Urinary incontinence

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Classification according to ICD-10
R32 Urinary incontinence, unspecified
N39.3 Stress incontinence
N39.4 Other specified urinary incontinence
ICD-10 online (WHO version 2019)

Urinary incontinence ( Latin incontinentia urinae ), better known as bladder weakness , describes the loss or failure to learn the ability to store urine in the bladder without loss and to determine the time and place of emptying. According to the definition of the professional associations, incontinence is officially already present from one drop of urine loss.

Forms of urinary incontinence

The most common forms are urge incontinence ( ICD-10 : N39.4), stress or exertional incontinence (ICD-10: N39.3) and overflow incontinence ( ICD-10 : N39.4).

Urge incontinence

It is characterized by such a sudden strong urge to urinate that it is often impossible to reach the toilet before an involuntary loss of urine occurs. Reasons are, for example, contractions of the voiding muscles , often caused by local inflammatory processes (e.g. bladder infections), obesity , diabetes mellitus or damage to the nerves that control these muscles, such as in Alzheimer's disease , multiple sclerosis , Parkinson's -Sickness or after a stroke .

A distinction is made between the motor urge incontinence associated with involuntary detrusor contraction (contractions of the bladder emptying muscles) and sensory urge incontinence without detrusor contraction.

Stress incontinence (stress incontinence)

In the case of stress incontinence, the increased internal abdominal pressure caused by stress, straining for a wide variety of reasons (lifting, carrying, climbing stairs, laughing, coughing, sneezing, escape of intestinal gases) triggers the more or less pronounced involuntary leakage of urine.

There are three degrees of severity according to Stamey:

1st degree: incontinence when coughing, sneezing, laughing
2nd degree: incontinence with abrupt body movements, when standing up, sitting down, lifting heavy objects
3rd degree: incontinence with effortless movements, lying down, complete emptying during sleep

In women, stress incontinence is often the result of multiple births, which lead to overstretching and slackening of the straps and the pelvic floor . This results in a descent of the organs of the small pelvis. In this case, an increased internal abdominal pressure still acts in full force on the urinary bladder, but at the same time can no longer reach the urethra and no longer support its closure pressure ( vaginal balls ). In men, on the other hand, this form of incontinence is usually the result of traumatic damage to the external bladder sphincter due to operations (e.g. radical prostatectomy ) or accidents.

In mild cases of female stress incontinence, conservative treatment options are in the foreground. The antidepressant duloxetine , for example, is suitable for this . In more severe cases, a number of surgical methods are available. The first stress incontinence operations were published in 1878. In 1912 Howard Atwood Kelly carried out a transverse gathering of the bladder neck. Today, a minimally invasive procedure, the TVT operation ( tension-free vaginal tape ) is primarily performed. Success rates of around 74 percent were observed in a 6-year study. In 1.6% of women, the ligament had to be removed after the procedure due to complications. In around 5% of the women, a micturition disorder remained despite the operation. A Dutch study compared DVT surgery with physiotherapy (with pelvic floor training ), the conservative treatment option. DVT surgery is superior to physiotherapy in this regard, and women are also more satisfied. Only about one in 10 women suffered minor surgical complications such as bruising or urge incontinence.

Minimally invasive interventions on the sphincter muscle can be attempted in men. In therapy-resistant cases, an artificial sphincter can be implanted, in which an inflatable cuff placed around the urethra is filled or emptied by means of a pump system . Injecting the urethra with hyaluronic acid leads to an improvement in about half of the patients within the first year, but the long-term success of this treatment is low and the complication rate is high. The use of mechanical aids, such as penis band / straps or occluder devices for incontinence , which are attached to the penis shaft and exert pressure on the urethra and thus prevent the unwanted loss of urine, is an effective therapy for urinary incontinence.

Mixed incontinence

Urge and stress incontinence are combined here.

Overflow incontinence

Overflow incontinence (also: incontinence with chronic retention , Ischuria paradoxa or Incontinentia paradoxa ) is caused by a constantly overflowing urinary bladder as a result of drainage disorders . Since the internal pressure finally exceeds the obstructive closure pressure , there is constant dripping of urine ( overflow bladder ).

The cause of overflow incontinence is usually a benign prostate enlargement , less often severe urethral strictures . Can addition of neurological diseases with a relaxation of the detrusor , such as those in a diabetic polyneuropathy or as a result of a lower motor neuron - lesion ( LMNL , Engl. Abbreviation for. Lower motor neuron lesion ; s also section ". Reflex incontinence «) Can occur, lead to an overflow bubble.
This often leads to a backlog of urine in the ureters and kidneys , which carries the risk of increasing renal insufficiency and even uremia .

The therapy consists, if possible, of eliminating the cause (prostate, urethra (see above)); in the event of irreversible changes in the use of permanent catheters or intermittent self-catheterization .

Reflex incontinence

Reflex incontinence arises from a disruption or destruction of the inhibitory pathways emanating from the brain and thus to a predominance of the activity impulses of the reflex arc between the urinary bladder and the bladder center in the cross part of the spinal cord (S2–4). These lead to reflex-like detrusor contractions with leakage of urine. Another problem is the lack of coordination of the muscles involved, which often leads to incomplete emptying with residual urine ( detrusor-sphincter dyssynergy ).

Such a condition occurs, for example, after a paraplegia above the bladder center (UMNL, upper motor neuron lesion ). Degenerative changes in the central nervous system, for example in people with multiple sclerosis, can have the same effect. In the LMNL ( lower motor neuron lesion ), on the other hand, a flaccid, completely denervated bladder with overflow incontinence occurs.

The therapy is preferably medicated. The intermittent self-catheterization enables residual urine to be emptied. The primary goal of self-catheterization is not only to urinate, but also to protect the upper urinary tract (kidneys).

Extraurethral incontinence

When extraurethralen incontinence is no failure of the locking apparatus of the urethra ( urethra before). The natural urine outlet is "bypassed" , for example, by a congenital malfunction of a ureter behind the sphincter, a cystocele , urethrocystocele or an injury-related fistula , such as a bladder- rectum or bladder- vaginal fistula as a result of surgery or radiation . Therapy is carried out through surgical correction.

Overactive bladder syndrome (OAB)

Overactive or irritable bladder syndrome is not a form of incontinence. If urine leakage occurs as part of the symptoms, one speaks of urge incontinence. The course of the disease can, however, also exist without loss of urine and manifest itself in an unpleasant and frequent need to urinate.

According to the nomenclature of the ICS (International Continence Society), the form of the disease is defined by a sudden, irrepressible urge to urinate, which forces the person affected to go to the toilet immediately. The micturition frequency must be at least 8 times per 24 hours for OAB. A distinction is made between OAB with incontinence (OAB wet) and without incontinence (OAB dry).

The old nomenclature for this is:

  • Sensory urge incontinence : Here, the perception of the bladder filling in the sense of a premature feeling of filling, for example due to inflammation , bladder stones or obstruction of the urinary tract, is disturbed.
  • Motor urge incontinence : Here the efferent nerve impulses to the detrusor muscle (the urinary bladder muscles responsible for emptying) are disinhibited, which leads to a premature, sometimes spasmodic detrusor contraction.

OAB can result from inflammation of the lower urinary tract ( urinary bladder , urethra ), from obstructive (constricting) changes such as e.g. B. urethral strictures , benign or malignant prostate enlargements or neurological disorders such. B. be dementias . In most affected patients, no cause is found.

The therapy is partly causal, i.e. eliminating the cause, but partly only symptomatic, i.e. only alleviating the symptoms.

Laughing incontinence

Laughing incontinence is considered a separate form of urinary incontinence. Typically, this type of incontinence occurs between the ages of 5 and 7 and is particularly common in girls at the onset of puberty. When people laugh, they lose control of their bladder function and the bladder is completely emptied. Unlike other forms of incontinence, the bladder system and surrounding organs are completely healthy. A urge to urinate is not felt before wetting. The real cause of laughing incontinence has not yet been conclusively researched; there are several possible explanations. Treatment can take place with medication including methylphenidate or with physiotherapy, especially pelvic floor training .

Psychological significance of incontinence

Since toilet training is very important in our society, incontinence often leads to social isolation, especially since many incontinence sufferers even shy away from consulting a doctor (urologist, gynecologist) out of shame. For this reason, it must be assumed that there is a high number of unreported cases of incontinence sufferers.

Since 2008 it has been observed that several providers of special products have changed their marketing strategies and are working towards removing taboos on the subject. In 2013, an awareness campaign was launched that promoted a more open approach to the disease on television.

See also

Individual evidence

  1. ^ Andreas J. Gross, Rolf-Hermann Ringert : Urogenital symptoms. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. Schattauer, Stuttgart (1997) 3rd, updated edition 2012, ISBN 978-3-7945-2666-6 , pp. 439-456; here: p. 444.
  2. ↑ Depression: Duloxetine works in two ways. In: Pharmaceutical newspaper. 6/2005.
  3. ↑ Horst Kremling : The stress ("stress") incontinence. Historical considerations. In: Würzburg medical history reports. Badn 14, 1996, pp. 5-10; here: p. 7 ff.
  4. ↑ Horst Kremling: Gynecological-urological borderline questions. In: Würzburg medical history reports. 23, 2004, p. 208.
  5. ↑ N. Kuuva, CG Nilsson: Long-term results of the tension-free vaginal tape surgery in women stress incontinent to unselected group of 129th In: Acta Obstet Gynecol Scand. 85 (4), 2006, pp. 482-487. PMID 16612712
  6. ↑ Julien Labrie, Bary LCM Berghmans, Kathelijn Fischer, Alfredo L. Milani, Ileana van der Wijk, Dina JC Smalbraak, Astrid Vollebregt, Ren P. Schellart, Giuseppe CM Graziosi, J. Marinus van der Ploeg, Joseph FGM Brouns, E. Stella M. Tiersma, Annette G. Groenendijk, Piet Scholten, Ben Willem Mol, Elisabeth E. Blokhuis, Albert H. Adriaanse, Aaltje Schram, Jan-Paul WR Roovers, Antoine LM Lagro-Janssen, Carl H. van der Vaart: Surgery versus Physiotherapy for Stress Urinary Incontinence. In: New England Journal of Medicine. 369, 2013, pp. 1124-1133. doi: 10.1056 / NEJMoa1210627
  7. ↑ F. Lone, AH Sultan, R. Thakar: Long-term outcome of transurethral injection of hyaluronic acid / dextranomer (NASHA / Dx gel) for the treatment of stress urinary incontinence (SUI). In: International urogynecology journal and pelvic floor dysfunction. Volume 21, Number 11, November 2010, pp. 1359-1364, ISSN  1433-3023 . doi: 10.1007 / s00192-010-1211-4 . PMID 20571764 .
  8. ↑ incontinence. (Penis straps) ( Memento from November 25, 2010 in the Internet Archive )
  9. ^ Arne Tiemann: Overactive bladder. DGU, July 2014, accessed on August 9, 2015 .
  10. ↑ Christopher S. Cooper: Voiding Dysfunction Clinical Presentation. Medscape, 2010.
  11. ↑ Not funny at all: the laughing incontinence: When laughter goes bad. ( Memento from August 25, 2013 in the Internet Archive ) ZDF, accessed on February 11, 2014.
  12. ^ Image film "Leap" by the German Continence Society on Youtube. Retrieved June 6, 2013.

literature

  • For the consensus group continence training in children and adolescents (ed.): Hannsjörg Bachmann, Christian Steuber: Continence training in children and adolescents (basic manual). Manual for standardized diagnostics, therapy and training in children and adolescents with functional urinary incontinence. Pabst, Lengerich / Berlin / Vienna 2010, ISBN 978-3-89967-616-7 .
  • For the consensus group continence training in children and adolescents (ed.): Hannsjörg Bachmann, Christian Steuber: Continence training in children and adolescents (training manual). Manual for standardized diagnostics, therapy and training in children and adolescents with functional urinary incontinence. Pabst, Lengerich / Berlin / Vienna 2012, ISBN 978-3-89967-806-2 .
  • For the consensus group continence training in children and adolescents (ed.): Hannsjörg Bachmann, Christian Steuber: Continence training in children and adolescents (track book). Manual for standardized diagnostics, therapy and training in children and adolescents with functional urinary incontinence. Pabst, Lengerich / Berlin / Vienna 2012, ISBN 978-3-89967-807-9 .
  • AG Hofstetter, F. Eisenberger (ed.): Urology for practice. Springer, 1986, ISBN 3-8070-0351-7 , pp. 203-229.
  • S2 guideline urinary incontinence of the German Society for Geriatrics (DGG). In: AWMF online (as of 2009)
  • S2e guideline for stress incontinence for women of the German Society for Gynecology and Obstetrics (DGGG). In: AWMF online (as of 2013)
  • Christian Dannecker among others: urinary incontinence in women . In: Dtsch Arztebl Int . No. 107 (24) , 2010, pp. 420-426 ( Article ).
  • Christof Börgermann among others: Therapy of stress incontinence in men . In: Dtsch Arztebl Int . No. 107 (27) , 2010, pp. 484-491 ( Article ).
  • Mark Goepel and others: Urinary incontinence in old age . In: Dtsch Arztebl Int . No. 107 (30) , 2010, pp. 531-536 ( Article ).