Updated: 1/18/2020

Urinary Incontinence

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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
  • 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
 

 

 

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(M2.RL.15.4676) A 54-year-old woman presents to her gynecologist complaining of incontinence. She reports leakage of a small amount of urine when she coughs or laughs as well as occasionally when she is exercising. She denies any pain with urination. She underwent menopause 2 years ago and noted that this problem has increased in frequency since that time. Her history is significant only for three uncomplicated pregnancies with vaginal births. Urinalysis, post-void residual, and cystometrogram are conducted and all show normal results. The patient's vital signs are as follows: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%. Physical examination is significant for pelvic organ prolapse on pelvic exam. Which of the following is a reasonable first step in the management of this patient's condition? Tested Concept

QID: 107224
1

Kegel exercises

89%

(24/27)

2

Imipramine

0%

(0/27)

3

Bethanechol

4%

(1/27)

4

Urethropexy

4%

(1/27)

5

Tension-free vaginal tape

0%

(0/27)

M 6 E

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Evidence (3)
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