation to void. Numerous medications have effects on the bladder that may reduce capacity, inhibit bladder function, increase diuresis and bladder load, or relax the urinary sphincter. Additionally, stool impaction and constipation both have been associated with increased prevalence of urinary incontinence. Treatments should first identify the etiologic factors of the incontinence and then reduce or remove the cause.