Urinary incontinence in easy way from bailey and love

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Here is Urinary Incontinence explained simply, directly from Bailey and Love's Short Practice of Surgery, 28th Edition:

Urinary Incontinence - Bailey and Love

What Is It?

Urinary incontinence (UI) is simply the involuntary (unintentional) leakage of urine. It affects 25-45% of men and women and becomes more common with age. It has a significant impact on quality of life.

Types (Classification)

Type	What Happens	Easy Memory
Stress UI (SUI)	Leakage on effort - coughing, sneezing, laughing, exercise	"Stress = physical stress on bladder"
Urgency UI (UUI)	Leakage with a sudden, strong urge to urinate that's hard to hold	"Gotta go NOW"
Mixed UI (MUI)	Both SUI and UUI together	"Mix of both"
Overflow / Chronic retention	Bladder doesn't empty fully; urine leaks out when full	"Cup overflowing"
Continuous UI	Constant leaking - suspect fistula or ectopic ureter	"Non-stop drip"
Nocturnal enuresis	Leakage during sleep (bedwetting)	"Night time leak"
Functional UI	Can't reach the toilet in time due to mobility/cognitive problems, but the bladder itself is normal	"Problem getting there, not the bladder"

Overactive Bladder (OAB) = urgency + frequency + nocturia, with or without leakage. Can be neurogenic or idiopathic.

How Continence Normally Works (Pathogenesis)

Staying dry depends on 4 things:

Normal bladder compliance - bladder expands without pressure rising (thanks to its elastic, low-collagen wall)
Intact urethral sphincter - keeps the outlet closed
Pelvic floor support - a "hammock" of fascia and muscles (pubocervical fascia + levator ani) that holds the bladder neck in place
Mucosal seal of the urethra - the soft tissue lining that creates a watertight closure

Why SUI happens:

The pelvic floor "hammock" becomes lax (from childbirth, ageing, menopause)
The urethra drops out of its normal position
During coughing/sneezing, raised intra-abdominal pressure is NOT transmitted to the urethra - so it can't resist the pressure, and urine leaks
Intrinsic sphincter deficiency (ISD) - the sphincter muscle itself is weak (from previous surgery, radiation, nerve damage, oestrogen loss)
Most women with SUI have BOTH laxity and ISD to varying degrees

Why UUI/OAB happens:

Detrusor (bladder muscle) overactivity - the muscle contracts before the bladder is full
Reduced bladder compliance from fibrosis, neurological causes, or chronic obstruction

Risk Factors

Predisposing (structural):

Family history
Ectopic ureter, urinary tract fistulae, urethral diverticulum
Neurological conditions - spina bifida, spinal cord injury, Parkinson's, stroke, multiple sclerosis
Pregnancy and childbirth (vaginal delivery)
Pelvic surgery or radiotherapy
Chronic bladder inflammation causing fibrosis (TB cystitis, ketamine cystitis, interstitial cystitis)

Exacerbating (making it worse):

Age
Obesity
Raised intra-abdominal pressure (chronic cough, constipation, heavy lifting)
Menopause (oestrogen loss weakens urethral mucosa)
Loop diuretics, certain medications
Urinary tract infection (UTI)
Diabetes mellitus
Immobility

In men, the most common cause of SUI is radical prostatectomy for prostate cancer.

Symptoms to Ask About

Storage symptoms:

Frequency (>8 times/day)
Urgency
Nocturia (>1 void/night)
Leakage with exertion/coughing

Voiding symptoms:

Hesitancy, slow stream, incomplete emptying, straining

Post-micturition:

Post-void dribble, feeling of incomplete emptying

Also ask about: haematuria (in women >40 years, must rule out malignancy)

Investigations

Investigation	Purpose
Bladder diary + symptom/QOL questionnaire	Baseline - how often, how much, triggers
Urine dipstick + MSU	Rule out UTI, haematuria
Digital examination	Pelvic floor tone, prolapse, masses
Post-void residual (PVR) ultrasound	Is bladder emptying properly?
Urodynamics	For MUI, voiding dysfunction, neurological causes, treatment failure, or recurrence after surgery
KUB ultrasound	For recurrent UTI or haematuria
Cystoscopy	If bladder pathology suspected

Management

Treatment is tailored to the type of incontinence and is stepped:

OAB / Urgency UI

Step	Treatment
Conservative	Limit fluids (avoid caffeine), bladder training (bladder drill) for ≥6 weeks, pelvic floor exercises (8 contractions x 3/day for ≥3 months), review medications
Medical	Anticholinergics: oxybutynin, tolterodine (side effects: dry mouth, constipation - avoid oxybutynin in elderly due to cognitive risk); β3-agonist: mirabegron; Desmopressin for nocturia
Surgical	Intravesical botulinum toxin A; Neuromodulation (tibial nerve or sacral nerve stimulation); Augmentation cystoplasty (risks: bowel disturbance, metabolic acidosis, mucus retention, UTI, malignancy); Urinary diversion (last resort)

Stress UI (SUI)

Step	Treatment
Conservative	Pelvic floor exercises (≥8 contractions x 3/day for ≥3 months), manage chronic cough, ISC if poor emptying
Medical	Duloxetine (SNRI) - only when conservative failed AND surgery contraindicated/declined
Surgical	Colposuspension (bladder neck suspension); Autologous rectus fascial sling; Retropubic mid-urethral mesh sling; Periurethral bulking agents; Artificial urinary sphincter

Do NOT offer: anterior colporrhaphy, needle suspension, paravaginal defect repair, porcine dermis sling, or Marshall-Marchetti-Krantz procedure for SUI.

Summary Box (Bailey and Love Key Points)

UI should be classified as UUI, SUI, or MUI
Initial management for ALL types = behavioural modification + bladder training + pelvic floor muscle training (PFMT)
OAB: first-line medical = anticholinergics; if failed = botulinum toxin A
For "end-stage" incontinence failing all measures: urinary diversion (ileal conduit) as last resort

Quick Memory Trick

Types: S-U-M-C-N-O-F
Stress - Urgency - Mixed - Continuous - Nocturnal - Overflow - Functional

Management (all types start with): Pelvic Floor + Behaviour
Then add medical → then surgical

- Bailey and Love's Short Practice of Surgery, 28th Edition (Chapter 83 & 87)

Intersinatl obstruction

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