Snapshot A 68-year-old woman presents to her primary care physician with leakage of urine when she sneezes, laughs, or coughs. She reports that these symptoms strictly occur during the day and never at night. She denies any subjective fever, dysuria, or hematuria. Pelvic examination is notable for a protrusion from the anterior vagina. (Stress incontinence) 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 cystocele may be present Q-type 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 injury to the pudendal nerve during birth process or use of regional anesthesia 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 - Life style modifications and pelvic floor exercises is first-line If unresponsive to first-line treatments then therapy is based on the predominant symptoms Vesicovaginal fistula Fistula that forms creating a connection between the bladder and vagina May be secondary to surgery, pelvic irradiation, malignancy, or prolonged labor Painless, continuous leakage of urine from vagina Fluid pooling in the vagina Methylene blue dye instilled into the bladder will then turn tampon placed in the vagina blue Surgery Urethral divereticulum An abnormal and localized outpouching of the urethral mucosa often due to recurrent periurethral gland infection Symptoms of urge incontinence Dysuria from recurrent UTIs Small, tender, anterior vaginal wall mass Urinalysis/urine culture Transvaginal ultrasound Pelvic MRI Surgery