Urinary Incontinence
Evaluation
General—involuntary loss of urine that is often underdiagnosed and underreported.
Epidemiology—♀ ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b35df143d2e09634522df3569b47c61ae}/ID(AB1-M10)”>> ♂; old ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b35df143d2e09634522df3569b47c61ae}/ID(AB1-M10)”>> young; ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b35df143d2e09634522df3569b47c61ae}/ID(AB1-M10)”>>25 million Americans suffer from urinary incontinence.
Risk factors—age, postchildbirth, and postpelvic surgery
Diagnostic algorithm
Obtain a 24-hour bladder diary that includes fluid intake, urinary episodes, and accidents.
Determine postvoid residual (PVR) volume; if ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b35df143d2e09634522df3569b47c61ae}/ID(AB1-M10)”>>100 mL, then abnormal.
Perform a complete abdominal and pelvic examination; assess lumbosacral nerve roots.
Obtain a urinalysis and urine culture.
Treat for urinary tract infection (UTI) if applicable.
Screen for diabetes if glucose is found on the urinalysis; treat if applicable.
Classification
Stress incontinence
Clinical—involuntary loss of urine during an increase in intraabdominal pressure
Activities include coughing, laughing, sneezing, lifting, exercise, and so on.
Mechanism—weakness of the urethral sphincter muscle from
Failure of anatomic supports and therefore displacement of the bladder base
Loss of bladder neck competence (may occur during vaginal delivery)
Intrinsic weakness of the urethral sphincter muscle (age, decreased estrogen levels, etc.)
Diagnostic algorithm
Limit drugs that worsen stress incontinence.
For example—α1-blockers, angiotensin-converting enzyme (ACE)-inhibitors
Treatment
Nonpharmacologic options
Pelvic muscle exercises (Kegel’s)
Weighted vaginal cones
Pelvic floor electrical stimulation
Occlusive devices (e.g., Pessaries)
Pharmacologic options
Localized estrogens (thicken the urethral mucosa)
Estradiol vaginal ring (Estring)—insert PV q3mo
α1-Agonists
Surgical options
Retropubic urethropexies
For example—Burch laparoscopic and Marshall-Marchetti-Krantz (MMK) procedures
Suburethral slings (may be minimally invasive)
Periurethral injection at the bladder neck
Urge incontinence (overactive bladder [OAB])
Clinical—involuntary loss of urine occurring when one feels the urge to urinate.
Bladder may or may not be full; typically unpredictable and sudden.
Mechanism—two possibilities
Inappropriate bladder contraction (detrusor instability)
Inappropriate relaxation of pelvic floor and sphincter muscles
Diagnostic algorithm
Obtain a urinalysis and urine culture to rule out UTI.
Limit drugs that worsen urge incontinence.
For example—diuretics, caffeine, alcohol
Treatment
Nonpharmacologic options
Behavioral therapy, including biofeedback
Pelvic floor electrical stimulation
Extracorporeal magnetic innervation (noninvasive)
Pharmacologic options
Antispasmodic (typically antagonize acetylcholine receptors)
