urinary%20incontinence
URINARY INCONTINENCE
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.

History

Detailed History (Women)
  • Onset & course of 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 & timing of incontinence, largest single volume voided
    • Precipitants to incontinence (eg coughing, sneezing, caffeine, alcohol, exercise, sounds of running water)
  • Optimum duration of diary is between 24 hr to 7 days

Other Components of History

  • Pregnancies & mode of delivery
  • Past surgeries, sexual function, bowel function (including constipation & fecal incontinence)
  • Impact on quality of life
  • History of prolapse
  • Prior incontinence therapies, including surgical treatments undertaken

Medication History

  • Drugs causing urinary retention w/ or w/o urinary frequency
    • Alpha-adrenergic agonists (Pseudoephedrine, Phenylpropanolamine)
    • Anticholinergic medications (tricyclic antidepressants, sedating antihistamines, Benzatropine, antipsychotics)
  • Drugs causing stress incontinence
    • Alpha blockers (Prazosin, Terazosin, Doxazosin)
    • ACE inhibitors if they induce cough
    • Loop diuretics & alcohol may overwhelm ability to get to the bathroom in time
  • Use of conjugate equine estrogens increases the risk of developing UI & worsens pre-existing UI
Detailed History (Men)
  • Helps in categorizing UI to stress, urge or mixed UI

Voiding Diary

  • Patient should be asked to complete a voiding diary that includes the following:
    • Frequency, volume & timing of incontinence
    • Precipitants to incontinence (eg coughing, sneezing, caffeine, alcohol, exercise, sounds of running water)
  • Optimum duration of diary is between 24 hr to 7 days
  • Also known as micturition time charts, frequency/volume charts, bladder diaries

Others

  • Past surgeries, sexual function, bowel habits (including constipation & fecal incontinence)
  • Impact on quality of life
  • Medication history

Physical Examination

Physical Exam (Women)

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 & 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 & enterocele
  • Direct observation of urine loss using cough stress test
  • Rectal exam
    • Assess sphincter tone & bulbocavernosus reflex
  • Neurologic exam
    • Observe gait & look for presence of muscular atrophy or neurologic deficits
    • Check vibration & peripheral sensation for the presence of peripheral neuropathy
Physical Exam (Men)
  • Abdominal, rectal, sacral, neurological
  • Digital rectal exam to assess prostate size, shape & consistency & to check for other rectal pathologies

Laboratory Tests

Diagnostic Exams (Women)

  • Urinalysis w/ or w/o urine culture
    • Urine cytology, in the presence of hematuria or pelvic pain
  • Serum creatinine & BUN to check for renal function
Diagnostic Exams (Men)
  • Urinalysis w/ or w/o urine culture
    • Should be part of the initial assessment
    • If infection found, treat then reassess

Post Void Residual (PVR) Volume

  • Amount of urine that remains in the bladder after voiding
    • Indicates poor voiding efficiency
  • Should be part of the initial assessment in the male patient as its presence is associated w/ UI symptoms
  • Catheterization is most accurate, but ultrasound may be preferred to avoid infection risk & it has higher patient acceptability
  • Presence of voiding dysfunction is considered in patients w/ persistent PVR >100 mL

Flow Rate

  • Determined by detailed clinical history

Pad testing

  • By using an absorbent pad worn over a period of time or during a protocol of physical exercise, urine loss is measured
  • Can be used to quantify the presence & severity of UI & also patient’s response to treatment

Note: Consider specialist referral in a patient w/ a complex history (eg recurrent incontinence or incontinence associated w/ hematuria, pain, recurrent urinary tract infections, prostate irradiation, pelvic surgery or radiotherapy, &/or voiding symptoms).

Imaging

Imaging (Women)

  • Voiding cystogram to check for stress incontinence, cystocele & degree of urethral motion
  • Intravenous pyelogram to rule out developmental abnormalities, tract anomalies & presence of fistula
  • Renal ultrasound
  • In the evaluation of women w/ uncomplicated stress incontinence, imaging studies of the upper or lower urinary tract should not be routinely done

Screening

Screening (Women)

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 or history of recurrent urinary tract infection, previous anti-incontinence surgery, significant pelvic prolapse or spinal cord injury
  • Catheterization is the most accurate method, but ultrasound may be preferred for higher patient acceptability & to avoid infection
    • PVRV <50 mL is considered adequate emptying while PVRV >200 mL is inadequate

Note: Consider specialist referral in a patient w/ a complex history (eg recurrent incontinence or incontinence associated w/ hematuria, pain, recurrent urinary tract infections, suspected fistula, pelvic surgery or radiotherapy, pelvic organ prolapse, &/or voiding symptoms)

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