Review Question - QID 221268

This patient with urinary leakage at night and an increased post-void residual, most likely has overflow incontinence secondary to diabetes. The most appropriate management of overflow incontinence due to diabetes is bethanchol.

Overflow incontinence is a condition of chronic urinary retention, featuring a chronically distended bladder due to detrusor underactivity or outlet obstruction that leads to urinary leakage with overfilling. The diagnosis of overflow incontinence can be made with postvoid residual measurements and urodynamic testing. Overflow incontinence is associated with neurogenic bladder such as in multiple sclerosis or diabetes and bladder outlet obstruction (such as in benign prostatic hyperplasia). The most appropriate medical treatment for this condition is bethanchol, which is a parasympathetic choline analogue. Placement of a urethral catheter may be necessary in acute settings to allow the patient to void.

MacLachlan and Rovner review the evidence regarding the diagnosis and treatment of incontinence in women. They discuss how incontinence can be classified into overflow, stress, urge, and mixed incontinence. They recommend bethanchol for overflow incontinence.

Figure/Illustration A is a bladder ultrasound demonstrating increased urine in the bladder (red circle). This finding is consistent with overflow incontinence.

Incorrect Answers:
Answer 2: Oxybutynin is an antimuscarinic agent used for the treatment of urinary urgency and overactive bladder. It would worsen overflow incontinence.

Answer 3: Topical estrogen can be used in patients who have stress incontinence in the setting of menopause. This would present with incontinence during coughing, sneezing, laughing, and physical exertion.

Answers 4 & 5: Intermittent catheterization is the preferred management for overflow urinary retention compared to indwelling Foley catheters, since indwelling catheters have a higher complication rate than intermittent catheterization, including a higher risk of subsequent urinary tract infection. In initial cases, medical management with bethanchol should be attempted before catheterization.

Bullet Summary:
Overflow incontinence is initially managed with medications such as bethanchol.