Urine sting refers to the appearance of pinprick-like pain in the suprapubic area and urethra during or after urination, often accompanied by symptoms such as frequent urination and urgency. It is more common in various urinary system lesions, such as cystitis, urethritis, urinary stones, etc.
Epidemiology
High-risk populationNon-specific group
symptom
Typical manifestations
Urine leaks, drips, or flows out of the urethra without subjective control.
1. Degree of incontinence
(1) Mild: Urine leakage occurs only when coughing, sneezing, or picking up heavy objects;
(2) Moderate: Urinary incontinence occurs when walking, standing, or exerting light force;
(3) Severe: Urinary incontinence can occur in both standing and lying positions. It can be divided into the following categories based on the manifestation and duration of symptoms:
2. Different durations
(1) Persistent overflow: This occurs in complete urinary incontinence, where urethral resistance is completely lost, the bladder cannot store urine, and urine continuously flows out of the bladder, leaving the bladder empty. This is commonly seen in injuries to the bladder neck and urethral sphincter caused by trauma, surgery, or congenital diseases. It can also be seen in ectopic urethral meatus and vesicovaginal fistula in women.
(2) Intermittent overflow: The bladder is overfilled, causing urine to overflow continuously. This is caused by chronic urinary retention due to severe mechanical (such as prostatic hyperplasia) or functional obstruction of the lower urinary tract. When the intra-bladder pressure rises to a certain level and exceeds the urethral resistance, urine continuously drips out of the urethra. The bladder of such patients is in a distended state. Because urination relies on spinal reflexes, when upper motor neuron lesions occur, patients will also experience involuntary intermittent overflow, and patients will not feel when urinating.
3. Common types
(1) Stress urinary incontinence: Urine leaks from the urethra when abdominal pressure increases (e.g., coughing, sneezing, climbing stairs, or running). It is mainly seen in women, especially those who have had multiple births or birth injuries, and occasionally in women who have not yet given birth.
(2) Urge incontinence: The patient has a strong urge to urinate and feels an urgent need to urinate, and urine is automatically released. The amount of urine released is large. Some patients can urinate completely. It is often accompanied by bladder irritation symptoms such as frequent urination and urgency, as well as lower abdominal distension and pain. It is seen in patients with partial upper motor neuron disease or acute cystitis, which are caused by strong local stimulation. Urinary incontinence occurs due to strong contraction of the detrusor muscle.
(3) Overflow incontinence: You experience frequent or constant dribbling of urine because your bladder is not completely empty.
(4) Functional incontinence: Physical or mental barriers prevent you from getting to the toilet quickly. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough.
(5) True urinary incontinence: There is an obstruction in the urethra, which causes a large amount of urine to fill the bladder. When the filling pressure exceeds the pressure of the urethral obstruction, involuntary urinary incontinence may occur. This is more common in diseases such as urethral stone obstruction or prostate hyperplasia causing posterior urethral obstruction, urinary retention, or neurogenic bladder.
(6) Mixed urinary incontinence: experiencing more than one type of urinary incontinence at the same time.
4. Complications
(1) Skin problems: Constantly damp skin can cause rashes, skin infections, and sores.
(2) Urinary tract infection: Incontinence increases the risk of recurrent urinary tract infection.
(3) Impact on personal life: Urinary incontinence can affect your social life, work and interpersonal relationships.
reason
OverviewUrinary incontinence is not a disease, but a symptom. It can be caused by daily habits, underlying medical conditions, or physical problems. In addition to some medications, pregnancy, childbirth, menopause, hysterectomy, prostate enlargement, prostate cancer, urinary tract obstruction, and neurological diseases can also cause urinary incontinence.
Cause of symptoms
1. Temporary urinary incontinence
Certain drinks, foods, and medicines may act as diuretics, irritating the bladder and increasing urine output.
(1) Food: alcohol, caffeine, carbonated drinks and soda, artificial sweeteners, chocolate, red peppers, and other foods high in spices, sugar, or acid (such as citrus fruits).
(2) Drugs: mainly include angiotensin-converting enzyme inhibitors (such as enalapril), sedatives, muscle relaxants, high-dose vitamin C, etc.
(3) Diseases: For example, urinary tract infection (UTI), which can irritate the bladder, causing a strong urge to urinate and sometimes incontinence; and constipation, where the rectum is located near the bladder and shares many of the same nerves. Hard, tight stool in the rectum can cause these nerves to overactivate and increase urinary frequency.
2. Persistent urinary incontinence
Urinary incontinence can also be an ongoing condition caused by underlying physical problems or changes.
(1) Pregnancy: Hormonal changes and increased fetal weight can cause stress urinary incontinence.
(2) Childbirth: Vaginal childbirth can affect the muscles that control the bladder and damage the bladder nerves and surrounding support tissues, leading to a drop in the pelvic floor (prolapse). The bladder, uterus, rectum, or small intestine may be pushed down from their usual position and protrude into the vagina. This protrusion may be associated with incontinence.
(3) Aging: Aging of the bladder muscles reduces the bladder’s ability to store urine. In addition, involuntary bladder contractions become more frequent.
(4) Menopause: Since estrogen helps maintain the health of the bladder and urethra, the estrogen produced by women after menopause will be significantly reduced, which will aggravate urinary incontinence.
(5) Hysterectomy: In women, many of the same muscles and ligaments support the bladder and uterus. Any surgery involving a woman’s reproductive system, including removal of the uterus, can damage the supporting muscles of the pelvic floor, leading to incontinence.
(6) Prostate enlargement: Especially in older men, incontinence often results from benign prostatic hyperplasia (BPH).
(7) Prostate cancer: In men, stress urinary incontinence or urge incontinence may be associated with untreated prostate cancer. Urinary incontinence is also a side effect of prostate cancer treatment.
(8) Obstruction: Tumors or stones anywhere in the urinary tract can block the normal flow of urine, leading to urinary incontinence.
(9) Neurological diseases: Multiple sclerosis, Parkinson’s disease, stroke, brain tumor or spinal injury can interfere with the nerve signals involved in bladder control, leading to urinary incontinence.
3. Risk factors
(1) Gender: Women are more likely to experience stress urinary incontinence. Pregnancy, childbirth, menopause, and normal female anatomy contribute to this difference. However, men with prostate disease are at increased risk for urge and urinary incontinence.
(2) Age: As you age, the muscles in your bladder and urethra lose some of their strength. As your bladder holds less, the likelihood of involuntary urine release increases.
(3) Overweight: Extra weight increases pressure on the bladder and surrounding muscles, which weakens the regulatory function of the bladder muscles and causes urine to leak when coughing or sneezing.
(4) Smoking: Smoking may increase the risk of urinary incontinence.
(5) Family history: If a direct relative suffers from urinary incontinence, especially urge incontinence, the risk of developing this disease will be higher.
(6) Other diseases: Neurological diseases or diabetes may increase the risk of incontinence.
Common diseases
Epispadias, bladder exstrophy, ectopic ureteral opening, urachal fistula, urethral sphincter and pelvic floor muscle injury, urethrovaginal fistula, ureterovaginal fistula, cystitis, thrombosis, inflammation, trauma, tumor compression, diabetes, etc.
Seeking medical treatment
Emergency (120) indications
1. Continuous and uncontrolled urine leakage;
2. Urinary incontinence after trauma;
3. Accompanied by other neurological symptoms such as fecal incontinence, lower limb paresthesia or movement disorders;
4. Other critical situations occur.
In all of the above cases, you must call the emergency number or go to the emergency room immediately.
Outpatient indications
1. Repeated involuntary urinary leakage symptoms;
2. Urinary leakage occurs when coughing, sneezing, picking up heavy objects, walking, standing, or exerting light force, and even when the patient is at rest or lying down, affecting the patient’s daily life and work, causing embarrassment, anxiety, and pain to the patient;
3. Urinary incontinence after surgery or childbirth;
4. Accompanied by other urination abnormalities, such as frequent urination, urgency, pain during urination, and difficulty urinating;
5. Accompanied by lumps in the waist and abdomen, pain and discomfort in the waist and abdomen, etc.
6. Patients with long-term urinary incontinence and recurrent urinary tract infections;
7. Long-term urinary incontinence accompanied by eczema, erosion, pressure sores, etc. around the urethral opening;
8. If other severe, persistent or progressive symptoms or signs occur, seek medical attention promptly.
All of the above require prompt medical consultation.
Treatment department
1. If you have simple urinary incontinence or other urinary system symptoms, you should go to a urology department for treatment.
2. In critical situations, seek emergency treatment.
3. If there are skin complications, please consult a dermatologist.
4. If you suspect that the cause is a neurological disease, you can consult a neurology department.
Medical preparation
1. Patients should try to eat a light diet a few days before the examination, avoid spicy food, and avoid drinking alcohol, staying up late, etc.
2. When going for a check-up, patients can prepare an extra set of underwear and outer pants to change after urinary incontinence occurs, or wear adult diapers.
3. Make an appointment in advance and bring your ID card, medical insurance card, medical card, etc.
4. If you have had medical treatment recently, please bring relevant medical records, examination reports, laboratory test results, etc.
5. If you have taken any medicines, vitamins or supplements recently, please bring the medicine box or instructions.
6. Family members can be arranged to accompany the patient to seek medical treatment.
7. Patients can prepare a list of questions they want to ask in advance.
What questions might a doctor ask a patient?
1. How long have you had symptoms of urinary incontinence? Has it gotten worse over time?
2. Do you feel the urge to urinate before you urinate? Does your incontinence only occur when you cough or sneeze, or does it occur when you walk or stand, or even when you are standing or lying down?
3. How much urine do you urinate each time? How often do you suffer from urinary incontinence?
4. Do you have any other symptoms besides urinary incontinence, such as frequent urination, urgency, pain when urinating, constipation, fecal incontinence, or lower abdominal distension and pain?
5. Have you ever had urethral or prostate surgery? Do you have a history of multiple births or birth trauma?
6. Has anyone in your immediate family ever suffered from prostate or colorectal cancer?
7. Do you often eat high-fat foods? Do you exercise regularly?
8. Do you smoke or drink alcohol? How long have you been smoking or drinking? How much do you drink per day?
What questions can patients ask their doctor?
1. Why do I have symptoms of urinary incontinence? What is the most likely cause?
2. Are my symptoms serious? What tests do I need?
3. Do I need to be hospitalized?
4. What treatment methods do I need now? Is it curable?
5. Are there any risks associated with these treatments? Will the disease recur after treatment?
6. What are the next steps in my diagnosis and treatment?
7. I have other diseases. Will this affect my treatment?
8. What should I pay attention to after returning home?
9. If medication is required, what are the usage, dosage, and precautions?
10. Do I need follow-up examinations? How often?
examine
Scheduled inspectionPatients often require urinalysis, urine culture, and renal function tests to make a preliminary diagnosis. If necessary, imaging studies may be combined to further investigate the nature and cause of urinary incontinence. Urodynamic testing is also a common test for patients with urinary incontinence. Urethral cystoscopy may also be performed for direct observation of the site of urinary incontinence.
Laboratory tests
Patients should undergo a urinalysis and urine culture to check for infection. Blood tests should be done to check renal function.
Imaging examinations
Cystourethrography is a common imaging test. On a lateral view, the posterior urethral angle is measured. Normally, it is 90° to 100° and disappears during urination. However, in patients with stress urinary incontinence, the urethra shortens and widens when not urinating, and the posterior urethral angle disappears. The bladder neck becomes funnel-shaped when not urinating, and this becomes more pronounced with increased abdominal pressure. Plain X-rays can also be used to determine the presence of urinary stones.
Other tests
1. Urodynamic examination
(1) Cystometry: Patients with stress urinary incontinence have decreased bladder pressure. The bladder pressure is classified into the following categories: ① Mild, with an intrabladder pressure of 60-80 cmH2O ; ② Moderate, with an intrabladder pressure of 24-60 cmH2O ; and ③ Severe, with an intrabladder pressure below 20 cmH2O . If there is no leakage when the intrabladder pressure is >150 cmH2O , it means that the cause of urinary incontinence is not in the urethra.
(2) Measurement of urethral pressure and internal bladder sphincter pressure: The maximum urethral pressure in normal individuals is 85-126 cmH2O for men and 35-115 cmH2O for women. Urethral pressure is generally reduced in patients with stress urinary incontinence, with a more pronounced decrease in proximal urethral pressure and maximum urethral pressure. The maximum urethral closure pressure is also reduced; urethral pressure does not increase during the provocation test. The internal bladder sphincter pressure wave disappears.
(3) Leak point pressure measurement: It can accurately reflect the functional status of the patient’s detrusor muscle and sphincter during urination.
2. Urethral cystoscopy
It can assess the functional status of the external sphincter and the presence of fibrosis in the bladder neck. In patients undergoing prostate surgery, it is important to note the presence of residual tissue. It can also assess the presence of urethral relaxation and bladder pathology.
diagnosis
Diagnostic principles
Urinary incontinence is often diagnosed based on medical history, laboratory tests, and specialized examinations. Urinary fistulas, enuresis, ectopic ureters, and cystocele can present with similar symptoms and require differential diagnosis.
Diagnostic basis
1. When asking about the medical history, pay attention to the following conditions:
(1) Age of occurrence.
(2) Whether there is a feeling of urination before it occurs.
(3) Is urinary incontinence intermittent or continuous?
(4) The relationship between urinary incontinence and increased abdominal pressure.
(5) Whether there is a history of long-term urinary tract infection or diabetes.
(6) History of pelvic, bladder, urethra, vaginal, or prostate surgery.
(7) History of neurological disease and spinal cord injury.
(8) Medication status.
2. Pay attention to the following situations during physical examination
Suprapubic bladder emptying and filling, spinal development, neurological examination, anal sphincter relaxation, female urethra length, anterior vaginal wall protrusion, penile cavernous reflex, and clitoral reflex.
3. Specialized tests
(1) Stress test: empty the bladder by catheterization and measure the residual urine volume. Inject 250 ml of normal saline into the bladder. The patient stands and clamps the anterior vaginal mucosa with an Alys clamp. Gently pull the clamp downward to aggravate urinary incontinence, and push it upward to stop urine leakage.
(2) Provocation test: The patient takes the lithotomy position, and the examiner manually separates the labia majora. If the patient coughs, urine may immediately flow out of the urethra. When the increased abdominal pressure is relieved, the urine flow stops immediately. This is a positive provocation test.
(3) Bladder neck elevation test: Based on the provocation test, the examiner uses the middle and index fingers of the right hand to lift the bladder neck from both sides through the vagina, and then performs the provocation test again. If urinary incontinence no longer occurs, the bladder neck elevation test is positive.
(4) Cotton swab test: A cotton swab inserted into the urethra is used to measure the posterior urethral angle to determine the severity of urethral prolapse.
Differential diagnosis
1. Urinary fistula
Urine leakage through the vagina in conditions such as ureterovaginal fistulas, vesico- or urethro-vaginal fistulas, urachal fistulas, and bladder exstrophy is often mistaken for urinary incontinence. During intravenous urography, the proximal end of the ureteral injury is often dilated, and extravasation of contrast medium may be seen. Cystoscopy, followed by ureteral catheterization and injection of methylene blue, allows visualization of the fistula opening in the vagina. For vesico- or urethro-vaginal fistulas, vaginal examination can confirm the location of the fistula opening, allowing visualization of a transurethral catheter through the fistula opening. Alternatively, a gauze pad can be inserted into the vagina, followed by transurethral injection of methylene blue, which will stain the gauze blue. Cystoscopy can also reveal the fistula opening, allowing insertion of a ureteral catheter through the opening and vaginal exit. For urachal fistulas, intermittent urine leakage from the umbilicus can be treated by injecting methylene blue into the umbilicus, staining the bladder urine blue. Contrast agent injected into the umbilicus can reveal the entire urachal fistula on a lateral X-ray. Cystoscopy can also demonstrate the connection between the bladder and the urachal region, extending to the umbilicus.
2. Enuresis
It occurs in children over 3 years old who have no organic lesions, can control urine during the day, and urinate unconsciously while sleeping at night. Occasionally, some children also have enuresis after falling asleep during the day, but physical examination and other special examinations are normal.
3. Ectopic ureteral opening
The ureteral opening is ectopically located in the urethra, with urine overflowing from the urethral opening. However, the overflow is persistent, unrelated to increased bladder pressure, and urination is normal. Excretory urography often reveals bilateral renal pelvis and ureteral anomalies, with the ectopic ureter draining into the upper renal pelvis, which is hypoplastic. B-ultrasound examination can reveal bilateral renal pelvises. Urethroscopy can confirm the diagnosis by visualizing the ectopic ureteral opening.
4. Cystocele
A history of urinary incontinence is accompanied by a feeling of heaviness in the lower abdomen and perineum, a high residual urine volume in the bladder, and anterior vaginal bulging with straining. X-ray findings on cystourethrography are that the posterior urethral angle and urethral obliquity are within normal limits, and cystography may reveal a partial bladder wall bulge. Symptoms of cystocele improve after anterior vaginal wall repair, but stress urinary incontinence persists or may even worsen.
treat
Expected treatmentThe ideal outcome of urinary incontinence treatment is to eliminate the cause, but this is often impossible in many cases, such as those with neurogenic incontinence, necessitating other methods of control. Most patients with urinary incontinence can initially be managed with nonsurgical treatments. Surgery may be appropriate for more severe cases or those who are ineffective with nonsurgical treatments.
Treatment
1. Non-surgical treatment
(1) Drug treatment
According to the characteristics of therapeutic drugs, they can be divided into the following aspects:
① Drugs that inhibit detrusor contraction: These include anticholinergics and tricyclic antidepressants, which are used to treat urge incontinence caused by detrusor hyperreflexia or overactivity. Examples of the former include atropine, propantheline bromide, and tolterodine; the latter include imipramine.
② Drugs that increase urethral resistance: such as α-adrenergic receptor stimulants (ephedrine, imipramine, etc.); β-adrenergic inhibitors (propranolol).
③ Drugs that reduce urethral resistance: such as α-receptor blockers (phentolamine, tamsulosin, prazosin, terazosin, etc.) can reduce the tension of urethral smooth muscle; polysynaptic inhibitors (baclofen, diazepam, etc.) can relieve external sphincter spasms.
④ Hormones: Estrogen can enhance the density and sensitivity of α-adrenal receptors, nourish the urethral mucosa, submucosal tissue, and collagen tissue around the pelvic floor and urethra to increase urethral resistance, and has a therapeutic effect on female patients with urinary incontinence.
(2) Pelvic floor exercises and biofeedback techniques
Consciously contract and relax the pelvic floor muscles, including levator ani and interrupted urination. This should include rapid and sustained contractions of the pelvic floor muscles to strengthen both fast and slow muscle fibers, primarily to rebuild the weak pelvic floor support function. The cure or improvement rate is 50% to 80%. Pelvic floor exercises can be supplemented with biofeedback techniques to enhance the therapeutic effect through positive feedback, such as a perineal contraction manometry device or a biofeedback device such as an audio or electromyography controller, allowing the patient to hear or see the intensity and duration of the contraction, thereby producing an auditory or visual enhancement effect. Some authors have used cystometry as a biofeedback technique for treating detrusor overactivity.
(3) Bladder training
Also known as behavioral modification, this approach is primarily used for patients with frequent urination, urgency, and urge incontinence. It involves having patients keep a careful urination diary and learn pelvic floor exercises. Patients then maintain a fixed urination interval based on their diary entry from the previous week. During this interval, they delay urination by contracting the sphincter, increasing the interval by 15 minutes each week until it reaches 3-4 hours. The principle is that approximately half of patients experience an urge to urinate during involuntary detrusor contractions and are able to eliminate these involuntary contractions by contracting the sphincter and forgoing urination.
(4) Electrical stimulation
Electrical stimulation treats urinary incontinence by contracting the sphincter and/or pelvic floor muscles and reflexively inhibiting the detrusor muscle. It can be used to treat stress incontinence and urge or reflex incontinence. Electrical stimulation includes inductive electrical stimulation, interferential electrical stimulation, and transcutaneous electrical nerve stimulation. Common sites of electrical stimulation include the vagina, perineum, and the posterior tibial nerve and sacral foramina nerve roots.
(5) Vaginal support and urethral clamp
Vaginal pessaries are used for patients with pelvic organ prolapse and urinary incontinence, providing temporary relief and an effective, non-invasive treatment. Urethral clamps are primarily used for male incontinence due to sphincter insufficiency, which can easily lead to urethral diverticula.
(6) Retention catheterization or intermittent self-catheterization
Mainly used for patients with overflow incontinence.
(7) Urethral filler treatment
Urethral bulking agents are primarily used to treat female stress urinary incontinence, with a cure rate of up to 25%. Urethral bulking agents dilate the urethral submucosa, thereby increasing pressure within the urethral lumen. Commonly used fillers include bovine glutaraldehyde-cross-linked collagen, carbon-coated zirconium beads, polytetrafluoroethylene, hyaluronic acid, polydimethylsiloxane, dimethyl sulfoxide, and autologous tissue (fat, cartilage). No other filler has a unique advantage that can replace other fillers. Fillers have been used for urinary incontinence in men after prostatectomy, but the results have been unsatisfactory.
(8) Intravesical instillation and detrusor injection therapy
Intravesical instillation of capsaicin and capsaicin analogs (RTX) blocks capsaicin receptors in the bladder wall and is used to treat urinary incontinence caused by detrusor hyperactivity. Transurethral endoscopic detrusor injection of botulinum toxin inhibits acetylcholine release and can treat urinary incontinence caused by detrusor hyperactivity.
2. Surgical treatment
Surgical treatment of urinary incontinence is aimed at inhibiting detrusor hyperreflexia or overactivity, increasing or decreasing urethral resistance, and strengthening pelvic floor support.
(1) Inhibit detrusor hyperreflexia or overactivity
① Nerve block or amputation.
② Perivesical nerve stripping.
③ Consider urinary diversion for severe patients.
④ Bladder augmentation is used to treat patients with low bladder compliance and small capacity.
(2) Increase or decrease urethral resistance
① Surgery to increase urethral resistance: including urethral lengthening or plication, and artificial urinary sphincter insertion.
② Surgery to reduce urethral resistance: including bladder neck incision, prostate surgery, internal urethrotomy for urethral stenosis, etc.
(3) Strengthen pelvic floor support
There are many surgical methods, but the basic ones are as follows:
① Needle suspension technique: a special needle with a thread is used to pass through the skin in the suprapubic area into the vagina to reposition or lift the bladder neck and urethra, such as the Raz technique.
② Suspension surgery: Various materials (such as autologous fascia or synthetic materials) are surgically placed behind the bladder neck to provide support or to compress the urethra when abdominal pressure increases. This can be performed through a vaginal incision, open surgery, or laparoscopy.
③Open surgery or colposuspension: such as Burch surgery and Marshall-Marchetti-Krantz surgery.
④ Laparoscopic surgery: The basic surgical method is the same as above, but the above three surgeries are improved using laparoscope.
Related drugsAtropine, propantheline bromide, tolterodine, imipramine, ephedrine, propranolol, phentolamine, tamsulosin, prazosin, terazosin, baclofen, diazepam, capsaicin, capsaicin analogs, botulinum toxin, etc.
daily
Nursing principles
1. Skin care
Urine spillage can irritate the surrounding skin. Wipe it with a towel and avoid frequent washing and flushing to avoid lowering the natural defense against bladder infection. You can use some skin care oils and creams, such as vaseline, to protect the skin from urine irritation.
2. Daily care
(1) Patients with urge incontinence or nocturnal incontinence should live in a room close to the toilet.
(2) Remove carpets or furniture that the patient may trip or bump into on the way to the toilet, and use night lights to illuminate the path to reduce the risk of falls.
(3) You can try wearing a diaper when going out.
prevention
Preventive measures
Urinary incontinence cannot always be prevented. The following measures can help reduce your risk:
1. Quit smoking and limit alcohol consumption, and avoid bladder irritants such as excessive caffeine and acidic foods.
2. Maintain a healthy weight.
3. Try not to drink water before going to bed.
4. Detect the disease early and treat it.
5. Do not hold your urine. Urinate as soon as you feel the urge.
6. Strengthen physical exercise to prevent and treat various chronic diseases.
7. Maintain a calm attitude and actively respond to opportunities and challenges in life and work.
8. Have regular sex life and develop good living habits to prevent urinary tract infections.
9. Eat a light diet and eat more fiber-rich foods to avoid constipation and increased abdominal pressure.
10. Postpartum women should also pay attention to losing weight, getting more rest, not being overly tired, and contracting the H gate 5-10 times a day.