Urinary%20incontinence%20in%20women Diagnosis

• 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

• 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

• 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

• 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