urinary%20incontinence%20in%20women
URINARY INCONTINENCE IN WOMEN
Urinary incontinence is the complaint of involuntary urine leakage.
Stress urinary incontinence is the involuntary urine leakage on effort or exertion or when coughing or sneezing.
Urge urinary incontinence is the one associated with or immediately preceded by urgency.
Mixed urinary incontinence is the involuntary urine leakage associated with both urgency and with exertion, effort, coughing or sneezing.

Classification

Major Types
Stress Incontinence
  • Involuntary urine leakage on effort or exertion, or when coughing or sneezing
  • Occurs during increased intraabdominal pressure that overcomes sphincter mechanism in the absence of bladder contraction
  • Irritative voiding symptoms and nocturia are absent
  • May be caused by poor pelvic support or intrinsic sphincter deficiency
Urge Incontinence
  • Involuntary urine leakage due to detrusor overactivity, associated with or immediately preceded by urgency
  • Patients are unable to hold back their urine when they feel the intense need to void
  • May be caused by detrusor myopathy, neuropathy, bladder cancer (CA), stones or infections
Mixed Incontinence
  • Involuntary urine leakage associated with both urgency and with exertion, effort, coughing or sneezing
  • Present when the bladder outlet is weak and detrusor is overactive

Overflow Incontinence

  • Also referred to as “incomplete emptying”, which describes the dribbling or continuous leakage associated with incomplete bladder emptying
  • May be caused by bladder overdistention, impaired detrusor contraction and/or bladder outlet obstruction
  • Associated symptoms include weak urinary stream, intermittency, hesitancy, frequency and nocturia
Incontinence related to reversible medical conditions
  • Transient incontinence
    • Arises from an acute medical condition affecting the lower urinary tract
    • Symptoms resolve when the medical condition is addressed and treated
  • Functional incontinence
    • Arises from chronic impairment of physical and/or cognitive functioning
    • Diagnosis of exclusion
    • Symptoms may resolve by improving patient’s functional status, treating comorbidities and changing medications

History

  • Onset and course of urinary incontinence (UI)
  • Associated lower urinary tract symptoms
    • Urgency, urinary frequency, nocturia, hesitancy, straining during urination, interrupted voiding, incomplete emptying
Voiding Diary
  • Patient should be asked to complete a voiding diary that includes the following:
    • Frequency, volume and timing of incontinence, largest single volume voided
    • Precipitants to incontinence (eg coughing, sneezing, caffeine, alcohol, exercise, sound of running water)
  • Optimum duration of diary is between 24 hours-7 days
Other Components of History
  • Pregnancies and mode of delivery
  • Past surgeries, sexual function, bowel function (including constipation and fecal incontinence)
  • Impact on quality of life
  • History of prolapse
  • Prior incontinence therapies, including surgical treatments undertaken
Medication History
  • Drugs causing urinary retention with or without urinary frequency
    • Alpha-adrenergic agonists (Pseudoephedrine, Phenylpropanolamine)
    • Anticholinergic medications (tricyclic antidepressants, sedating antihistamines, Cogentin, antipsychotics)
  • Drugs causing stress incontinence
    • Alpha blockers (Prazosin, Terazosin, Doxazosin)
    • ACE inhibitors if they induce cough
    • Loop diuretics and alcohol may overwhelm ability to get to the bathroom on time
  • Use of conjugate equine estrogens increases the risk of developing UI and worsens pre-existing UI

Physical Examination

  • Comprehensive physical exam should include the following:
    • Examine the general condition of the patient
    • Cardiovascular exam to assess the presence of volume overload
    • Palpate abdomen for mass or tenderness
    • Genital exam
      • Inspect vaginal mucosa for atrophy, narrowing of introitus, vault stenosis and inflammation
      • Bimanual exam to evaluate presence of masses or tenderness
      • Assess whether pelvic support is adequate or not
      • Check for urethral hypermobility
      • Check for presence of cystocele, rectocele and enterocele
    • Direct observation of urine loss using cough stress test
    •  Rectal exam
      •  Assess sphincter tone and bulbocavernosus reflex
    •  Neurologic exam
      •  Observe gait and look for presence of muscular atrophy or neurologic deficits
      •  Check vibration and peripheral sensation for the presence of peripheral neuropathy

Laboratory Tests

  • Urinalysis with or without urine culture
    • Urine cytology, in the presence of hematuria or pelvic pain
  • Serum creatinine and blood urea nitrogen (BUN) to check for renal function
  • Voiding cystogram to check for stress incontinence, cystocele and degree of urethral motion
  • Intravenous pyelogram to rule out developmental abnormalities, tract anomalies and presence of fistula
  • Renal ultrasound
  • In the evaluation of women with uncomplicated stress incontinence, imaging studies of the upper or lower urinary tract should not be routinely done
Cough Stress Test
  • Patients who have not recently voided urine may be asked to stand over a pad, then they should cough vigorously
  • Observe if there is leakage of urine on the pad
  • Abrupt leakage gives a diagnosis of stress incontinence while delayed leakage suggests mixed incontinence
Post Void Residual Volume (PVRV)
  • Consider if patient has symptoms of voiding dysfunction, history of recurrent urinary tract infection, previous anti-incontinence surgery, significant pelvic prolapse or spinal cord injury or complicated urinary incontinence
  • Should also be used for monitoring patients on therapy that may cause or worsen voiding dysfunction
  • Catheterization is the most accurate method but ultrasound may be preferred for higher patient acceptability and to avoid infection
    • PVRV <50 mL is considered adequate emptying while PVRV >200 mL is inadequate
Urodynamics
  • Aids in providing or confirming diagnosis of urinary incontinence
  • Often done before invasive treatment for urinary incontinence
    • Performed if the results may affect the choice of invasive treatment
Note: Consider specialist referral in a patient with a complex history (eg recurrent incontinence or incontinence associated with hematuria, pain, recurrent urinary tract infections, suspected fistula, pelvic surgery or radiotherapy, pelvic organ prolapse, and/or voiding symptoms)
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