Urinary incontinence is the involuntary loss of urine. Some experts believe that incontinence is only present when the patient sees this as a problem. The disease is far too little attention and too little reported. Many patients do not tell their doctor about the problem, and many doctors do not ask explicitly for incontinence. Incontinence can occur at any age but is more common in older people, especially women, about 30% of which are affected, compared with 15% of older men.
(See also urinary incontinence in children and micturition at a glance.) Urinary incontinence is the involuntary loss of urine. Some experts believe that incontinence is only present when the patient sees this as a problem. The disease is far too little attention and too little reported. Many patients do not tell their doctor about the problem, and many doctors do not ask explicitly for incontinence. Incontinence can occur at any age but is more common in older people, especially women, about 30% of which are affected, compared with 15% of older men. Incontinence affects the quality of life considerably by creating a sense of shame, stigma, isolation and depression. Many older people are housed in nursing homes because their incontinence is a heavy burden on their caregivers. In bedridden patients exhausted and the urine macerated skin and promotes bedsore formation. Older people with urinary urgency have a greater fall and fracture risk. Forms incontinence can manifest itself as an almost permanent rain or intermittent urination with or without the feeling of water can be to have to. Some patients have an extreme urgency (irrepressible urge to urinate) with only a short or no warning and can not until a toilet suppress the urge to urinate (known. Urge incontinence). Incontinence can by movements that increase intra-abdominal pressure, arise or worsen. Dribbling is probably normal very frequently and in men. It is sometimes helpful to recognize the clinical pattern, but often, the causes also overlap and then a part of the treatment is the same. As urge incontinence uncontrolled loss of urine is called (from medium to large volume), which begins as soon as the urgent overwhelming need of urination occurs. Nocturia and nocturnal incontinence are common. Urge incontinence is the most common form of incontinence in the elderly, but can also occur in younger. It is often triggered by ingestion of diuretics and increases if a toilet can not be reached quickly enough. For women, wearing a atrophic vaginitis, which often occurs with aging, contribute to narrowing and irritation of the urethra and urinary urgency. Stress incontinence is characterized as a loss of urine due to abrupt increase in intra-abdominal pressure such. As when coughing, sneezing, laughing, bending or lifting. The lost amount of urine is usually small to medium in size. It is the most common type of incontinence in women, often as a result of complications in childbirth or as a result of atrophic urethritis. Men can stress incontinence after surgery such. B. develop a radical prostatectomy. Stress incontinence is typically more pronounced in obese people because of increased intra-abdominal pressure is transferred to the bladder dome. Overflow incontinence is characterized by continuously dripping from an overfull bladder. The dead volume is usually low, but it trickles continuously, resulting in a large total loss of urine. Overflow incontinence is the second most common form of incontinence in men. Functional incontinence is characterized by cognitive or physical disorders, such. As by dementia or stroke, or environmental conditions that interfere with control of urination. For example, the patient can not recognize the necessity of urination, can not know where the toilet is, or not be able to go to a remote toilet. Neural Pathways and Harntraktmechanismen that control continence may be unimpaired. Mixed incontinence is a combination of o. G. To form. Most combinations are urge and stress incontinence and urge incontinence or stress with functional incontinence. Etiology The disorders differ in different age groups. With the aging process bladder capacity decreases as well as the ability to suppress the urge to urinate. Arbitrary bladder contractions (detrusor muscle) are increasing, the bladder contractility is impaired. In this way, it becomes increasingly difficult to postpone urination, on the other hand, the micturition is incomplete. The residual urine volume increases, probably up to ? 100 ml (normal <50 mL). Endopelvic fascia is weaker; In postmenopausal women, estrogen levels decrease, resulting in atrophic urethritis, vaginitis athropischen and a decreased urethral resistance, shortening the urethra length and reduction in the maximum closure pressure. In men, the prostate size increases, blocked for. T. the urethra, resulting in incomplete bladder emptying and overstretching of the detrusor. These changes form from many healthy older men continents and can encourage incontinence. In younger patients, incontinence often begins suddenly with little loss of urine and usually forms under a slight or no therapy quickly returns. Often there is a single cause of incontinence in young people, older there are often several. A subdivision in reversible (temporary) or permanent causes can be useful. However, the causes and mechanisms often overlap and occur in combination. Temporary incontinence There are several causes of transient incontinence (see Table: Causes of temporary incontinence). A useful reminder for the many temporary causes is the so-called diappers rule (Editor's note .: in reference to the English word diaper = diaper...). Delirium, infection (usually symptomatic UTI), A trophic urethritis and vaginitis, drugs (such with alpha-adrenergic, cholinergic or anticholinergic properties, diuretics, sedatives), Mental disorders (esp. depression), excessive urine excretion (polyuria), reduced mobility and constipation. Causes of temporary incontinence cause comments Gastrointestinal disorders Stuhleinklemmungen The mechanism may involve mechanical disorders of the bladder or urethra. Patients usually to urge or overflow incontinence, typically of fecal incontinence. Urogenital diseases Atrophic Vaginitis Urethritis Atrophic narrowing of the urethral and vaginal epithelium and submucosa can cause local irritation and reduce urethral resistance, length and maximum closing pressure with the loss of mucosal seal. These disorders are usually characterized by urinary urgency and occasionally by "scalding dysuria". Urinary bladder irritation foreign body triggers spasms. HWI Only symptomatic UTI causing incontinence. Dysuria and urinary urgency may hinder the timely achievement of the toilet patients. Neuropsychiatric disorders delirium depression psychosis Awareness of the need or the ability of urination is impaired. Restriction of movement weakness injury using fixations access to the toilet is impaired. Systemic diseases Excessive urination due to various diseases (e.g., as diabetes insipidus, diabetes mellitus) Frequent urination, urinary urgency and nocturia may arise. Drug therapy Alcohol Alcohol has a diuretic effect and may cause sedation, delirium, or immobility, which can lead to functional incontinence. Caffeine (z. B. in coffee, tea, cola and some other soft drinks, cocoa, chocolate and energy drinks) The urine production and excretion are increased, resulting in polyuria, frequent urination, urinary urgency and nocturia. Alpha-adrenergic antagonists (eg. As alfuzosin, doxazosin, prazosin, tamsulosin, terazosin) The bladder neck muscles in women or the smooth muscle of the prostate in men is limp and sometimes causes stress incontinence. Anticholinergics (z. B. antihistamines, antipsychotics, benztropine, tricyclic antidepressants) The bladder contractility may be impaired, and sometimes causes urinary retention and overflow incontinence. These drugs can also lead to lead delirium, constipation and fecal impaction. Calcium channel blockers (e.g., diltiazem, nifedipine, verapamil) The detrusor contractility is reduced and sometimes causes urinary retention and overflow incontinence, nocturia by peripheral edema, constipation, and impaction. Diuretics (eg. As bumetanide, furosemide, [not thiazides]) The urine production and excretion are increased, resulting in polyuria, frequent urination, urinary urgency and nocturia. Hormone therapy (systemic estrogen / progestin therapy) The collagen in the para-urethral connective tissues is reduced, resulting in mock urethral closure. Misoprostol misoprostol relaxes the urethra and can therefore lead to stress incontinence. Opioids Opioids cause urinary retention, constipation, fecal impaction, sedation and delirium. Psychotropic drugs (eg. B. neuroleptics, benzodiazepines, sedative hypnotics, tricyclic antidepressants) The awareness of the need of urination is clouded and dexterity and mobility is reduced. These drugs can cause delirium. Permanent incontinence, permanent incontinence is caused by an ongoing problem that affects the nerves or muscles. The mechanisms that explain this problem are usually classified as Blasenauslassinkompetenz or -obstruktion, Detrusorüber- or Detrusorminderaktivität, sphincter detrusor dyssynergia or a combination thereof described (see Table: Causes of permanent incontinence). These mechanisms, however, are also involved in temporary reasons. Causes of permanent incontinence urodynamic diagnosis Neurological causes Nichtneuroligsche causes Blasenauslassinkompetenz lesion of the lower motor neuron (rare) In men, radical prostatectomy * Intrinsic sphincter deficiency hypermobility of the urethra in women multiple vaginal deliveries, pelvic surgery (eg. As hysterectomy), age-related changes (eg. B . atrophic urethritis) in men prostate surgery bladder outlet lesion of the spinal cord s causing bladder sphincter dyssynergia (rare) Anterior urethral stricture urethral diverticulum (rare) or large bladder diverticulum (very rare) bladder stones bladder neck suspension in women cystocele (if large) In men, benign prostatic hyperplasia and prostate cancer detrusor overactivity Alzheimer's disease spinal cord injury / dysfunction Multiple Sclerosis stroke bladder carcinoma cystitis Idiopathic outflow obstruction or incompetence Detrusorunteraktivität Autonomic neuropathy (eg. As a result of diabetes, alcoholism or vitamin B12 deficiency) herniated disc plexopathy spinal neural tube defect (rare, can overactivity cause) Surgical affections (. B. anteroposterior resection) tumor Chronic bladder outlet obstruction Idiopathic (common in women) bladder sphincter dyssynergia lesion spinal cord brain lesion affect pathways to the pontine micturition micturition disorder of childhood (poor relaxation of the sphincter with bladder contraction may be due to the fear of bed-wetting or soiling of the clothes) * Other surgery of Prostat a rarely result in permanent incontinence. The Auslassinkompetenz is a common cause of stress incontinence. In women, it is usually due to a weakness of the pelvic floor or endopelvic fascia. Such weakness usually results from multiple vaginal deliveries, pelvic surgery (incl. Hysterectomy), age-related changes (incl. Atrophic urethritis) or a combination of these changes. As a result, the vesicourethral connection, the bladder neck and the urethra decreases are hyper mobile, and the pressure in the urethra drops below the bladder. Common cause in men is damage to the sphincter or bladder neck and posterior urethral after radical prostatectomy. A common cause of incontinence in men is a bladder outlet obstruction, even though most men are not incontinent with obstruction. The obstruction in men is usually a benign prostatic hyperplasia, prostate cancer or urethral stricture due one. In men and women fecal impaction can cause an obstruction. In women, however, the obstruction may be the result of previous surgery for incontinence or cystocele, which leads to a kinking of the urethra during micturition. The obstruction leads to chronic over-stretching of the bladder and the loss of their ability to contract. As a result, the bladder may not empty completely, and it forms an overflow bladder. Constipation can also lead to detrusor overactivity and urge incontinence. If the detrusor muscle loses its ability to contract, an overflow incontinence may be the result. Some causes of bladder outlet obstruction (eg. As large bladder diverticulum, cystocele, bladder infections, stones and tumors) are reversible. Detrusor overactivity is a common cause of urge incontinence in elderly and young patients. The detrusor contracts for no apparent reason at intervals along, typically when the bladder is filled only partially or hardly. The detrusor overactivity may be idiopathic or result of a dysfunction in the frontal Miktionskontrollzentrum (typical age-related changes, dementia or stroke) or a consequence of outlet obstruction. A detrusor (hyperactivity) with impaired contractility represents a variant of urge incontinence, which marks urination, frequent urination, weak urinary stream, urinary retention, and residual urine are Blasenwandtrabekulierung> 50 ml. This variant can be a benign prostatic syndrome (BPS) or simulate a stress incontinence in women in men. A Detrusorminderaktivität caused urinary retention and overflow incontinence in about 5% of patients with incontinence. This can be caused injury to the spinal cord or nerve roots that supply the bladder (eg for herniated disk, tumor or after surgery.), A peripheral or autonomic neuropathy or other neurological disorders (see Table: Causes of permanent incontinence). These substances are often the cause temporary disturbances. Anticholinergics and opioids set the detrusor contractility greatly reduced. The detrusor may be less active with chronic bladder outlet obstruction in men because of the detrusor muscle is replaced by fibrosis and connective tissue, which can hinder urination despite elimination of the obstruction. In women Detrusorminderaktivität is usually idiopathic. A slightly smaller Detrusorminderfunktion is often found in older women. Such weakness does not cause incontinence, but can complicate treatment if added other causes of incontinence. Detrusor sphincter dyssynergia (loss of coordination between the bladder contraction and relaxation of the external sphincter) may cause an obstruction caused overflow incontinence. The dyssynergia is often the result of a spinal cord injury that disrupts the way to the pontine micturition center where Sphinkterrelaxation and bladder contraction are coordinated. Rather than relax in the bladder contraction, the sphincter also contracts and thus obstructed the bladder outlet. The dyssynergy causes severe trabecularization, diverticula, Christmas configuration of the bladder, hydronephrosis and renal failure. A functional disorder such as impaired cognition, decreased mobility, decreased manual dexterity, concurrent other disabilities and lack of motivation can contribute to incontinence, but they cause hardly alone especially in the elderly. Assessment Most patients spend shame about their incontinence do not volunteer information about it, even though they come perhaps to talk about relating to any symptoms (eg. As urinary frequency, nocturia, delayed Miktionsbeginn). All adults the question should therefore be asked: “Have you ever lost Urine?” Physicians should not assume that incontinence is irreversible, just because she is a long time. In addition, a urinary retention must be excluded before any treatment for detrusor overactivity is initiated. Tips and risks Most patients are embarrassed to mention incontinence, therefore all adults should be asked about it. History The history focuses on the duration and nature of urination, bowel function, medication, gynecological or pelvic surgery. A voiding diary can provide clues to causes. The patient or a caregiver holds about 48 to 72 h urine volume and micturition as firmly as any incontinence episode in certain activities (especially food, drink, medication) or in sleep. The amount of urine loss can be used as drops, low, medium or described dripping or h are estimated by means of pad test by weighing the trapped in the templates or incontinence pads urine for 24 hours. If the set of most nightly involuntary micturition significantly lower than the functional bladder capacity (defined as the largest single Miktionsmenge in voiding diary), then the cause of incontinence is more of a sleep-related problem (patients urinate because they are already awake) or an independent bladder disorder (patients without dysfunction of the bladder or sleep-related problem will only be awake to urinate when the bladder is full.). Of men with obstructive symptoms such as delayed Miktionsbeginn, weak urinary stream, Harnstottern, sensation of incomplete bladder emptying, a third to a detrusor overactivity without obstruction. Urination or a sudden stream of urine without warning or previous increase in intra-abdominal pressure (often called reflex or unconscious incontinence) typically indicates a detrusor overactivity. The term overactive bladder is sometimes used to describe urgency (with or without incontinence), which is often accompanied by frequent urination and nocturia, benutzt.Körperliche investigation are Central to neurological, pelvic and rectal exams. The neurological examination includes the collection of mental status, gait, function of the lower extremities. Attention is paid also for signs of peripheral or autonomic neuropathy, including orthostatic hypotension. Neck and upper extremities should be checked for signs of cervical spondylosis or stenosis. The spine should be examined for signs of previous surgeries and for deformation, dimples or hair anywhere that suggest a neural tube defect. has innervation of the external urethral sphincter, the common sacral nerve roots with the anal sphincter, can be checked by: Perineal reflexes Voluntary contraction of the anal sphincter (S2-S4) Analsphinkterreflex (S4-S5), initiates a Analsphinkterkontraktion with gentle tapping of the perineal skin of the Bulbocavernosusreflex (S2-S4), which causes, by pressing on the glans penis or clitoris a Analsphinkterkontraktion. However, the absence of these reflexes is not necessarily pathological. The pelvic examination in women can atrophic vaginitis or urethritis or urethral hypermobility and pelvic floor weakness arise with or without uterine prolapse. A pale, thin vaginal mucosa with loss of wrinkles indicates atrophic vaginitis. A urethral hypermobility can be detected when coughing by the posterior vaginal wall is stabilized with a speculum. A cystocele, enterocele, Rectozele or uterine prolapse speak (reductions of the pelvic organs) for a pelvic floor weakness. If the other side is stabilized with a speculum, a bulging of the front wall of the vagina displays a cystocele, while the bulging of the posterior vaginal wall demonstrates a rectocele or enterocele. A pelvic floor weakness is not the cause, unless there is a big Zystozelenprolaps proven. Rectal exam Kotverstopfungen can be found, rectal tumors and prostate in men, a node or cell carcinoma. The prostate size should be documented, but only weakly correlated with the outlet obstruction. Suprapubic palpation and percussion to determine the bubble size (except for acute urinary retention) of little significance. Stress urine test can be performed on the examination table when stress incontinence is suspected; this method has a sensitivity and specificity of> 90%. The bubble should be well filled. The patient lies or sits with her legs on the table, relaxes the perineal area and coughs once vigorously: Immediate loss of urine, beginning with the coughing and stops talking for stress incontinence. Delayed or persistent urinary leakage indicates a triggered by the cough detrusor overactivity. Incontinence that can be resolved in this manner should respond well to surgical correction. If cough triggers incontinence, the maneuver can be repeated by the examiner introduces one or two fingers into the vagina to lift the urethra (Marshall-Bonney test). The results may be false-positive when patients have to urinate a sudden urge during the investigation. The result of the test can be falsely negative if the patient does not really relaxed, the bubble is not sufficiently filled, the cough is not strong enough or a large cystocele present. In women with large cystocele the test while lying down and, where possible, should be repeated by pushing away the cystocele tests urinalysis and urine culture serum urea, creatinine residual urine volume Sometimes urodynamic studies are required urinalysis, urine culture and the determination of urea and serum creatinine. Other tests include the measurement of blood sugar and calcium (with albumin for the determination of protein-free calcium levels), provided that the voiding diary suggesting polyuria, and the electrolytes (if confused patients) and vitamin B12 levels if the clinical findings neuropathy suggest. The residual urine should be determined by catheter or ultrasound. Residual urine and Gesamtmiktionsvolumen suggest bladder capacity and help to examine the bladder filling sensation. A residual urine volume <50 ml is considered normal, <100 ml are for patients> 65 years may be acceptable, but not for younger patients. A residual urine> 100 ml indicates a Detrusorminderaktivität or outlet obstruction. Urodynamic studies are appropriate when the clinical examination did not lead or with the appropriate tests to diagnose if the anomalies must be accurately determined prior to surgery. A cystometry can help urge incontinence to diagnose, but sensitivity and specificity are unknown. Sterile water is introduced into the bladder in 50 ml increments with a 50 ml syringe and a 12 – to 14-F urethral catheter introduced to the patient feels urgency or bladder contractions that are detected by changes in the fluid level in the syringe. If <300 ml cause urinary urgency or contractions, detrusor overactivity and urge incontinence are likely. In men, for the detection or exclusion of bladder outlet Harnflussmessungen be performed. Although the results depend on the filling volume, but a peak flow rate of <12 ml / s with a voided volume of ? 200 ml and prolonged micturition speak for outlet obstruction or Detrusorminderaktivität. A rate of ? 12 ml / s excludes obstruction and may indicate a detrusor overactivity. In the investigation - especially if stress incontinence suspected and surgery is being considered - the patient is instructed to place his hand while urinating on the lower abdomen to check for a liability. If a load, then this indicates a Detrusorschwäche that may predispose patients to a postoperative retention. Provocation tests (with bethanechol or ice) are used to provoke bladder contractions. In the Cystomanometry pressure volume curves and bladder contractions are recorded while the bladder is filled with sterile water. Electromyography of the perineal muscles used to examine the pelvic floor function. Urethral, ??rectal and abdominal pressure can be measured simultaneously. Video studies of the pressure flow, usually in connection with the Miktionszysturethrographie, bladder contraction, bladder neck activity and detrusor sphincter synergy can simultaneously record. However, the devices for this study are not available everywhere. Therapy Bladder training Kegel exercises Drug therapy Specific causes are treated accordingly. Drugs that can cause incontinence or deteriorate be discontinued or the dosage regimen changed (z. B. diuretics are metered such that a toilet at the onset of action is easily accessible). Other forms of treatment must be adapted to the type of incontinence. Regardless of the type and cause of incontinence some general measures are helpful. General measures Patients will be asked to reduce their fluid intake at specific times (eg. As before leaving the apartment or 3-4 hours before bedtime) to avoid fluids that may irritate the bladder (z. B. caffeinated drinks ), and drink day as concentrated urine can irritate the bladder more than 1500-2000 ml /. Some patients, especially those with reduced mobility or cognitive impairment, profit from portable urine bags. Others benefit from absorbing templates or specially padded underwear. These products can significantly improve the quality of life of patients and their caregivers. On the other hand, they should not replace the measures to control or eliminate incontinence. Moreover, these products must o