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Cloacal exstrophy

Cloacal exstrophy

Cloacal exstrophy

Cloacal exstrophy, also known as OEIS Syndrome, occurs when a portion of the large intestine lies outside of the body and on either side of it and connected to it are the two halves of the bladder. The intestine may be short and the anus may not open. The bony pelvis is also split open like a book. In males, the penis is usually flat and short, with the exposed inner surface of the urethra on top. The penis is sometimes split into a right and left half. In girls, the clitoris is split into a right half and left half and there may be one or two vaginal openings. Cloacal exstrophy (OEIS syndrome) is a very rare birth defect, affecting 1 in every 250,000 births. Although cloacal exstrophy is a serious condition and requires a series of operations, the long-term outcome is good for many children. Patients and families need to be counseled about the complexity of the anomaly, the need for multiple procedures, and long-term expectations for continence, sexual function, and fertility.

Cloacal exstrophy is known as OEIS Syndrome because of the four features that are typically found together 1:

  • Omphalocele: Some of the abdominal organs protrude through an opening in the abdominal muscles in the area of the umbilical cord. The omphalocele may be small, with only a portion of the intestine protruding outside the abdominal cavity, or large, with many of the abdominal organs (including intestine, liver and spleen) protruding outside the abdominal cavity.
  • Exstrophy of the bladder and rectum: The bladder is open and separated into two halves. The rectum and colon are similarly open and the segment of the rectum is placed between the bladder halves on the surface of the abdomen.
  • Imperforate anus: The anus has not been formed or perforated and the colon connects to the bladder.
  • Spinal defects: These defects may either be major or minor. Often children born with cloacal exstrophy are also born with some degree of spina bifida.

With cloacal exstrophy there are often other birth defects, like spina bifida. This occurs in up to 75 percent of cases. Kidney abnormalities and omphalocele are also common. An omphalocele is when an infant’s intestine or other abdominal organs are open to the outside the body. This is from a hole in the belly button (navel) area. The intestines are covered only by a thin layer of tissue and can be easily seen.

Cloacal exstrophy (OEIS Syndrome) is a complex anomaly that often requires several surgical procedures and requires lifelong medical follow-up care.

As soon as possible, surgical reconstruction is done. Surgery is major, and often done in parts. The schedule of surgery depends on the child’s condition and overall health. Surgery can return the bladder and bowel organs back into the body, to a healthy position. It can provide ways for bowel and urinary control, better kidney function, and improve the way the sex organs or genitals look.

Reconstruction surgery often starts within the first few days of life. It is sometimes delayed to allow the baby to grow and develop. Surgical repair is generally divided into steps and include:

  • Repair of spinal abnormalities, and if needed, the repair of a large omphalocele.
  • Once the child has recovered from spinal surgery, the gastrointestinal tract is treated. Many babies require a stoma because the colon is not normal, and the anus is not formed. The stoma will allow for waste to be released from the intestines to a pouch on the outside of the body.
  • Closure of the exposed bladder and bowel and reconstruction of the genitals are next. This may be done in steps if the pelvic bones are widely separated. For a successful closure, a pelvic osteotomy (cutting the bones to allow the pelvis to close more easily) is critical. In some cases, the abdominal wall, the bladder and genitals (genitourinary system) and the bowel may be repaired at the same time. Bladder reconstruction often includes the use of a catheter for some time.

Figure 1. Cloacal exstrophy

cloacal exstrophy

Cloacal exstrophy

[Source 2 ]

Figure 2. Cloacal exstrophy ultrasound

Cloacal exstrophy ultrasound

Footnote: Fetal ultrasound at 36 weeks’ gestation demonstrating bowel loops herniating between 2 bladder plates (“elephant trunk”).

[Source 3 ]

Figure 3. Cloacal bladder exstrophy female infant

cloacal bladder exstrophy female infant

Figure 4. Cloacal bladder exstrophy male infant

Cloacal bladder exstrophy male infant

Will my child be able to have children when they reach adulthood?

In many cases, the answer to this question is: yes. But almost always, assisted fertility is necessary for adults.

With regard to sexuality, males are generally potent, but some report inadequate phallus or residual curvature. Females report normal sexual function 4.

With respect to fertility and childbearing, retrograde ejaculation or iatrogenic obstruction of the ejaculatory ducts or vas deferens after surgical reconstruction may result in abnormal semen analysis. Antegrade ejaculation is preserved after single-stage repair, but abnormal semen parameters are common. However, fertilization, with viable pregnancy, has been achieved by male patients with cloacal exstrophy 5.

Females have had successful pregnancies 6. Cesarean delivery is recommended to avoid injury to continence mechanism. Postpartum uterine prolapse is common because of aggravation of preexisting abnormal pelvic support.

Cloacal exstrophy causes

The cause of cloacal exstrophy is currently unknown, so there is also no known way to prevent it. On the basis of the known embryologic principles of cloacal development, any inciting event would have to occur early in pregnancy.

There is a higher incidence of cloacal exstrophy in families in which one member is affected as compared with the general population. Offspring of patients with exstrophy-epispadias complex have a 1 in 70 risk (500 times that of the general population) of being affected. Nevertheless, familial occurrence is uncommon in large series 7. The heritability of cloacal exstrophy has not been established, because no offspring have been reported. Moreover, there’s no evidence to suggest that anything done by expectant parents leads to the condition.

At present, 22q11.2 duplication is the genetic variant most commonly associated with bladder exstrophy-epispadias complex 8.

Cloacal exstrophy has been reported in twins. Concordance rates show strong evidence of genetic effects 9, but less than 100% concordance among identical twins suggests some role for environmental effect on development of exstrophy-epispadias.

A higher incidence of bladder exstrophy is observed in infants of younger mothers and in those with relatively high parity.

Maternal tobacco exposure is associated with more severe defects (cloacal vs classic exstrophy).

Growing evidence suggests an increased incidence of cloacal exstrophy and bladder exstrophy-epispadias with in-vitro fertilization (IVF) pregnancies 10.

Cloacal exstrophy symptoms

In some cases, cloacal exstrophy is detected from a routine prenatal ultrasound. In other cases, it isn’t diagnosed until birth, when physicians can clearly see the exposed organs.

Antenatal ultrasound findings suggestive of exstrophy-epispadias complex include the following:

  • Repeated failure to visualize the bladder on ultrasound
  • Lower-abdominal-wall mass
  • Low-set umbilical cord
  • Abnormal genitalia
  • Increased pelvic diameter

Additional antenatal ultrasound findings suggestive of cloacal exstrophy include the following:

  • Omphalocele
  • Limb abnormalities
  • Myelomeningocele
  • Trunk sign from prolapsed intestine

Increased use of fetal magnetic resonance imaging (MRI) may further improve the accuracy of antenatal diagnosis, but this test is not necessary if suspicion is high on the basis of ultrasound findings.

Classic bladder exstrophy and cloacal exstrophy are obvious to all in the delivery room. Variants of the exstrophy-epispadias complex exist, including skin-covered bladder exstrophy, duplicate bladders, superior vesical fistula, and epispadias with major bladder prolapse 11. Most exstrophy variants and epispadias are also identifiable at birth. Unrecognized female epispadias may present as persistent childhood incontinence. Unrecognized split-symphysis variants of exstrophy may be identified in childhood only because of persistent incontinence or a waddling gait.

Physical examination

Patients with classic bladder exstrophy or epispadias typically appear as term infants. Patients with cloacal exstrophy, however, are often preterm. They may have respiratory embarrassment requiring mechanical ventilation.

Abdominal findings

In classic cloacal bladder exstrophy (see the images above), the bladder is open on the lower abdomen, with mucosa fully exposed through a triangular fascial defect. The abdominal wall appears long because of a low-set umbilicus on the upper edge of the bladder plate. The distance between the umbilicus and anus is foreshortened. The recti diverge distally, attaching to the widely separated pubic bones. Indirect inguinal hernias are frequent (>80% of males, >10% of females) because of wide inguinal rings and the lack of an oblique inguinal canal.

Nearly all patients with cloacal exstrophy have an associated omphalocele. The bladder is open and separated into two halves, flanking the exposed interior of the cecum. Openings to the remainder of the hindgut and to one or two appendices are evident within the cecal plate. Terminal ileum may prolapse as a “trunk” of bowel onto the cecal plate.

In cloacal exstrophy variants, the pubic symphysis is widely separated, and the recti diverge distally. The umbilicus is low or elongated. A small superior bladder opening or a patch of isolated bladder mucosa may be present. The intact bladder may be externally covered by only a thin membrane. Isolated ectopic bowel segments have been reported.

Genital findings

In describing the anatomy of the penis, the terms dorsal and ventral refer to a normal phallus in the erect state. The dorsal surface is in continuity with the abdominal wall, and the ventral surface is in continuity with the scrotum.

In cloacal exstrophy, the penis is generally quite small and bifid, with a hemiglans located just caudal to each hemibladder. Infrequently, the phallus may be intact in the midline. In females, the clitoris is bifid, and two vaginas are present. The anus is absent.

In exstrophy variants, the genitalia generally are intact (see the image below), though epispadias can occur.

In classic bladder exstrophy in males, the phallus is short and broad with upward curvature (dorsal chordee). The glans lies open and flat like a spade, and the dorsal component of the foreskin is absent. The urethral plate extends the length of the phallus without a roof. The bladder plate and urethral plate are in continuity, with the verumontanum and ejaculatory ducts visible within the prostatic urethral plate. The anus is anteriorly displaced with a normal sphincter mechanism.

In classic bladder exstrophy in females, the clitoris is uniformly bifid with divergent labia superiorly. The open urethral plate is in continuity with the bladder plate. The vagina is anteriorly displaced. The anus is anteriorly displaced with a normal sphincter mechanism.

In male epispadias, the phallus is short and broad with upward curvature (dorsal chordee). The glans lies open and flat like a spade, and the dorsal component of the foreskin is absent. The urethral meatus is located on the dorsal penile shaft, anywhere between the penopubic angle and the proximal margin of the glans.

In female epispadias, the clitoris is most often bifid with divergent labia superiorly. The dorsal aspect of the urethra is open distally. The urethra and bladder neck are patulous and may allow visualization of bladder. Bladder mucosa may prolapse through the bladder neck.

Musculoskeletal findings

In classic bladder exstrophy, the pubic symphysis is widely separated. Divergent rectus muscles remain attached to the pubis. External rotation of the innominate bones results in a waddling gait in ambulatory patients but does not appear to result in orthopedic problems later in life.

In cloacal exstrophy, the examination is the same as for bladder exstrophy. As many as 65% of patients have a clubfoot or major deformity of a lower extremity. As many as 80% of patients have vertebral anomalies.

In split-symphysis variants of exstrophy, the pubic symphysis is widely separated (see the image below), and the rectus muscles are divergent.

Neurologic findings

In cloacal exstrophy, as many as 95% of patients have myelodysplasia, which may include myelomeningocele, lipomeningocele, meningocele, or other forms of occult dysraphism. These patients are at risk for neurologic deterioration, and they should be observed closely. Early neurosurgical consultation is appropriate if a radiographic abnormality of the spinal cord or canal is observed.

Cloacal exstrophy diagnosis

Cloacal exstrophy can usually be diagnosed by fetal ultrasound before an infant is born. Upon birth, a physical exam will confirm the diagnosis.

Laboratory studies

Before complex reconstruction of the urinary tract, it is important to obtain information about the patient’s baseline renal function. In patients with cloacal exstrophy, losses from the terminal ileum short-gut physiology can result in significant electrolyte abnormalities.

Imaging studies

Baseline examination of the kidneys with ultrasonography is recommended for all patients with exstrophy because increased bladder pressure after bladder closure can lead to hydronephrosis and upper urinary tract deterioration. Congenital upper urinary tract anomalies are uncommon with classic exstrophy and epispadias but are present in approximately one third of patients with cloacal exstrophy (eg, ectopic pelvic kidney, renal agenesis, or hydronephrosis).

Spinal ultrasound or radiography may be helpful. Myelodysplasia should be excluded in newborns with cloacal exstrophy. This can be accomplished by means of ultrasound early in life. In cloacal exstrophy, magnetic resonance imaging (MRI) is recommended to help identify occult abnormalities that may predispose to symptomatic spinal cord tethering.

Bilateral vesicoureteral reflux (VUR) is present in nearly all patients with classic bladder exstrophy. Voiding cystourethrography (VCUG) is performed in early childhood to assess bladder capacity in preparation for reconstructive continence surgery. Evaluation of the bladder neck and proximal urethra is recommended in patients with epispadias in order to plan surgical management.

Managing pregnancy after a cloacal exstrophy diagnosis

Because cloacal exstrophy is a high-risk condition, you will need to be monitored throughout your pregnancy. In some cases, pregnancy may be complicated by polyhydramnios (excess amniotic fluid) during the third trimester, which may trigger preterm labor and delivery. Your delivery should also be planned at our state-of-the-art facility. This way, our delivery team can address any complications should they arise and the baby will have immediate access to treatment and the best surgical professionals.

Cloacal exstrophy treatment

Cloacal exstrophy is treated through surgical repair after birth, usually in stages to address each defect. This requires an in-depth treatment plan to be created for your child’s specific needs. The extent of cloacal exstrophy surgery required for your baby depends on the type and severity of his or her abnormalities.

Your child will undergo a series of surgeries over a number of years — referred to as staged reconstruction. The exact timing, nature and outcome of each cloacal exstrophy surgery will depend on your child’s particular situation. Your child’s surgeons will create a treatment plan based on the type and the extent of your child’s condition and discuss the plan with you. Usually surgery begins in the first days of life with the highest-priority procedure. Surgeons usually repair the bladder, create a colostomy (an opening in the colon with an attached “bag” that allows stool to pass) and repair the abdominal wall defect.

Babies with spinal defects usually have them repaired sometime in the first few days of life. Later surgeries include urinary and genital reconstruction, as well as an operation to create a rectum and close the colostomy opening. There are no fetal interventions (surgical procedures while inside the uterus) for cloacal exstrophy.

Treatment may include:

  • Abdominal repair: Typically, soon after your child is born, the surgeons will repair the omphalocele by closing the bladder and creating a colostomy so your child can eliminate stool. With a colostomy, the large intestine is separated from the bladder halves and reclosed. The two halves of the bladder are brought together and placed into the abdomen. The end of the large intestine is brought to the surface of the skin through an opening in the abdomen. A plastic bag, called a colostomy pouch, is placed over the opening to collect the stool.
  • Other surgery, such as surgery to repair the spine, may be planned around the initial stage of the abdominal repair.

After the initial surgery, your child will remain in the hospital where we will monitor the intestine as it begins to function. Our team will work with you and your family to ensure that the plan for your child is clear and that you have access to the supports you need.

  • Osteotomies: Once your child has healed from his first procedure and had some time to grow, we will schedule the second stage of the repair. This primarily involves working on the bladder. The orthopedic surgeon on our team will perform osteotomies to help ensure that your child’s pelvis can best support the bladder over time. During the osteotomy the hip bones are cut and adjusted. Your child will need to be in traction or in a spica cast for several weeks following this surgery.
  • Pull-through procedure: If your child was born with a significant amount of colon and is capable of forming solid stool, a surgical procedure, known as a “pull through” may eventually be performed. The purpose of this procedure is to connect the colon to the rectum.

Subsequent surgeries may also involve major urinary reconstructive surgery and further genital reconstruction. These issues will be discussed with you and your family as your child grows up.

Cloacal exstrophy repair

Reconstruction of exstrophy-epispadias complex remains one of the greatest challenges facing the pediatric urologist. Many modifications in surgical procedures have improved outcomes, but the optimal approach remains uncertain. Longitudinal prospective assessment of the two main current surgical approaches (staged procedure and total reconstruction) is critical for optimizing functional and cosmetic outcomes.

Complete primary reconstruction is now more than 20 years old; however, each approach is in a constant state of minor modification. Data on this approach continue to mature and are updated almost yearly 12. Analysis of each experience focuses on daytime continence with volitional voiding, need for further surgical procedures, and complication rates. In experienced hands, the safety and efficacy of the different approaches are comparable.

Goals of therapy include provision of urinary continence with preservation of renal function and reconstruction of functional and cosmetically acceptable genitalia. Creation of a neoumbilicus is also important to many of these patients.

Surgical techniques used in the treatment of exstrophy-epispadias complex include the following:

  • Staged functional closure for classic bladder exstrophy (ie, modern staged repair of exstrophy) 13
  • Complete primary repair for classic bladder exstrophy
  • Urinary diversion for classic bladder exstrophy
  • Closure for cloacal exstrophy
  • Gender reassignment

Staged functional closure for classic bladder exstrophy

Modern staged repair of exstrophy, which represents the traditional surgical approach, comprises a series of operations. Initial bladder closure is completed within 72 hours of birth. If this is delayed, pelvic osteotomies are required to facilitate successful closure of the abdominal wall and to allow the bladder to lie within a closed and supportive pelvic ring.

Epispadias repair with urethroplasty is performed at age 12-18 months. This allows enough increase in bladder outlet resistance to improve the bladder capacity.

Bladder neck reconstruction (typically a modified Young-Dees-Leadbetter repair) is performed at age 4 years. This allows continence and correction of vesicoureteral reflux (VUR). Multiple modifications have been proposed. The procedure is delayed until bladder capacity is adequate; better results are reported with a capacity greater than 85 mL.

Chua et al retrospectively studied a modification of staged exstrophy repair aimed at incorporating the advantages of complete primary repair for classic bladder exstrophy by avoiding concurrent epispadias repair and adding bilateral ureteral reimplantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral reimplantation) at the initial repair 14. They found staged repair of bladder exstrophy with bilateral ureteral reimplantation to be a safe alternative for exstrophy-epispadias repair, preventing penile tissue loss and yielding long-term outcomes comparable to those of complete primary repair for classic bladder exstrophy.

The radical soft-tissue mobilization (radical soft-tissue mobilization) procedure, also referred to as the Kelly repair, has been suggested as an alternative approach to staged reconstruction of bladder exstrophy 15. Radical soft-tissue mobilization has been performed not only as the second part of a two-step strategy (after bladder closure) but also as part of a combined procedure that includes delayed bladder closure and radical soft-tissue mobilization in a single stage without pelvic osteotomy 16.

Complete primary repair for classic bladder exstrophy

Compared with modern staged repair of exstrophy, complete primary repair for classic bladder exstrophy is a newer approach to exstrophy closure. Primary bladder closure, urethroplasty, and genital reconstruction are performed in a single stage in newborns. This procedure involves complete penile disassembly in males and mobilization of the urogenital complex in females. Hypospadias is a common outcome in males and requires subsequent reconstruction.

The goal is early bladder cycling. A subset of patients have achieved continence without bladder neck reconstruction.

In a study of 34 boys treated with a modified penile disassembly technique (15 with bladder exstrophy who underwent complete primary repair for classic bladder exstrophy, 11 with penopupic epispadias after previous closure of bladder exstrophy, and eight with isolated complete epispadias), Anwar et al found the modified technique to yield excellent cosmetic results 17. Preservation of the distal urethral plate along with both hemiglans avoided shortening and prevented occurrence of hypospadias.

Urinary diversion for classic bladder exstrophy

Urinary diversion was the original surgical treatment of choice. Diversion may be performed in a patient with an extremely small bladder plate not suitable for functional closure 18. In Europe, early diversion has been widely used, with success for most exstrophy patients.

Closure for cloacal exstrophy

Treatment of myelodysplasia and gastrointestinal anomalies has priority over management of urinary and genital anomalies.

Closure can be either staged or performed in a single stage, depending on the overall condition of the child and the severity of the abdominal wall defect. If a large omphalocele is present, successful closure of the abdomen and the bladder in one stage may be difficult to accomplish.

The first stage involves separation of the gastrointestinal and genitourinary (genitourinary) tracts, closure of the colon, creation of a colostomy, and closure of the omphalocele. The bladder plates are brought together in the midline.

Because virtually all of these patients have some element of short-gut syndrome, the hindgut should be incorporated into the gastrointestinal tract to maximize absorptive surface area. Ileostomy should be avoided because of the high incidence of recurrent hospitalizations for dehydration and severe electrolyte abnormalities. The decision between rectal pull-through and permanent colostomy is based on the surgeon’s preference and the projected potential for social fecal continence 19.

Subsequent bladder closure is carried out as in surgical management of classic bladder exstrophy. The principles of complete primary repair have been applied at this point as well. Consideration may be given to continent diversion as the second stage, on the basis of poor potential for volitional voiding and continence.

Because of more severe pubic diastasis, pelvic osteotomies are required. Staged pelvic osteotomy (staged pelvic osteotomy) with gradual closure of the pelvis may be needed in severe cases 20. In a study comparing staged pelvic osteotomy before bladder closure with combined pelvic osteotomy (combined pelvic osteotomy) at the time of closure in cloacal exstrophy patients, Inouye et al found that staged pelvic osteotomy reduced preoperative diastasis more than combined pelvic osteotomy did, without appearing to incur increased rates of complication, closure failure, or incontinence 21.

Gender reassignment

Historically, all males with cloacal exstrophy underwent early gender conversion because of inadequate male genitalia. Testicular histology is normal despite frequent cryptorchidism.

Evidence suggesting that testosterone in utero has a significant impact on the developing brain has led to a change in surgical philosophy, as has anecdotal evidence suggesting that raising a 46,XY cloacal exstrophy patient as female can result in significant gender dysphoria. Cloacal exstrophy is now included as a subset of disorders of sex development 22. Multidisciplinary evaluation and both early and long-term counseling should be offered.

Intraoperative concerns

Multiple or lengthy surgical procedures with exposure to latex antigens increase the risk of latex sensitization or allergy 23. Approximately 30% of patients with bladder exstrophy have demonstrated symptoms of latex allergy, and 70% reveal sensitization (elevation of specific immunoglobulin E [IgE] antibody) to latex antigens. For practical purposes, all patients with exstrophy-epispadias complex should be considered to be latex-sensitive.

Full latex precautions are recommended in the operating room, beginning with preparation for the first operative procedure. Potential latex-containing materials in the operating room include gloves, catheters, drains, masks, anesthesia materials, bandages, and thromboembolic stockings. Polyvinyl chloride and silicone are acceptable alternatives. Latex allergy should be considered seriously in the event of intraoperative anaphylaxis. The offending agent should be removed and the surgical procedure aborted if necessary.

Treatment includes cardiopulmonary resuscitation with fluids, epinephrine, steroids, and histamine blockade. In those with a known latex allergy, premedication with steroids and histamine H1 and H2 blockers should be considered.

After cloacal exstrophy repair

The goal of surgeons and doctors is to help improve the child’s quality of life. Better tools for anesthesia and infant nutrition have helped to increase the survival rate for newborns with this condition.

Postoperatively, patients with exstrophy remain in the hospital in modified Bryant traction (legs adducted and pelvis slightly elevated) for 3 weeks after bladder closure. Alternative techniques of immobilization may be used, based on osteotomies or institutional protocol.

Bladder and kidneys are drained fully with multiple catheters during the first few weeks after closure.

Nutritional support is mandatory for patients with cloacal exstrophy. Patients with classic bladder exstrophy may also have early difficulties feeding because of the body position in traction.

It’s important to work closely with your health care team to prevent infection after surgery, and learn about long-term care. After surgery, a child born with cloacal exstrophy can usually grow to manage urine and stool in a socially acceptable way. Further operations may be needed over time to improve the child’s ability to control their bladder and bowel function. More surgery may also be needed to rebuild and/or make better the outer sex organs.

Time and patience will be important for the parents and child. Neurologic issues from spina bifida, if present, can be managed, but requires ongoing medical care.

Complications

In the treatment of complex congenital anomalies, the distinction between technical complications and problems inherent to the anomaly is not always obvious.

Failure of closure may occur. If the bladder plate is adequate, reclosure with pelvic osteotomies is recommended. In this instance, bladder closure and epispadias repair are performed in one stage. Urinary diversion is the alternative therapy.

A vesicocutaneous fistula or urethrocutaneous fistula may form after primary closure or urethral reconstruction. If spontaneous closure does not occur, surgical repair is required.

Loss of the hemiglans or corporal body has been reported as a result of complete primary repair 24.

Minor orthopedic complications may occur after osteotomy or immobilization.

Upper urinary tract deterioration is a potential complication. Causes include excessive outlet resistance and high pressure in a small-capacity reservoir and persistent VUR.

Abnormal bladder function may result in poor emptying. Clinical problems related to poor emptying include recurrent febrile infections, epididymitis, bladder stones, acute urinary retention, and rupture of the native bladder.

Bladder prolapse is a potential complication. Posterior bladder wall may prolapse through the patulous bladder neck after primary closure (see the image below). Recurrent prolapse, congestion, ischemia of bladder mucosa, or failure of ureteral drainage warrants early surgical correction.

Malignancy is a rare late complication of bladder exstrophy and is more common in untreated patients whose bladders are left exstrophic for many years. Adenocarcinoma is the most common of these malignancies, from the precursor cystitis glandularis, which is caused by chronic irritation and inflammation of exposed mucosa of the exstrophic bladder. Squamous cell carcinoma and rhabdomyosarcoma have also been reported.

Adenocarcinoma may develop adjacent to the ureterointestinal anastomosis in patients with urinary diversions that mix the urinary and fecal streams. This malignancy was reported in more than 10% of patients in one series 25. Patients younger than 25 years with ureterosigmoidostomy have a 7000-fold greater risk of adenocarcinoma of the colon than the general population (mean latency, 10 years).

Complications of short-gut syndrome are as follows:

  • Paucity of hindgut and, in many cases, limited small intestine can result in electrolyte abnormalities in patients with cloacal exstrophy
  • Dehydration is particularly a concern during an acute GI illness with diarrhea
  • Nutritional supplementation may be required

Cloacal exstrophy prognosis

Surgical techniques to treat cloacal exstrophy have improved dramatically in recent years, which means 90% to 100% of babies survive after surgery. Their quality of life and degree of need for ongoing care vary from case to case.

Mortality with classic bladder exstrophy or epispadias is rare. Historically, cloacal exstrophy was associated with significant mortality. Reconstruction was not attempted until the 1970s. Advances in the care of critically ill neonates and recognition of the importance of early parenteral nutritional support have allowed successful reconstruction and survival of children with cloacal exstrophy.

Survival rates after surgical treatment are excellent. With respect to bladder function or continence, reports vary according to the type of reconstruction performed 26. Objective and subjective evidence indicates that many exstrophic bladders do not function normally after reconstruction and may deteriorate over time.

Continence rates of 75-90% have been reported after staged reconstruction in classic exstrophy, but more than one continence procedure may be required (eg, bladder neck reconstruction, bladder augmentation, bladder neck sling, or artificial urinary sphincter). Many of these patients require clean intermittent catheterization (CIC) through the urethra or a continent stoma because they are unable to void spontaneously to completion. Less encouraging results also are reported.

Continence results after staged reconstruction are poor (< 25%) in cloacal exstrophy because of abnormal bladder innervation in many patients. Experience with rectal reservoirs (ureterosigmoidostomy and variants) for exstrophy continence demonstrates rates higher than 95%, but they present long-term malignancy risks 27. Continent reconstruction with intestinal bladder augmentation and clean intermittent catheterization has a success rate greater than 90%.

With regard to psychosocial concerns, education, employment, and social relationships generally are not affected substantially in adults with a history of bladder exstrophy and epispadias 28. Age-appropriate adaptive behaviors may be delayed in children with chronic medical conditions 29. One study revealed below-average daily living skills and socialization but above-average self-esteem. Children may need support in disclosing their condition to new peers.

Multiple anomalies associated with cloacal exstrophy can have a significant impact on daily life. Patients are affected by permanent colostomy, the need for clean intermittent catheterization, and impaired ambulation.

Diet

Some young patients with cloacal exstrophy are seriously affected by short-gut syndrome and may depend on long-term supplemental parenteral nutrition for growth and development.

References
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  2. Bladder Exstrophy. https://www.auanet.org/education/auauniversity/education-products-and-resources/pathology-for-urologists/urinary-bladder/histoanatomic-abnormalities/malformations/bladder-exstrophy
  3. Clements MB, Chalmers DJ, Meyers ML, Vemulakonda VM. Prenatal diagnosis of cloacal exstrophy: a case report and review of the literature. Urology. 2014;83(5):1162-1164. doi:10.1016/j.urology.2013.10.050
  4. Bujons A, Lopategui DM, Rodríguez N, Centeno C, Caffaratti J, Villavicencio H. Quality of life in female patients with bladder exstrophy-epispadias complex: Long-term follow-up. J Pediatr Urol. 2016 Aug. 12 (4):210.e1-6.
  5. Stein R, Hohenfellner K, Fisch M, Stöckle M, Beetz R, Hohenfellner R. Social integration, sexual behavior and fertility in patients with bladder exstrophy–a long-term follow up. Eur J Pediatr. 1996 Aug. 155 (8):678-83.
  6. Dy GW, Willihnganz-Lawson KH, Shnorhavorian M, Delaney SS, Amies Oelschlager AM, Merguerian PA, et al. Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience. J Pediatr Urol. 2015 Aug. 11 (4):213.e1-6.
  7. Gambhir L, Höller T, Müller M, Schott G, Vogt H, Detlefsen B, et al. Epidemiological survey of 214 families with bladder exstrophy-epispadias complex. J Urol. 2008 Apr. 179 (4):1539-43.
  8. Beaman GM, Woolf AS, Cervellione RM, Keene D, Mushtaq I, Urquhart JE, et al. 22q11.2 duplications in a UK cohort with bladder exstrophy-epispadias complex. Am J Med Genet A. 2019 Jan 9.
  9. Reutter H, Qi L, Gearhart JP, Boemers T, Ebert AK, Rösch W, et al. Concordance analyses of twins with bladder exstrophy-epispadias complex suggest genetic etiology. Am J Med Genet A. 2007 Nov 15. 143A (22):2751-6.
  10. Wood HM, Babineau D, Gearhart JP. In vitro fertilization and the cloacal/bladder exstrophy-epispadias complex: a continuing association. J Pediatr Urol. 2007 Aug. 3 (4):305-10.
  11. Maruf M, Benz K, Jayman J, Kasprenski M, Michaud J, Di Carlo HN, et al. Variant Presentations of the Exstrophy-Epispadias Complex: A 40-Year Experience. Urology. 2018 Dec 18.
  12. Bhatnagar V. Bladder exstrophy: An overview of the surgical management. J Indian Assoc Pediatr Surg. 2011 Jul. 16 (3):81-7.
  13. Baird AD, Nelson CP, Gearhart JP. Modern staged repair of bladder exstrophy: a contemporary series. J Pediatr Urol. 2007 Aug. 3 (4):311-5.
  14. Chua ME, Ming JM, Fernandez N, Varghese A, Farhat WA, Bagli DJ, et al. Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy. J Pediatr Urol. 2018 Sep 25.
  15. Ben-Chaim J, Hidas G, Wikenheiser J, Landau EH, Wehbi E, Kelly MS, et al. Kelly procedure for exstrophy or epispadias patients: Anatomical description of the pudendal neurovasculature. J Pediatr Urol. 2016 Jun. 12 (3):173.e1-6.
  16. Leclair MD, Faraj S, Sultan S, Audry G, Héloury Y, Kelly JH, et al. One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results. J Pediatr Urol. 2018 Dec. 14 (6):558-564.
  17. Anwar AZ, Mohamed MA, Hussein A, Shaaban AM. Modified penile disassembly technique for boys with epispadias and those undergoing complete primary repair of exstrophy: long-term outcomes. Int J Urol. 2014 Sep. 21 (9):936-40.
  18. Ko JS, Lue K, Friedlander D, Baumgartner T, Stuhldreher P, DiCarlo HN, et al. Cystectomy in the Pediatric Exstrophy Population: Indications and Outcomes. Urology. 2018 Jun. 116:168-171.
  19. Levitt MA, Mak GZ, Falcone RA Jr, Peña A. Cloacal exstrophy–pull-through or permanent stoma? A review of 53 patients. J Pediatr Surg. 2008 Jan. 43 (1):164-8; discussion 168-70.
  20. Mathews R, Gearhart JP, Bhatnagar R, Sponseller P. Staged pelvic closure of extreme pubic diastasis in the exstrophy-epispadias complex. J Urol. 2006 Nov. 176 (5):2196-8.
  21. Inouye BM, Tourchi A, Di Carlo HN, Young EE, Mhlanga J, Ko JS, et al. Safety and efficacy of staged pelvic osteotomies in the modern treatment of cloacal exstrophy. J Pediatr Urol. 2014 Dec. 10 (6):1244-8.
  22. Houk CP, Lee PA. Consensus statement on terminology and management: disorders of sex development. Sex Dev. 2008. 2 (4-5):172-80.
  23. Shnorhavorian M, Grady RW, Andersen A, Joyner BD, Mitchell ME. Long-term followup of complete primary repair of exstrophy: the Seattle experience. J Urol. 2008 Oct. 180 (4 Suppl):1615-9; discussion 1619-20.
  24. Schaeffer AJ, Purves JT, King JA, Sponseller PD, Jeffs RD, Gearhart JP. Complications of primary closure of classic bladder exstrophy. J Urol. 2008 Oct. 180 (4 Suppl):1671-4; discussion 1674.
  25. Krishnamsetty RM, Rao MK, Hines CR, Saikaly EP, Corpus RP, DeBandi HO. Adenocarcinoma in exstrophy and defunctional ureterosigmoidostomy. J Ky Med Assoc. 1988 Aug. 86 (8):409-14.
  26. Kibar Y, Roth C, Frimberger D, Kropp BP. Long-term results of penile disassembly technique for correction of epispadias. Urology. 2009 Mar. 73 (3):510-4.
  27. Husmann DA, Rathbun SR. Long-term follow up of enteric bladder augmentations: the risk for malignancy. J Pediatr Urol. 2008 Oct. 4 (5):381-5; discussion 386.
  28. Mukherjee B, McCauley E, Hanford RB, Aalsma M, Anderson AM. Psychopathology, psychosocial, gender and cognitive outcomes in patients with cloacal exstrophy. J Urol. 2007 Aug. 178 (2):630-5; discussion 634-5.
  29. Ebert A, Scheuering S, Schott G, Roesch WH. Psychosocial and psychosexual development in childhood and adolescence within the exstrophy-epispadias complex. J Urol. 2005 Sep. 174 (3):1094-8.
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BladderKidneysProceduresUretersUrethraUrinary System

Uroflowmetry

Uroflowmetry

Uroflowmetry

Uroflowmetry is a simple, diagnostic screening procedure used to measures the flow rate of urine over time (urine speed and urine volume). Uroflowmetry tracks how fast urine flows, how much flows out, and how long it takes. It’s a diagnostic test to assess how well your urinary tract functions. Your doctor may suggest uroflowmetry if you have trouble urinating, or have a slow stream. Uroflowmetry test is noninvasive (the skin is not pierced), and may be used to assess bladder and sphincter function. Uroflowmetry measurements are performed in a health care provider’s office; no anesthesia is needed.

By measuring the average and top rates of urine flow, this test can show an obstruction in your urinary tract such as an enlarged prostate. When combined with the cystometrogram, uroflowmetry can help find problems like a weak bladder.

For uroflowmetry test, you should arrive at the doctor’s office with a fairly full bladder. If possible, do not urinate for a few hours before the test.

You will be asked to urinate privately into a special toilet that has a container for collecting the urine and a scale or a funnel connected to the electronic uroflowmeter. The equipment creates a graph that shows changes in urine flow rate from second to second so your doctor can see when the flow rate is the highest and how many seconds it takes to get there. This records information about your urine flow on a flow chart. The flow rate is calculated as milliliters (ml) of urine passed per second. Both average and top flow rates are measured.

Results of this test will be abnormal if the bladder muscles are weak or urine flow is blocked. Another approach to measuring flow rate is to record the time it takes to urinate into a special container that accurately measures the volume of urine.

Common urine flow patterns:

  • Flow rate (Q): Volume of fluid expelled via the urethra per unit time (mL/s).
  • Voided volume (Vvoid): Total volume expelled via the urethra (mL).
  • Average flow rate (Qave): Voided volume divided by the flow time.
  • Maximum flow rate (Qmax): Maximum measured value of the flow rate after correction for artefacts.
  • Voiding time: Total duration of micturition (second).
  • Flow time: Time over which measurable flow actually occurs.
  • Time to maximum flow: Elapsed time from onset of flow to maximum flow.

The fastest flow rate, also known as maximum flow rate (Qmax), is used to understand if a block or obstruction is severe.

Your doctor will know your test results right away. Average results are based on your age and sex.

  • Typically, urine flow rate from 10 ml to 21 ml per second. Women range closer to 15 ml to 18 ml per second.
  • A slow or low flow rate may mean there is an obstruction at the bladder neck or in the urethra, an enlarged prostate, or a weak bladder.
  • A fast or high flow rate may mean there are weak muscles around the urethra, or urinary incontinence problems.

You may be asked to take other tests to fully learn what’s going on for treatment. Your urologist will create a treatment plan based on test results and your health history.

Facts about urine:

  • Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed.
  • The volume of urine formed at night is about half that formed in the daytime.
  • Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi.
  • The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Figure 1. Uroflowmetry

Uroflowmetry

How does the urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the food components that it needs, waste products are left behind in the bowel and in the blood.

The urinary system helps the body to eliminate liquid waste called urea and keeps the chemicals, such as potassium and sodium, and water in balance. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys, where it is removed along with water and other wastes in the form of urine.

Urinary system parts and their functions:

  • Two kidneys. This pair of purplish-brown organs is located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys also help to regulate blood pressure. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
  • Two ureters. These narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.
  • Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder’s walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.
  • Two sphincter muscles. These circular muscles help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder
  • Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the bladder
  • Urethra. This tube allows urine to pass outside the body

Figure 2. Urinary system and anatomy

Urinary system anatomy

urinary tract system

Reasons for the uroflowmetry test

Uroflowmetry is a quick, simple diagnostic screening test that provides valuable feedback about the health of the lower urinary tract. It is commonly performed to determine if there is obstruction to normal urine outflow. Medical conditions that can alter the normal flow of urine include, but are not limited to, the following:

  • Benign prostatic hypertrophy. A benign enlargement of the prostate gland that usually occurs in men over age 50. Enlargement of the prostate interferes with normal passage of urine from the bladder. If left untreated, the enlarged prostate can obstruct the bladder completely.
  • Cancer of the prostate, or bladder tumor.
  • Urinary incontinence. Involuntary release of urine from the bladder.
  • Urinary blockage. Obstruction of the urinary tract can occur for many reasons along any part of the urinary tract from kidneys to urethra. Urinary obstruction can lead to a backflow of urine causing infection, scarring, or kidney failure if untreated.
  • Neurogenic bladder dysfunction. Improper function of the bladder due to an alteration in the nervous system, such as a spinal cord lesion or injury.
  • Frequent urinary tract infections.

Uroflowmetry may be performed in conjunction with other diagnostic procedures, such as cystometry, cystography, retrograde cystography, and cystoscopy.

There may be other reasons for your doctor to recommend uroflowmetry.

Urine flow rate test

Uroflowmetry is performed by having a person urinate into a special funnel that is connected to a measuring instrument. The measuring instrument calculates the amount of urine, rate of flow in seconds, and length of time until completion of the void. This information is converted into a graph and interpreted by a doctor. The information helps evaluate function of the lower urinary tract or help determine if there is an obstruction of normal urine outflow.

During normal urination, the initial urine stream starts slowly, but almost immediately speeds up until the bladder is nearly empty. The urine flow then slows again until the bladder is empty. In persons with a urinary tract obstruction, this pattern of flow is altered, and increases and decreases more gradually. The uroflowmeter graphs this information, taking into account the person’s gender and age. Depending on the results of the procedure, other tests may be recommended by your doctor.

Other related procedures that may be used to diagnose urinary outflow obstruction or lower urinary tract dysfunction include cystometry, cystography, retrograde cystography, and cystoscopy.

Before the urology flow rate test

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
  • Generally, no prior preparation, such as fasting or sedation, is required.
  • You may be instructed to drink about four glasses of water several hours before the test is performed to ensure that your bladder is full. In addition, you should not empty your bladder before arriving for the procedure.
  • If you are pregnant or suspect that you are pregnant, you should notify your doctor.
  • Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
  • Based on your medical condition, your doctor may request other specific preparation.

During the urology flow rate test

Uroflowmetry may be performed on an outpatient basis or as part of your stay in the hospital. Procedures may vary depending on your condition and your doctor’s practices.

Generally, uroflowmetry follows this process:

  1. You will be taken into the procedure area and instructed how to use the uroflowmetry device.
  2. When you are ready to urinate, you will press the flowmeter start button and count for five seconds before beginning urination.
  3. You will begin to urinate into the funnel device that is attached to the regular commode. The flowmeter will record information as you are urinating.
  4. You should not push or strain as you urinate. You should remain as still as possible.
  5. When you have finished urinating, you will count for five seconds and press the flowmeter button again.
  6. You should not put any toilet paper into the funnel device.
  7. The procedure will be concluded at this point. Depending on your specific medical condition, you may be asked to perform the test on several consecutive days.

After the urology flow rate test

Generally, there is no special type of care following uroflowmetry. However, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Uroflowmetry normal flow

There is great variation in uroflowmetry parameters even in the non‐symptomatic population 1, although flow curves are generally repeatable for the same patient. In particular, there are no definitive ‘normal’ ranges for maximum flow rate (Qmax), although it decreases with age and voided volume (but not in a directly proportional manner). Males aged <40 years usually have a Qmax of >25 mL/s, and females usually have a Qmax of 5–10 mL/s more than males at a given bladder volume. Beware the ‘normal flow’ that in fact represents the effect of a compensatory increase in the voiding pressure generated by the detrusor in patients with bladder outlet obstruction 2.

Decreased urine flow

This is the most common abnormal flow trace seen in practice and is represented by a dampened curve with decreased Qmax and prolonged flow time. A significantly decreased Qmax (generally accepted as <15 mL/s) cannot be used to distinguish between BOO in men, outflow obstruction in women, and impaired detrusor contractility 6; in appropriate cases, formal multichannel urodynamic studies with concomitant measurements of flow and detrusor pressures are important to delineate between these conditions.

Despite the limitations, Qmax remains the single best non‐invasive urodynamic test to detect possible lower urinary tract obstruction. The test is also useful in some clinical situations to guide further evaluation to predict outcome after surgery and for preoperative counseling:

  • Males with a Qmax above the threshold value of 15 mL/s (or 12 mL/s) 3 may have a poorer outcome after prostate surgery for presumed bladder outlet obstruction 4 and these men should be considered for formal urodynamics to arrive at a definite diagnosis and decrease treatment failures.
  • Females undergoing mid‐urethral sling surgery with a Qmax of <15 mL/s at preoperative uroflowmetry are more likely to fail a trial of void after sling surgery 5.

Plateau urine flow

A long flow time, associated with a poor flow is typical of a stricture in the lower urinary tract. Another commonly encountered scenario is the patient with post‐radical prostatectomy incontinence. One should suspect an anastomotic stricture if this flow curve pattern is seen in the office during initial postoperative assessment. The patient should be considered for a cystoscopy with a view to treat the stricture as the next step in management, rather than referral for a formal urodynamic study as difficult catheterisation is commonly encountered.

Intermittent urine flow

This may be seen in patients who void with some abdominal straining due to bladder outlet obstruction or a poorly contractile detrusor, and is often superimposed on a decreased or plateauing curve pattern.

‘Saw‐tooth’ urine flow

Often pathogneumonic of detrusor‐sphincter‐dyssynergia, this curve should prompt urgent pressure‐flow studies to investigate high intravesical pressures that might damage the upper tracts.

‘Super‐voider’

This is seen after surgery for bladder outlet obstruction (e.g. TURP or urethroplasty), in patients with decreased urethral resistance (e.g. intrinsic urethral sphincter deficiency), or occasionally in those with detrusor overactivity. It may be considered ‘normal’ if there are no symptoms or signs to suggest underlying pathology, and is sometimes seen in young healthy female patients who may have a Qmax exceeding 40 mL/s.

‘Kicking the bucket’, and other artefacts

Urologists must be wary of artefacts and always compare the automated printout reading with the curve and clinical context. Smooth muscle physiology suggests that there should not be any abrupt spikes on a trace. A patient who accidentally kicks the flowmeter can appear to have a ‘normal’ Qmax. Other artefacts created by abdominal straining, squeezing the prepuce, or even variations in the direction of the urinary stream (within the funnel of the uroflowmeter) are common and urologists must recognise these.

Uroflowmetry procedure risks

Because uroflowmetry is a noninvasive procedure, it is safe for most persons. The test is usually done in privacy to ensure that the person voids in a natural setting.

There may be risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Certain factors or conditions may interfere with the accuracy of uroflowmetry. These factors include, but are not limited to, the following:

  • Straining with urination
  • Body movement during urination
  • Certain medications that affect bladder and sphincter muscle tone
References
  1. Wyndaele JJ. Normality in urodynamics studied in healthy adults. J Urology 1999; 161: 899–902.
  2. Jarvis, T.R., Chan, L. and Tse, V. (2012), PRACTICAL UROFLOWMETRY. BJU Int, 110: 28-29. doi:10.1111/bju.11617
  3. McLoughlin J, Gill KP, Abel PD, Williams G. Symptoms versus flow rates versus urodynamics in the selection of patients for prostatectomy. Br J Urol 1990; 66: 303–305.
  4. Jensen KM, Jorgensen JB, Mogensen P. Urodynamics in prostatism. I. Prognostic value of uroflowmetry. Scand J Urol Nephrol 1988; 22: 109–117.
  5. Wheeler TL, Richter HE, Greer WJ, Bowling CB, Redden DT, Varner RE. Predictors of success with postoperative voiding trials after a mid‐urethral sling procedure. J Urol 2008; 179: 600–604.
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12 Body SystemsBladderUrinary System

Urinary bladder

bladder anatomy

Urinary bladder

The urinary bladder is a hollow, collapsible muscular sac that stores and expels urine situated in the pelvic cavity posterior to the pubic symphysis. In males, it is
directly anterior to the rectum; in females, it is anterior to the vagina and inferior to the uterus (see Figure 1). Folds of the peritoneum hold the urinary bladder in position. When slightly distended due to the accumulation of urine, the urinary bladder is spherical. When it is empty, it collapses. As urine volume increases, it becomes pear shaped and rises into the abdominal cavity.

Urinary bladder capacity averages 700–800 mL. It is smaller in females because the uterus occupies the space just superior to the urinary bladder.

Anatomy of the Urinary Bladder

In the floor of the urinary bladder is a small triangular area called the trigone. The two posterior corners of the trigone contain the two ureteral openings; the opening into the urethra, the internal urethral orifice, lies in the anterior corner (see Figure 2). Because its mucosa is firmly bound to the muscularis, the trigone has a smooth appearance. Three coats make up the wall of the urinary bladder. The deepest is the mucosa, a mucous membrane composed of transitional epithelium and an underlying lamina propria similar to that of the ureters. The transitional epithelium permits stretching. Rugae (the folds in the mucosa) are also present to permit expansion of the urinary bladder. Surrounding the mucosa is the intermediate muscularis, also called the detrusor muscle (to push down),
which consists of three layers of smooth muscle fibers: the inner longitudinal, middle circular, and outer longitudinal layers. Around the opening to the urethra the circular fibers form an internal urethral sphincter; inferior to it is the external urethral sphincter, which is composed of skeletal muscle and is a modification of the deep muscles of the perineum. The most superficial coat of the urinary bladder on the posterior and inferior surfaces is the adventitia, a layer of areolar connective tissue that is continuous with that of the ureters. Over the superior surface of the urinary bladder is the serosa, a layer of visceral peritoneum.

Figure 1. Anatomy of the male urinary system

male urinary system anatomy

Figure 2. Anatomy of the female urinary system

Anatomy of the female urinary system

Figure 3. Urinary bladder location

urinary bladder location

Figure 4. Urinary bladder anatomy

bladder anatomy

Voiding Urine

Discharge of urine from the urinary bladder, called micturition, is also known as urination or voiding. Micturition occurs via a combination of involuntary and voluntary muscle contractions. When the volume of urine in the urinary bladder exceeds 200–400 mL, pressure within the bladder increases considerably, and stretch receptors in its wall transmit nerve impulses into the spinal cord. These impulses propagate to the micturition center in sacral spinal cord segments S2 and S3 and trigger a spinal reflex called the micturition reflex. In this reflex arc, parasympathetic impulses from the micturition center propagate to the urinary bladder wall and internal urethral sphincter.

The nerve impulses cause contraction of the detrusor muscle and relaxation of the internal urethral sphincter muscle. Simultaneously, the micturition center inhibits somatic motor neurons that innervate skeletal muscle in the external urethral sphincter. On contraction of the urinary bladder wall and relaxation of the sphincters, urination takes place. Urinary bladder filling causes a sensation of fullness that initiates a conscious desire to urinate before the micturition reflex actually occurs. Although emptying of the urinary bladder is a reflex, in early childhood we learn to initiate it and stop it voluntarily.

Through learned control of the external urethral sphincter muscle and certain muscles of the pelvic floor, the cerebral cortex can initiate micturition or delay its occurrence for a limited period.

Figure 5. Bladder control

neural control of urination

Bladder Control Problems in Men (Urinary Incontinence)

Urinary incontinence is the loss of bladder control, resulting in the accidental leakage of urine from the body 1. For example, a man may feel a strong, sudden need, or urgency, to urinate just before losing a large amount of urine, called urgency incontinence.

Urinary incontinence can be slightly bothersome or totally debilitating. For some men, the chance of embarrassment keeps them from enjoying many activities, including exercising, and causes emotional distress. When people are inactive, they increase their chances of developing other health problems, such as obesity and diabetes.

How common is urinary incontinence in men ?

Urinary incontinence occurs in 11 to 34 percent of older men. Two to 11 percent of older men report daily urinary incontinence 2. Although more women than men develop urinary incontinence, the chances of a man developing urinary incontinence increase with age because he is more likely to develop prostate problems as he ages. Men are also less likely to speak with a health care professional about urinary incontinence, so urinary incontinence in men is probably far more common than statistics show. Having a discussion with a health care professional about urinary incontinence is the first step to fixing this treatable problem.

What causes urinary incontinence in men ?

Urinary incontinence in men results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

A man may have factors that increase his chances of developing urinary incontinence, including:

  • birth defects—problems with development of the urinary tract
  • a history of prostate cancer—surgery or radiation treatment for prostate cancer can lead to temporary or permanent urinary incontinence in men

Urinary incontinence is not a disease. Instead, it can be a symptom of certain conditions or the result of particular events during a man’s life. Conditions or events that may increase a man’s chance of developing urinary incontinence include:

  • Benign prostatic hyperplasia—a condition in which the prostate is enlarged yet not cancerous. In men with benign prostatic hyperplasia, the enlarged prostate presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty, leaving some urine in the bladder. The narrowing of the urethra and incomplete emptying of the bladder can lead to urinary incontinence.
  • Chronic coughing—long-lasting coughing increases pressure on the bladder and pelvic floor muscles.
  • Neurological problems—men with diseases or conditions that affect the brain and spine may have trouble controlling urination.
  • Physical inactivity—decreased activity can increase a man’s weight and contribute to muscle weakness.
  • Obesity—extra weight can put pressure on the bladder, causing a need to urinate before the bladder is full.
  • Older age—bladder muscles can weaken over time, leading to a decrease in the bladder’s capacity to store urine.

What are the types of urinary incontinence in men ?

The types of urinary incontinence in men include:

  • Urgency incontinence
  • Stress incontinence
  • Functional incontinence
  • Overflow incontinence
  • Transient incontinence

Urgency Incontinence

Urgency incontinence happens when a man urinates involuntarily after he has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for men with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

The following conditions can damage the spinal cord, brain, bladder nerves, or sphincter nerves, or can cause involuntary bladder contractions leading to urgency incontinence:

  • Alzheimer’s disease—a disorder that affects the parts of the brain that control thought, memory, and language
  • Injury to the brain or spinal cord that interrupts nerve signals to and from the bladder
  • Multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and the body
  • Parkinson’s disease—a disease in which the cells that make a chemical that controls muscle movement are damaged or destroyed
  • Stroke—a condition in which a blocked or ruptured artery in the brain or neck cuts off blood flow to part of the brain and leads to weakness, paralysis, or problems with speech, vision, or brain function

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. In men, stress incontinence may also occur:

  • after prostate surgery
  • after neurologic injury to the brain or spinal cord
  • after trauma, such as injury to the urinary tract
  • during older age

Functional Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a place to urinate in time. For example, a man with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A man in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a man to walk to the restroom quickly or open his pants in time.

Overflow Incontinence

When the bladder doesn’t empty properly, urine spills over, causing overflow incontinence. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Men with overflow incontinence may have to urinate often, yet they release only small amounts of urine or constantly dribble urine.

Transient Incontinence

Transient incontinence is urinary incontinence that lasts a short time. Transient incontinence is usually a side effect of certain medications, drugs, or temporary conditions, such as:

  • Urinary tract infection, which can irritate the bladder and cause strong urges to urinate
  • Caffeine or alcohol consumption, which can cause rapid filling of the bladder
  • Chronic coughing, which can put pressure on the bladder
  • Constipation—hard stool in the rectum can put pressure on the bladder
  • Blood pressure medications that can cause increased urine production
  • Short-term mental impairment that reduces a man’s ability to care for himself
  • Short-term restricted mobility

How is urinary incontinence in men diagnosed ?

Men should tell a health care professional, such as a family practice physician, a nurse, an internist, or a urologist—a doctor who specializes in urinary problems—they have urinary incontinence, even if they feel embarrassed. To diagnose urinary incontinence, the health care professional will:

  • take a medical history
  • conduct a physical exam
  • order diagnostic tests

Medical History

Taking a medical history can help a health care professional diagnose urinary incontinence. He or she will ask the patient or caretaker to provide a medical history, a review of symptoms, a description of eating habits, and a list of prescription and over-the-counter medications the patient is taking. The health care professional will ask about current and past medical conditions.

The health care professional also will ask about the man’s pattern of urination and urine leakage. To prepare for the visit with the health care professional, a man may want to keep a bladder diary for several days beforehand. Information that a man should record in a bladder diary includes:

  • the amount and type of liquid he drinks
  • how many times he urinates each day and how much urine is released
  • how often he has accidental leaks
  • whether he felt a strong urge to go before leaking
  • what he was doing when the leak occurred, for example, coughing or lifting
  • how long the symptoms have been occurring

The health care professional also may ask about other lower urinary tract symptoms that may indicate a prostate problem, such as:

  • problems starting a urine stream
  • problems emptying the bladder completely
  • spraying urine
  • dribbling urine
  • weak stream
  • recurrent urinary tract infections
  • painful urination

Physical Exam

A physical exam may help diagnose urinary incontinence. The health care professional will perform a physical exam to look for signs of medical conditions that may cause urinary incontinence. The health care professional may order further neurologic testing if necessary.

Digital rectal exam. The health care professional also may perform a digital rectal exam. A digital rectal exam is a physical exam of the prostate and rectum. To perform the exam, the health care professional has the man bend over a table or lie on his side while holding his knees close to his chest. The health care professional slides a gloved, lubricated finger into the patient’s rectum and feels the part of the prostate that lies in front of the rectum. The digital rectal exam is used to check for stool or masses in the rectum and to assess whether the prostate is enlarged or tender, or has other abnormalities. The health care professional may perform a prostate massage during a digital rectal exam to collect a sample of prostate fluid that he or she can test for signs of infection.

The health care professional may diagnose the type of urinary incontinence based on the medical history and physical exam, or he or she may use the findings to determine if a man needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or more of the following diagnostic tests based on the results of the medical history and physical exam:

  • Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container at home, at a health care professional’s office, or at a commercial facility. A health care professional tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in urine.
  • Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A man collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the man has a urinary tract infection.
  • Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show kidney function problems or a chemical imbalance in the body. The lab also will test the blood to assess the level of prostate-specific antigen, a protein produced by prostate cells that may be higher in men with prostate cancer.
  • Urodynamic testing. Urodynamic testing includes a variety of procedures that look at how well the bladder and urethra store and release urine. A health care professional performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely; they may include the following:
    + uroflowmetry, which measures how rapidly the bladder releases urine
    + postvoid residual measurement, which evaluates how much urine remains in the bladder after urination
    + reduced urine flow or residual urine in the bladder, which often suggests urine blockage due to benign prostatic hyperplasia

How is urinary incontinence in men treated ?

Treatment depends on the type of urinary incontinence.

Urgency Incontinence

As a first line of therapy for urgency incontinence, a health care professional may recommend the following techniques to treat a man’s problem:

  • behavioral and lifestyle changes
  • bladder training
  • pelvic floor exercises
  • urgency suppression

If those treatments are not successful, the following additional measures may help urgency incontinence:

  • medications
  • electrical nerve stimulation
  • bulking agents
  • surgery

A health care professional may recommend other treatments for men with urgency incontinence caused by Benign Prostatic Hyperplasia.

Behavioral and lifestyle changes. Men with urgency incontinence may be able to reduce leaks by making behavioral and lifestyle changes:

  • Eating, diet, and nutrition. Men with urgency incontinence can change the amount and type of liquid they drink. A man can try limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—to decrease leaks. Men also should limit alcoholic drinks, which can increase urine production. A health care professional can help a man determine how much he should drink based on his health, how active he is, and where he lives. To decrease nighttime trips to the restroom, men may want to stop drinking liquids several hours before bed.
  • Engaging in physical activity. Although a man may be reluctant to engage in physical activity when he has urgency incontinence, regular exercise is important for good overall health and for preventing and treating urinary incontinence.
  • Losing weight. Men who are overweight should talk with a health care professional about strategies for losing weight, which can help improve urinary incontinence.
  • Preventing constipation. Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to urinary incontinence. The opposite is also true: Urinary problems, such as urinary incontinence, can make gastrointestinal problems worse.

To Help Prevent Bladder Problems, Stop Smoking

People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chance of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time 3.

Bladder training. Bladder training is changing urination habits to decrease incidents of urinary incontinence. The health care professional may suggest a man use the restroom at regular timed intervals, called timed voiding, based on the man’s bladder diary. A man can gradually lengthen the time between trips to the restroom to help stretch the bladder so it can hold more urine.

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles hold in urine more effectively than weak muscles. A man does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination.

Men also may learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video monitor displays the measurements as graphs, and sounds indicate when the man is using the correct muscles. The health care professional uses the information to help the man change abnormal function of the pelvic floor muscles. At home, the man practices to improve muscle function. The man can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of urinary incontinence, its severity, and the man’s ability to perform the exercises.

Urgency suppression. By using certain techniques, a man can suppress the urge to urinate, called urgency suppression. Urgency suppression is a way for a man to train his bladder to maintain control so he does not have to panic about finding a restroom. Some men use distraction techniques to take their mind off the urge to urinate. Other men find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urge to urinate.

Medications. Health care professionals may prescribe medications that relax the bladder, decrease bladder spasms, or treat prostate enlargement to treat urgency incontinence in men.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Tricyclic antidepressants. Tricyclic antidepressants such as imipramine (Tofranil) can calm nerve signals, decreasing spasms in bladder muscles.

Alpha-blockers. Terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo) are used to treat problems caused by prostate enlargement and bladder outlet obstruction. These medications relax the smooth muscle of the prostate and bladder neck, which lets urine flow normally and prevents abnormal bladder contractions that can lead to urgency incontinence.

5-alpha reductase inhibitors. Finasteride (Proscar) and dutasteride (Avodart) block the production of the male hormone dihydrotestosterone, which accumulates in the prostate and may cause prostate growth. These medications may help to relieve urgency incontinence problems by shrinking an enlarged prostate.

Beta-3 agonists. Mirabegron (Myrbetriq) is a beta-3 agonist a person takes by mouth to help prevent symptoms of urgency incontinence. Mirabegron suppresses involuntary bladder contractions.

Botox. A health care professional may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urinary incontinence in men with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing urinary incontinence. A health care professional performs the procedure during an office visit. A man receives local anesthesia. The health care professional uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, a urologist may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency—urination more often than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation 4.

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. The patient receives local anesthesia for the procedure. In an outpatient center, a urologist inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although researchers consider percutaneous tibial nerve stimulation safe, they continue to study the exact ways that it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center using local anesthesia. Based on the patient’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The patient can turn the stimulator on or off at any time.

A patient may consider getting an implanted device that delivers regular impulses to the bladder. A urologist places a wire next to the tailbone and attaches it to a permanent stimulator under the skin.

Bulking agents. A urologist injects bulking agents, such as collagen and carbon spheres, near the urinary sphincter to treat incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, the health care professional may perform a skin test to make sure the man doesn’t have an allergic reaction to the bulking agent. A urologist performs the procedure during an office visit. The man receives local anesthesia. The urologist uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a man may need to have injections again.

Surgery. As a last resort, surgery to treat urgency incontinence in men includes the artificial urinary sphincter (AUS) and the male sling. A health care professional performs the surgery in a hospital with regional or general anesthesia. Most men can leave the hospital the same day, although some may need to stay overnight.

Artificial urinary sphincter. An artificial urinary sphincter is an implanted device that keeps the urethra closed until the man is ready to urinate. The device has three parts: a cuff that fits around the urethra, a small balloon reservoir placed in the abdomen, and a pump placed in the scrotum—the sac that holds the testicles. The cuff contains a liquid that makes it fit tightly around the urethra to prevent urine from leaking. When it is time to urinate, the man squeezes the pump with his fingers to deflate the cuff. The liquid moves to the balloon reservoir and lets urine flow through the urethra. When the bladder is empty, the cuff automatically refills in the next 2 to 5 minutes to keep the urethra tightly closed.

Male sling. A health care professional performs a sling procedure, also called urethral compression procedure, to add support to the urethra, which can sometimes better control urination. Through an incision in the tissue between the scrotum and the rectum, also called the perineum, the health care professional uses a piece of human tissue or mesh to compress the urethra against the pubic bone. The surgeon secures the ends of the tissue or mesh around the pelvic bones. The lifting and compression of the urethra sometimes provides better control over urination.

Stress Incontinence

Men who have stress incontinence can use the same techniques for treating urgency incontinence.

Functional Incontinence

Men with functional incontinence may wear protective undergarments if they worry about reaching a restroom in time. These products include adult diapers or pads and are available from drugstores, grocery stores, and medical supply stores. Men who have functional incontinence should talk to a health care professional about its cause and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Men with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a man how to use a catheter. A man may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the man’s thigh with a strap. Men using a continuous catheter should watch for symptoms of an infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to urinary incontinence, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat urinary tract infections.

Bladder Control Problems in Women (Urinary Incontinence)

Urinary incontinence in women results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both 5. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

A woman may be born with factors that increase her chances of developing urinary incontinence, which include:

  • birth defects—problems with development of the urinary tract
  • genetics—a woman is more likely to have urinary incontinence if other females in her family have urinary incontinence
  • race—Caucasian women are more likely to be affected than Hispanic/Latina, African American, or Asian American women

Urinary incontinence is not a disease. Urinary incontinence can be a symptom of certain conditions or the result of certain events during a woman’s life. Conditions or events that may increase a woman’s chance of developing urinary incontinence include:

  • Childbirth—the childbirth process can damage the muscles and nerves that control urination
  • Chronic coughing—long-lasting coughing increases pressure on the bladder and pelvic floor muscles
  • Menopause—reduces production of the hormone that keeps the lining of the bladder and urethra healthy
  • Neurological problems—women with diseases or conditions that affect the brain and spine may have trouble controlling urination
  • Physical inactivity—decreased activity can increase a woman’s weight and contribute to muscle weakness
  • Obesity—extra weight can put pressure on the bladder, causing a need to urinate before the bladder is full
  • Older age—bladder muscles can weaken over time, leading to a decrease in the bladder’s capacity to store urine
  • Pelvic organ prolapse—causes sagging of the bladder, bowel, or uterus out of their normal positions
  • Pregnancy—the fetus can put pressure on the bladder during pregnancy.

How common is urinary incontinence in women ?

Research shows that 25 to 45 percent of women have some degree of urinary incontinence. In women ages 20 to 39, 7 to 37 percent report some degree of urinary incontinence. Nine to 39 percent of women older than 60 report daily urinary incontinence. Women experience urinary incontinence twice as often as men 2. Pregnancy, childbirth, menopause, and the structure of the female urinary tract account for this difference.

What are the types of urinary incontinence in women ?

The types of urinary incontinence in women include:

  • Stress incontinence
  • Urgency incontinence
  • Mixed incontinence
  • Other types of incontinence

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. Physical changes from pregnancy and childbirth often cause stress incontinence. Weakening of pelvic floor muscles can cause the bladder to move downward, pushing the bladder slightly out of the bottom of the pelvis and making it difficult for the sphincters to squeeze tightly enough. As a result, urine can leak during moments of physical stress. Stress incontinence can also occur without the bladder moving downward if the urethra wall is weak. This type of incontinence is common in women, and a health care professional can treat the condition.

Urgency Incontinence

Urgency incontinence is the loss of urine when a woman has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for women with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

Damage to the spinal cord or brain, the bladder nerves, or the bladder muscles may cause involuntary bladder contractions. Bladder nerves and muscles can be affected by:

  • Alzheimer’s disease—a brain disorder that affects the parts of the brain that control thought, memory, and language
    injury
  • Multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and body
  • Parkinson’s disease—a disease in which cells that make a chemical that controls muscle movement are damaged or destroyed
  • Stroke—a condition in which the blood supply to the brain is suddenly cut off, caused by a blockage or the bursting of a blood vessel in the brain or neck

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Mixed Incontinence

Mixed incontinence is when stress and urgency incontinence occur together.

Other Types of Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a toilet in time. For example, a woman with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A woman in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a woman to walk to the toilet quickly or unbutton her pants in time.

Transient incontinence is urinary incontinence that lasts a short time. Transient incontinence is usually caused by medications or a temporary condition, such as:

  • a urinary tract infection (UTI)—a UTI can irritate the bladder, causing strong urges to urinate
  • caffeine or alcohol consumption—consumption of caffeine or alcohol can cause rapid filling of the bladder
  • chronic coughing—chronic coughing can put pressure on the bladder
  • constipation—hard stool in the rectum can put pressure on the bladder
  • medication—blood pressure medications can cause increased production of urine
  • short-term mental impairment
  • short-term restricted mobility

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. A health care professional can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

How is urinary incontinence in women diagnosed ?

Women should let their health care provider, such as a family practice physician, a nurse, an internist, a gynecologist, urologist, or a urogynecologist—a gynecology doctor who has extra training in bladder problems and pelvic problems in women—know they have urinary incontinence, even if they feel embarrassed. To diagnose urinary incontinence, a health care professional will take a medical history and conduct a physical exam. The health care professional may order diagnostic tests, such as a urinalysis.

Medical History

The health care professional will take a medical history and ask about symptoms, patterns of urination and urine leakage, bowel function, medications, history of childbirth, and past pelvic operations. To prepare for the visit with the health care professional, a woman may want to keep a bladder diary for several days beforehand. Information that a woman should record in a bladder diary includes:

  • what and how much she drinks
  • how many times she urinates and how much urine is released
  • how often she has accidental leaks
  • whether she feels a strong urge to go before leaking
  • what she was doing when leaks occurred, for example, coughing or lifting

Physical Exam

The health care professional will also perform a limited physical exam to look for signs of medical conditions that may cause urinary incontinence. The health care professional may order further neurologic testing if necessary. The health care professional may also perform pelvic and rectal exams.

Pelvic exam. A pelvic exam is a visual and physical exam of the pelvic organs. The health care professional has the woman come to the exam with a full bladder. The woman will sit upright with her legs spread and asks her to cough. This test is called a cough stress test. Leakage of urine indicates stress incontinence. The health care professional then has the woman lie on her back on an exam table and place her feet on the corners of the table or in supports. The health care professional looks at the pelvic organs and slides a gloved, lubricated finger into the vagina to check for prolapse or other physical problems that may be causing urinary incontinence. The health care professional will determine the woman’s pelvic muscle strength by asking her to squeeze her pelvic floor muscles.

Digital rectal exam. A digital rectal exam is a physical exam of the rectum. The health care professional slides a gloved, lubricated finger into the rectum, usually during a pelvic exam. A health care professional uses the digital rectal exam to check for stool or masses in the rectum that may be causing urinary incontinence.

The health care professional may diagnose the type of urinary incontinence based on the medical history and physical exam or use this information to determine if a woman needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or both of the following diagnostic tests, based on the results of the medical history and physical exam:

Urinalysis. Urinalysis is testing of a urine sample. The patient collects the urine sample in a special container in a health care professional’s office or a commercial facility for testing and analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when blood or protein is present in urine. A person does not need anesthesia for this test. The test can show if the woman has a urinary tract infection, a kidney problem, or diabetes.

Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A woman collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the woman has a urinary tract infection.

Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show problems with kidney function or a chemical imbalance in the body.

Urodynamic testing. Urodynamic testing is any procedure that looks at how well the bladder, urethra, and sphincters store and release urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely.

How is urinary incontinence in women treated ?

Treatment depends on the type of urinary incontinence. Health care professionals may recommend behavioral and lifestyle changes, stopping smoking, bladder training, pelvic floor exercises, and urgency suppression as a first-line therapy for most types of urinary incontinence.

Stress Incontinence

Behavioral and lifestyle changes. Women with urinary incontinence may be able to reduce leaks by making behavioral and lifestyle changes. For example, the amount and type of liquid women drink can affect urinary incontinence. Women should talk with their health care professional about whether to drink less liquid during the day; however, women should not limit liquids to the point of becoming dehydrated.

Signs of dehydration in women include:

  • constipation
  • dark-colored urine
  • dizziness
  • dry skin
  • fatigue, or feeling tired
  • less frequent urination than usual
  • light-headedness
  • thirst

A health care professional can help a woman determine how much she should drink to prevent dehydration based on her health, how active she is, and where she lives.

To decrease nighttime trips to the bathroom, women may want to stop drinking liquids several hours before bedtime if suggested by a health care professional.

Limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—may decrease leaks. Women should also limit alcoholic drinks, which can increase urine production.

Although a woman may be reluctant to engage in physical activity when she has urinary incontinence, regular exercise is important for weight management and good overall health. Losing weight may improve urinary incontinence and not gaining weight may prevent urinary incontinence. If a woman is concerned about not having easy access to a bathroom during physical activity, she can walk indoors, like in a mall, for example. Women who are overweight should talk with their health care professional about strategies for losing weight. Being obese increases a person’s chances of developing urinary incontinence and other diseases, such as diabetes. According to one study, decreasing obesity and diabetes may lessen the burden of urinary incontinence, especially in women 6.

Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to urinary incontinence. The opposite is also true: Urinary problems such as urinary incontinence can make GI problems worse. For example, medications such as antimuscarinics, which health care professionals use to treat urinary incontinence, have side effects such as constipation.

Health care professionals can offer several options for treating constipation.

Although a woman may be reluctant to engage in physical activity when she has urinary incontinence, regular exercise is important for weight management and good overall health.

Stopping Smoking. People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chances of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time 7.

Bladder training. Bladder training is changing urination habits to decrease incidents of urinary incontinence. Based on a woman’s bladder diary, the health care professional may suggest using the bathroom at regular timed intervals, called timed voiding. Gradually lengthening the time between trips to the bathroom can help by stretching the bladder so it can hold more urine. Recording daily bathroom habits may be helpful.

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold in urine than weak muscles. A woman does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination. A health care professional can help a woman learn proper technique.

Women may also learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video screen displays the measurements as graphs, and sounds indicate when the woman is using the correct muscles. The health care professional uses the information to help the woman change abnormal function of the pelvic floor muscles. At home, the woman practices to improve muscle function. The woman can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of urinary incontinence, its severity, and the woman’s ability to perform the exercises on a regular basis.

If behavioral and lifestyle changes, stopping smoking, bladder training, and pelvic floor muscle exercises are not successful, additional measures for stress incontinence, including medical devices, bulking agents, and—as a last resort—surgery, may help.

Medical devices. A health care professional may prescribe a urethral insert or pessary to treat stress incontinence. A urethral insert is a small, tamponlike, disposable device inserted into the urethra to prevent leakage. A woman may use the insert to prevent urinary incontinence during a specific activity or wear it throughout the day. The woman removes the insert to urinate. A pessary is a stiff ring inserted into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less leakage. The woman should remove the pessary regularly for cleaning.

Bulking agents. A doctor injects bulking agents, such as collagen and carbon beads, near the urinary sphincter to treat urgency and stress incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, a health care professional may perform a skin test to make sure the woman doesn’t have an allergic reaction to the bulking agent. A doctor performs the procedure during an office visit. The woman receives local anesthesia. The doctor uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a woman may need to have injections again. The treatment is effective in about 40 percent of cases 8.

Surgery. The bladder neck dropping toward the vagina can cause incontinence problems. Surgery to treat stress incontinence includes retropubic suspension and sling procedures. A doctor performs the operations in a hospital. The patient receives general anesthesia. Most women can leave the hospital the same day, though some may need to stay overnight. Full recovery takes 2 to 3 weeks; women who also have surgery for pelvic organ prolapse at the same time may have a longer recovery time.

Retropubic suspension. With retropubic suspension, the doctor raises the bladder neck or urethra and supports it using surgical threads called sutures. The doctor makes an incision in the area between the chest and the hips—also called the abdomen—a few inches below the navel and secures the sutures to strong ligaments within the pelvis to support the urethral sphincter.

Sling. The doctor performs sling procedures through a vaginal incision and uses natural tissue, man-made sling material, or synthetic mesh tape to cradle the bladder neck or urethra, depending on the type of sling procedure being performed. The doctor attaches the sling to the pubic bone or pulls the sling through an incision behind the pubic bone or beside the vaginal opening and secures it with stitches.

The Urinary Incontinence Treatment Network compared the suspension and sling procedures and found that according to women’s bladder diaries, about 31 percent with a sling and 24 percent with a suspension were still continent, or able to hold urine, all of the time 5 years after surgery. However, 73 percent of women in the suspension group and 83 percent of women in the sling group said they were satisfied with their results. Rates of adverse events such as urinary tract infections and urinary incontinence were similar for the two groups, at 10 percent for the suspension group and 9 percent for the sling group 9.

Serious complications are associated with the use of surgical mesh to repair incontinence. Possible complications include erosion through the lining of the vagina, infection, pain, urinary problems, and recurrence of incontinence.

Each woman should speak to her health care professional to help decide which surgery, if any, is right for her.

Urgency Incontinence

Women who have urgency incontinence can use the same techniques as for stress incontinence, including bladder training, urgency suppression, pelvic floor exercises, and behavioral and lifestyle changes. A woman can also try urgency suppression techniques, medications, Botox injections, and electrical nerve stimulation if necessary.

Urgency suppression. By using certain techniques, a woman can suppress the strong urge to urinate, called urgency suppression. Urgency suppression is a way to train the bladder to maintain control so a woman does not have to panic about finding a bathroom in the meantime. Some women use distraction techniques to take their mind off the urge to urinate. Other women find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urgency to urinate.

Medications. Health care professionals may prescribe medications that relax the bladder or decrease bladder spasms to treat urgency incontinence in women.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), which a person can buy over the counter, tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Tricyclic antidepressants. Tricyclic antidepressants such as imipramine (Tofranil) can calm nerve signals, decreasing spasms in bladder muscles.

Beta-3 agonists. Mirabegron (Myrbetriq) is a beta-3 agonist a person takes by mouth to help prevent symptoms of incontinence. Mirabegron suppresses involuntary bladder contractions.

Botox. A doctor may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urgency incontinence in women including those with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing urinary incontinence. A doctor often performs the procedure during an office visit. A woman receives local anesthesia. The doctor uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency—urinating more than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation 4.

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. Anesthesia is not normally needed for the procedure. In an outpatient center, a health care professional inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although percutaneous tibial nerve stimulation is considered safe, researchers continue to study the exact ways it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves a health care professional implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center often with local anesthesia. Based on the person’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair—or through special devices inserted into the vagina. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The person can turn the stimulator on or off at any time. If a period of test stimulation is successful, a health care professional will implant a device that delivers regular impulses to the bladder. A health care professional places a wire next to the tailbone and attaches it to a permanent stimulator under the skin of the lower abdomen.

If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency, and other symptoms.

Mixed Incontinence

Depending on the type of symptoms a woman has, she may successfully treat her mixed incontinence with techniques, medications, devices, or surgery. A health care professional can help decide what kind of treatments may work for each symptom.

Functional Incontinence

Women with functional incontinence may wear protective undergarments if they worry about reaching a toilet in time. Women who have functional incontinence should talk to their health care professional about its causes and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Women with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a woman how to use a catheter. A woman may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the woman’s thigh with a strap. Women using a continuous, often called indwelling, catheter should watch for symptoms of a urinary tract infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to urinary incontinence, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat urinary tract infections.

How can someone cope with leaking urine ?

Even after treatment, some women still leak urine from time to time. Certain products can help women cope with leaking urine:

  • Pads. Women can wear disposable pads in their underwear to absorb leaking urine.
  • Adult diapers. A woman can wear an adult diaper to keep her clothes dry.
  • Waterproof underwear. Waterproof underwear can protect clothes from getting wet.
  • Disposable pads. Disposable pads can be used to protect chairs and beds from urine.
  • Special skin cleaners and creams. Special skin cleaners and creams may help the skin around the urethra from becoming irritated. Creams can help block urine from skin.
  • Urine deodorizing tablets. A woman should talk with a health care professional about whether urine deodorizing tablets can make her urine smell less strongly.

Eating, Diet, and Nutrition

No direct scientific evidence links eating, diet, and nutrition to either improving or worsening urinary incontinence. However, many people find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation, which can sometimes lead to urinary incontinence 10. Moreover, good eating, diet, and nutrition are directly related to preventing factors that increase the chances of developing urinary incontinence, such as obesity and diabetes.

References
  1. Bladder Control Problems in Men (Urinary Incontinence). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-men
  2. Buckley BS, Lapitan MCM. Prevalence of urinary incontinence in men, women, and children—current evidence: findings of the Fourth International Consultation on Incontinence. Urology. 2010;76(2):265–270.
  3. National Cancer Institute. What You Need to Know About Bladder Cancer. Rockville, MD; 2010. Booklet.
  4. Staskin DR, Peters KM, MacDiarmid S, Shore N, de Groat WC. Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care. Current Urology Reports. 2012;13(5):327–334.
  5. Bladder Control Problems in Women (Urinary Incontinence). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women
  6. Markland AD, Richter HE, Fwu CW, Eggers P, Kusek JW. Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008. Journal of Urology. 2011;186(2):589–593.
  7. National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. What You Need to Know About Bladder Cancer. Rockville, MD: National Cancer Institute; 2010. NIH Publication No.10-1559.
  8. Deng DY. Urinary incontinence in women. Medical Clinics of North America. 2011;95(1):101–109.
  9. Brubaker L, Richter HE, Norton PA, et al. 5-year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. Journal of Urology. 2012;187(4):1324–1330.
  10. Friedlander JI, Shorter B, Moldwin RM. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU International. 2012;109(11):1584–1591.
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