urinary%20incontinence%20in%20women
URINARY INCONTINENCE IN WOMEN
Treatment Guideline Chart
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.

Urinary%20incontinence%20in%20women Diagnosis

History

  • Onset and course of urinary incontinence (UI) including severity of symptoms, fluid intake 
  • Associated lower urinary tract symptoms: Urgency, urinary frequency, nocturia, hesitancy, straining during urination, interrupted voiding, incomplete emptying, dribbling

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 

  • History of prolapse 
  • Pregnancies and modes of delivery
  • Past surgeries, sexual function, bowel function (including chronic constipation and fecal incontinence)
  • Prior incontinence therapies (eg pad use) including surgical treatments undertaken
  • Social history including smoking and heavy lifting
  • Impact on quality of life

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
    • 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
    • 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
      • Check for any pelvic organ prolapse and determine its degree/stage
      • Assess whether pelvic support is adequate or not
      • Check for urethral hypermobility (present in most women with symptoms of stress UI) 
        • An immobile fixed urethra is suggestive of complex UI and may need further work-up
      • 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

Laboratory Tests

  • Urine dipstick test and urinalysis with or without urine culture and sensitivity
    • Urine cytology in the presence of hematuria or pelvic pain
  • HBA1c; serum creatinine and blood urea nitrogen (BUN) to check for renal function

Diagnostic Exams

  • Renal ultrasound to exclude hydronephrosis or hydroureter in women with advanced pelvic organ prolapse
  • Intravenous pyelogram to rule out developmental abnormalities, tract anomalies and presence of fistula
  • Voiding cystogram to check for stress incontinence, cystocele and degree of urethral motion
  • Cystoscopy should be done in women with gross hematuria or complicated UI and may also be indicated in those with symptoms of refractory UI, iatrogenic genitourinary fistulas or injuries and persistent post-void dribbling
  • 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 UTI, previous anti-incontinence surgery, significant pelvic prolapse or spinal cord injury or complicated UI
  • 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 due to higher patient acceptability, avoidance of infection and lower incidence of adverse events from the procedure
    • PVRV <50 mL is considered adequate emptying while PVRV >200 mL is inadequate; a PVRV persistently >150 mL warrants further evaluation

Urodynamics 

  • Should only be considered in women with symptoms of complicated or refractory UI 
  • Aids in providing or confirming diagnosis of UI if with conflicting history and physical exam findings
  • Often done before invasive treatment for UI
    • Performed if the results may affect the choice of invasive treatment
    • Multichannel filling and voiding cystometry should not be done prior to primary surgery if patient is diagnosed with stress UI or stress-predominant mixed UI
Note: Consider specialist referral in a patient with a complex history (eg recurrent incontinence or incontinence associated with hematuria, pain, recurrent UTIs, suspected fistula, pelvic surgery or radiotherapy, pelvic organ prolapse, and/or voiding symptoms)
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