Updated: 2/23/2020

Urinary Incontinence

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Snapshot
  • A 42-year-old woman presents to her primary care physician due to involuntary passage of urine. She reports to voiding small amounts of urine throughout the day and night. She says that this occurs without warning. Medical history is significant for multiple sclerosis treated with ocrelizumab. Physical examination is notable for a distended bladder. (Overflow incontinence secondary to multiple sclerosis)
Introduction
  • Clinical definition
    • involuntary urinary leakage
  • Diagnostic studies
    • all patients with urinary incontinence should have a urinalysis
    • if symptoms are concerning for a urinary tract infection obtain a urine culture
 
Urinary Incontinence
Type
Pathogenesis Presentation
Diagnosis Treatment
Stress incontinence
  • May be secondary to a number of factors such as
    • weakened pelvic floor muscles
      • e.g., vaginal deliveries
    • poor intrinsic sphincter function
    • increased urethral mobility
  • Urinary incontinence with ↑ intra-abdominal pressure
    • e.g., coughing, sneezing, laughing, and physical exertion
  • No urine loss at night
  • Physical exam
    • a cystocele may be present 
  • Q-tip test
  • Strengthening the pelvic floor muscles via
    • Kegel exercises
      • first-line
  • Topical estrogen for post-menopausal women
  • Pessary
  • Midurethral sling in patients unresponsive to initial therapy and pessary
Urge incontinence
  • Detrusor muscle overstimulation 
  • Frequent urinary leakage that also occurs at night
    • disrupts sleep
  • Urge to urinate and may be unable to reach the bathroom in time
  • Urodynamic testing
  • Antimuscarinics 
    • e.g., oxybutynin
  • Mirabegron
Overflow incontinence
  • Incomplete bladder emptying results in urinary leakage secondary to
    • detrusor muscle underactivity 
      • e.g., age, diabetes mellitus, and multiple sclerosis
    • bladder outlet obstruction
      • e.g., fibroids and benign prostatic hyperplasia
  • Urine loss without warning or triggers
  • Post-void residual volume measurements
  • Urodynamic testing
  • Clean intermittent catheterization
Mixed Incontinence -
  • Symptoms of both stress and urge incontinence
-
  • Lifestyle modifications and pelvic floor exercises are first-line
  • If unresponsive to first-line treatments then therapy is based on the predominant symptoms
 

 

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Private Note