Review Question - QID 216753

This patient with morbid obesity and multiparity presents with involuntary urine leakage during sneezing or coughing, and an empty, contracted bladder on post-void bladder scan, consistent with stress incontinence. Stress incontinence is due to urethral hypermobility or intrinsic sphincter deficiency.

Stress incontinence is characterized by urinary leakage during events that increase intra-abdominal pressure (e.g. coughing, sneezing, laughing, lifting). Patient history typically does not reveal nocturnal incontinence, and post-void bladder scan demonstrates an empty, contracted bladder. Obesity, multiple vaginal deliveries, and pelvic surgery increase the risk of developing stress incontinence. Diagnosis can be made via a cotton swab test, in which a lubricated cotton swab is inserted into the urethra, the patient is asked to cough and strain, and the angle of cotton swab rotation is recorded to determine extent of urethral hypermobility. Treatment of stress incontinence includes pelvic floor muscle exercises, weight loss, and pessaries.

Aoki et al. summarize the symptoms, pathophysiology, evaluation, and management of stress and urgency incontinence.

Incorrect Answers:
Answer 1: Bladder outflow tract obstruction is characteristic of overflow incontinence. Overflow incontinence commonly presents in men with benign prostatic hyperplasia or fibroids. The obstruction leads to incomplete bladder emptying during urination, which causes the bladder to overfill and constantly leak or dribble urine. Bladder scan of these patients demonstrates a distended bladder with substantial postvoid residual.

Answer 2: Compression of lumbosacral spinal roots can cause cauda equina syndrome, which leads to detrusor muscle hypoactivity and subsequent overflow incontinence. Detrusor hypoactivity causes chronic bladder distension, which leads to high bladder pressures and constant leakage or dribbling of urine without urge and feelings of incomplete bladder emptying. Treatment involves catheterization.

Answer 3: Osmotic diuresis can occur due to hyperglycemia and subsequent polyuria. While chronic, uncontrolled diabetes can lead to peripheral neuropathy resulting in overflow incontinence, osmotic diuresis does not independently cause the patient's symptoms. Moreover, overflow incontinence presents with involuntary leakage of urine that typically occurs with change in position and a large postvoid residual on bladder scan.

Answer 4: Overactivity of the detrusor muscle is characteristic of urgency incontinence, which can occur in conditions of spasticity, such as multiple sclerosis. Urgency incontinence presents with an empty, contracted bladder on bladder scan, as in this patient; however, it also involves a sudden, overwhelming need to empty one’s bladder.

Bullet Summary:
Stress incontinence occurs in situations of increased intra-abdominal pressure (e.g. sneezing, coughing, laughing, Valsalva) and is due to urethral hypermobility or intrinsic sphincter deficiency.