Classification
Major Types
Stress Incontinence
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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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