Incontinence of Urine in Women-Urinary control depends on two major factors first, the presence of competent sphincter mechanism able to resist sudden increase in intraabdominal pressure and secondly, the capacity to inhibit a bladder contraction until it is crucial to recognize which factor is impaired, for the treatment of sphincter weakness is mainly surgical.
Sphincter weakness with the symptom of stress incontinence commonly occurs for the first time in pregnancy, probably due to weight gain, increasing þe forces opening the sphincter or atrophic changes of the menopause which awaken it.
Anterior vaginal prolapse is a further weakening factor but it is not the prime cause for many patients suffer after stress incontinence due to an incompetent sphincter and has no prolapse whilst others have a prolapse and yet possess good control;
Incontinence due to failure to inhibit a bladder contraction
This is much more common than generally realized, and its occurrence only when a patient cannot find a lavatory will make most doctors suspect an uninhibited contraction. This symptom of stress incontinence, that is incontinence after an acute rise in intra-abdominal pressure which is usually considered to be a weak sphincter.
However, it may be due to a failure to inhibit. In such women coughing triggers, a bladder contraction and the leak of urine is due to contraction and not urine escaping from a mechanically weak sphincter.
Incontinence can also occur if intrinsic inhibition is impaired, as in old age, emotional stress or neurological disease or if the stimulus to micturition is increased, usually by inflammatory or an infective lesion in the bladder or urethra commonly incontinence is due to a combination of both an increased stimulus and impaired inhibition.
This is relatively uncommon and is due to neurological disease, pelvic tumor or urethral stenosis.
Making a diagnosis Incontinence of Urine in Women
it is very essential to take a careful history and listen to what the patient says, for this alone often gives the diagnosis. The objective of the history taking is to find out the circumstances under which urine is lost and to gain an impression of bladder behavior.
Patients with stress incontinence due to sphincter weakness have no reason to have disturbed bladder function, should have no frequency and be able to restrain the desire to micturate for at least half an hour. Exceptions are those women with cystourethrocele. and sphincter weakness who may have a daytime frequency.
The aim is to access sphincter competence and to look for prolapse. The power of thē forces opening the sphincter is dependent on the forces generated by a cough and degree of obesity. Sphincter competence is best estimated by asking the patient to cough forcefully while separating the labia and watching the urethral meatus. A short spot of urine allows the diagnosis of a sphincter weakness to be made with confidence.
If sphincter weakness is suspected but cannot be demonstrated repeat the exercises while the patient is erect. Meanwhile, in all patients try to demonstrate prolapse. This is best done by passing a sims speculum and asking the patient to bear down.
Failure to respond to antibiotics therapy and relapse after response to treatment are indications for urinary tract evaluation. The majority will not have a serious disease and the doctor will then have the problems of looking after a patient with chronic inflammatory bladder disease.
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