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the bladder. As the bladder overfills, urine tends to dribble in small amounts. The diagnosis is often
challenging and the condition may be seen in patients with a chronic unrecognized problem.
Diagnosis
The medical history will not always make clear what type of incontinence a patient has. However,
multiparous females and patients with previous pelvic surgeries or radiation or neurological
symptomatology may be able to guide the examiner towards the source and type of their incontinence.
Tools such as a pad test and voiding diary may elucidate the voiding habits and other conditions of a
patient. Recording the situations, number of pads and estimated volumes (by weighing pads) may help
bring about an understanding of the patient’s condition. In addition, objective recordings of intake and
output of fluids along with timing may further elucidate the problem.
The physical examination should focus on anatomical and neurological signs. Complete pelvic and
neurological examination will assist the clinical diagnosis of incontinence. Further examinations such as
3 RBC/hpf: red blood cells per high power field
ICAO Preliminary Unedited Version — November 2009 III-6-7
the Q-tip test4, uroflowmetry, post-void residual assessment, cystoscopy, formal video urodynamics, and
an assessment of periurethral and vault supporting structures should be performed.
Management
The aetiology of urinary incontinence is highly varied, as are the treatments. Continuous and stress
incontinence typically warrant surgical treatment for definitive care, whereas urge incontinence tends to
be best managed by medication. Treatment modalities including behavioural techniques such as
biofeedback and pelvic floor exercises may alleviate the need for surgery. This approach may be a
preferred initial treatment in a pilot. Of course, each category of incontinence requires a thorough
urological evaluation to ensure adequate necessary care.
Aeromedical considerations
Incapacitation secondary to incontinence will warrant suspension from flight until definitive diagnosis
and treatment are performed. Most incontinence is not of a degree in itself to warrant aeromedical
disqualification and may be conservatively managed in many patients. If the condition requires surgical
correction, the operative surgeon must document complete resolution and recovery prior to return to
aviation duties.
Pharmacological treatment may require further aeromedical review depending upon the drugs used.
Anticholinergic medications are used for their direct relaxing effects on the smooth detrusor muscle of the
bladder (m. detrusor vesicae). These medications are usually well tolerated by most but they may worsen
an existing myopia. They may also cause dry mouth, fatigue, constipation and even, on rare occasions,
supraventricular tachycardia. Finally, anticholinergic medications will exacerbate closed-angle glaucoma
and is an absolute contraindication in such patients. Since these side-effects are of concern in the aviation
environment, a ground trial is necessary. For similar reasons, any medications or herbal preparations used
to treat this malady should be administered in carefully controlled settings and in consultation with the
medical assessor of the licensing authority.
UROLOGICAL INFECTION
Infection is the most common disease process of all that affects the urinary tract. Infections of the urinary
system are globally categorized into two broad classifications: complicated and uncomplicated. Thorough
urological investigation is mandatory in all but the simplest urinary infections in order to detect any
anatomical or physiological pathology. Depending on the anatomical location, chronicity of infection,
host factors, and source, an infection can result in incapacitation during flight. This concern is particularly
applicable in the face of urinary obstruction, which should always be treated as an emergency which
requires immediate intervention.
Acute infections of the urinary system should, as a rule, be disqualifying for aviation duties. Often a
license holder will have clinically recovered from an acute infection but will require further suppressive
drug treatment for an extended period of time. In such cases the medical examiner will have to decide if
the medications used for treatment are compatible with safe flying.
4 Q-tip test: a test for determining the mobility of the urethra by inserting a cotton-swab (Q-tip) into the female
urethra and measuring the angle between it and the horizontal plane. Above 30 degrees is indicative of stress
incontinence.
ICAO Preliminary Unedited Version — November 2009 III-6-8
Disease process
The inflammatory response and changes of the urothelium secondary to bacterial invasion, usually via
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Manual of Civil Aviation Medicine 1(152)
