Urinary incontinence resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Maneesha Nandimandalam, M.B.B.S.[2]

## Overview[edit | edit source]

Urinary incontinence is defined as an involuntary leakage of urine. The causes can be temporary or permanent. Most common reversible causes include dementia, delirium, infections, atrophic vaginitis, psychological, drugs, stool impaction. It is broadly classified into 5 types based on the characteristics on the urinary incontinence.

## Causes[edit | edit source]

### Life Threatening Causes[edit | edit source]

* Cerebrovascular accident[1] [2]

* Idiopathic parkinson's disease
* Infection
* Limbic encephalitis
* Metastatic prostate cancer
* Mitochondrial parkinson's disease
* Multiple sclerosis
* Parkinson disease
* Pelvic cancer
* Prostate cancer
* Schaefer-stein-oshman syndrome
* Spinal cord neoplasm
* Spinal fracture
* Stroke
* Toxic mushrooms
* Tumor
* Wilms tumor
* Wohlwill-andrade syndrome

### Common Causes[edit | edit source]

* Bladder Cancer[3][4][5][6][7][8][9][10]
* Botulinum toxin
* Delerium
* Drugs: Bethanechol chloride, Meropenem, Tiagabine
* Infection
* Inflammation
* Multiparity
* Neuropathic bladder dysfunction
* Neurologic
* Obesity
* Obstetric/gynecologic surgery
* Outlet obstruction
* Pelvic surgery
* Polyuria
* Postpartum
* Pregnancy
* Prostate surgery
* Restricted mobility
* Sphincteric atony
* Stool impaction
* Tumor
* Vaginitis
* Vesicovaginal fistula

## Diagnosis[edit | edit source]

The approach to the diagnosis of Urinary incontinence is based on a step-wise approach strategy. Below is an algorithm summarising the identification and diagnosis of different types of Urinary incontinence . The algorithm is developed and modified according to American Urological Evaluation (AUA) Guidelines. Shown below is an algorithm summarizing the diagnosis of Urinary incontinence according to The American Urological Association guidelines.

| Patients presenting with symptoms of urinary incontinence|

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Look for temporary causes

* Dementia, delirium

* Infections

* Atrophic vaginitis

* Psychological

* Drugs

* Stool impaction

Look for chronic incontinence

* History and physical exam including a cough test for stress incontinence

* Review voiding dairy

* Do all the lab work

* Measure post void residual urine volume

| Based on all the findings arrive at a diagnosis|

"Urge incontinence"
❑Urgency
❑ Frequency
❑Nocturia
❑ Cough stress test: May show delayed leakage after cough
❑ PVR urine< 50ml
❑Variable vol loss seen in voiding dairy

Overflow incontinence
❑No urgency
❑Absence of symptoms on physical activity
❑ Cough stress test:No leakage
❑ PVR urine> 200ml
❑Voiding dairy: varies

Stress incontinence
❑Symptoms seen on coughing, sneezing, exercise, increased intra-abdominal pressure
❑ No nocturia
❑ Cough stress test:Leakage coincides with cough
❑ PVR urine< 50ml
❑Voiding dairy: Small volume leakage

Functional incontinence
❑Cognitive dysfunction, immobility seen
❑ Cough stress test:No leakage
❑ PVR urine: Varies
❑Voiding dairy: Sometimes a pattern seen with incontinence

Mixed incontinence
❑Symptoms with physical activity, urgency noted
❑ Cough stress test:May show leakage
❑ PVR urine<50ml
❑Voiding dairy: Varies

## Treatment[edit | edit source]

| Treatment for different types of urinary incontinence|

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Stress incontinence
❑Lifestyle modifications like weight loss, smoking cessation, decreasing fluid intake, treating constipation if present
❑Pelvic floor muscle (Kegel) exercises that will strengthen the pelvic floor musculature
❑Supervised pelvic floor therapy
❑Vaginal weighted cones
❑Biofeedback

Urge incontinence
❑behavioral therapy (controlling fluid intake, prompted voiding, constipation management, etc.)
❑Electrical stimulation
❑ Pelvic floor muscle strengthening (Kegel and floor muscle exercises)
❑Weight loss
❑ PVR urine< 50ml
❑Variable vol loss seen in voiding dairy

Overflow incontinence
❑Clean intermittent catheterization
❑Indwelling urethral catheter
❑ Relieving the obstruction

| D04|

| D05

If above modalities failed|

Pharmacologic management
❑ Antimuscarinics (e.g., darifenacin, solifenacin, oxybutynin,tolterodine)
❑Topical vaginal estrogen

Pharmacologic management
❑ Alpha-adrenergic antagonists (e.g. terazosin, tamsulosin)

| E04|

| E05|

❑Pessaries placement
❑Midurethral sling surgical procedure

❑Surgical management like neuromodulation

❑Surgical management like neuromodulation

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

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## Do's[edit | edit source]

* The content in this section is in bullet points.

## Don'ts[edit | edit source]

* The content in this section is in bullet points.

## References[edit | edit source]

1. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
2. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
3. ↑ "pdfs.semanticscholar.org" (PDF).
4. ↑ Brown JS, Bradley CS, Subak LL, Richter HE, Kraus SR, Brubaker L, Lin F, Vittinghoff E, Grady D (May 2006). "The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence". Ann. Intern. Med. 144 (10): 715–23. PMC 1557357. PMID 16702587.
5. ↑ Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE (March 2008). "What type of urinary incontinence does this woman have?". JAMA. 299 (12): 1446–56. doi:10.1001/jama.299.12.1446. PMID 18364487.
6. ↑ Videla FL, Wall LL (June 1998). "Stress incontinence diagnosed without multichannel urodynamic studies". Obstet Gynecol. 91 (6): 965–8. PMID 9611005.
7. ↑ DuBeau CE, Kuchel GA, Johnson T, Palmer MH, Wagg A (2010). "Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence". Neurourol. Urodyn. 29 (1): 165–78. doi:10.1002/nau.20842. PMID 20025027.
8. ↑ "Diagnosis of Urinary Incontinence - American Family Physician".
9. ↑ Frank C, Szlanta A (November 2010). "Office management of urinary incontinence among older patients". Can Fam Physician. 56 (11): 1115–20. PMC 2980426. PMID 21075990.
10. ↑ Imam KA (2004). "The role of the primary care physician in the management of bladder dysfunction". Rev Urol. 6 Suppl 1: S38–44. PMC 1472846. PMID 16985854.

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