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This is a new topic BethShelly BethShelly 0 17 Apr 28, 2017 by BethShelly BethShelly


Editor: Elisabetta Costantini, March 2016


CURRENT DEFINITION
Continuous urinary incontinence (CUI) is the complaint of continuous involuntary loss of urine (1)
OLD DEFINITION
Continuous urinary incontinence (CUI) is the complaint of continuous leakage (2)
DEFINITION ON THE BASIS OF SIGN AND SYMPTOMS
Uncategorised incontinence: is the observation of involuntary leakage that cannot be classified into one of the categories (stress or urgency incontinence) on the basis of signs and symptoms (2)
IS IT A NEW TOPIC?
No!! It is known,but nobody talks about it roundly!! In fact in the literature there are no specific studies about this issue, so there are no epidemiological data. The only data available are those of the pathologies that cause CUI, thus indirectly it can be considered as epidemiological data of CUI.
CUI can be classified based on the causes and the site of leakage.
Classification on the basis of the causes:
  • Iatrogenic or cancer causes (Urogenital fistula)
  • Congenital causes (Ectopic ureter)
  • Functional causes (Intrinsic sphincter deficiency (ISD)
Classification on the basis of the site of the leakage:
  • Extra urethral incontinence: is defined as the observation of urine leakage through channels other than the urethral meatus, for example, fistula (1)
  • Urethral incontinence: is defined as the observation of urine leakage through the urethra.


CONTROVERSIES: AN ENIGMATIC TOPIC!
Continuous urinary incontinence may be the manifestation of a congenital condition, the result of urogenital fistula or of severe intrinsic sphincter deficiency (ISD) (neurological or not). It can also represent an altered perception of urinary incontinence: for example the patient is not able to separate the time of leakage from dry periods, when incontinence is severe and leakages occur “all the time”. In fact they may be unable to contextualize the leakage in stress, urgency or special situations. In other cases the patient is not able to determine the type of leakage . In fact she thinks the wetness she feels is urine when in fact it is sweating or vaginal discharge.
HOW CAN WE DIFFERENTIATE A CASE OF TRUE CONTINUOUS URINARY INCONTINENCE FROM URINARY INCONTINENCE WHICH IMITATES CONTINUOUS URINARY INCONTINENCE?
A careful medical and urogynecologic history may be useful (obstetric trauma, pelvic surgery, radiation therapy, type of leakage)
In case of vescicovaginal fistula (VVF) there is a constant urinary leakage from the vagina (extra urethral incontinence). The amount of urinary leakage varies from patient to patient and may be proportional to the size of the fistulus tract. When a large fistula is present patients have continuous urinary leakage from the vagina, while in case of small fistula drainage may be minimal and intermittent. In fact in the supine position the amount of leakage is small, but on rising to a seated or standing position the amount of leakage may increase precipitously. After hysterectomy VVF may manifest after removal of the urethral catheter, 1 to 2 weeks later, or after months or years after completion of radiotherapy. In case of ureterovaginal fistula (UVF) continuous urinary incontinence may manifest 1 to 4 weeks after surgery, and in these patients, in contrast to VVF, the normal bladder filling is maintained from the contralateral ureter with normal voiding habits. Vescicouterine fistula (VUF) in general doesn’t cause continuous urinary leakage, because the cervix works like a sphincter. Nevertheless, immediately after delivery, when the cervix is still incompetent, the patient may present CUI (urine flows from the bladder into the uterus -through fistula- and from uterine cavity into the vagina). Symptoms of urethrovaginal fistula (UrethVF) depend on the size and location of the fistula along the urethral lumen. Only a large fistula localized at the bladder neck can cause continuous urine drainage, while a small fistula, localized at the distal urethral lumen causes minimal incontinence and may be associated with a splayed urinary stream. Sometimes patients may have “vaginal voiding and pseudoincontinence” because they report postural (urinary) incontinence (1).
A careful clinical urogynecologic examination may be useful in finding any fistula or other clues to explain the leakage. In case of a diagnosis of a fistula, the related flowchart should be followed.
In case of a negative medical examination for fistula, one should think of a severe form of urinary incontinence (neurological or not neurological stress urinary incontinence associated with ISD or overflow incontinence).Uroflowmetry with post-void residual measurement, micturition diary for a 3 –day period with associated pad-test, abdominal ultrasonography, urine analysis and culture as well as the second level exams such as urodynamic testing and transperineal ultrasonography,can be helpful in diagnosis.Without iatrogenic or functional causes one might suspect an ectopic ureter that can be misdiagnosed for many years as a chronic vaginal discharge. In such a case a dye test can be helpful to verify if the leakage represents urine versus another fluid such as vaginal discharge.

TREATMENT OF TRUE CONTINUOUS URINARY INCONTINENCE
The treatment of CUI depends on a clear understanding of the cause and pathophysiology underlying the patient’s condition.

References
  1. 1. Bernard T. Haylen, Dirk de Ridder, Robert M. Freeman; An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction Neurourology and Urodynamics 29:4–20 (2010)
  2. 2. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A; The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21(2):167-78.

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