13. Female Urinary Incontinence

Question 1

Define: Urinary Incontinence (UI)

Answer 1

Involuntary loss of urine

Question 2

Define: Stress Incontinence (SI) (1)

Answer 2

Involuntary leakage of urine during effort, exertion, sneezing, or coughing

Question 3

Define: Urodynamic SI (1)

Answer 3

When SI is confirmed during urodynamic testing by identifying leakage from the urethra coincident with ↑ intra-abdo pressure, but in the absence of bladder contraction

Question 4

Define: Urge incontinence (2)

Answer 4

• involuntary loss of urine with a strong desire to void
• Note: Involuntary bladder contractions (detrusor overactivity) are the hallmark of Dx.

Question 5

Define: Overflow incontinence (1)

Answer 5

Large volume of urine in bladder due to incomplete emptying

Question 6

Define: Continuous incontinence (1)

Answer 6

Continuous leakage of urine due to vesicovaginal fistula

Question 7

UI has been shown to improve or resolve after removal of ___ in institutionalized geriatric patients.

Answer 7

fecal impactions

Question 8

Describe: Epidemiology of Urinary Incontinence (4)

Answer 8

• Up to 70% of women living in the community setting and up to 50% of nursing home residents are affected by UI.
• Prevalence of incontinence increases with increasing age.
• Approximately one in four women with UI seeks medical help.
• Among ambulatory women with incontinence, SI represents 29% to 75% , detrusor overactivity 7% to 33% , and the remainders are mixed forms.

Question 9

Name DDX of UI in women: GU etiologies (7)

Answer 9

• Problem with filling/storing:
  
  • Stress Incontinence
  • Detrusor overactivity (idiopathic or neurogenic)
  • Mixed types
• Fistula (vesical, ureteral, urethral)
• Congenital (i.e., ectopic ureter)
• Urinary retention and overflow incontinence
• UTI/ urethritis
• Atrophic urethritis/vaginitis
• Pregnancy

Question 10

Name DDX of UI in women: Non-GU etiologies (6)

Answer 10

• Functional:
  
  • Cognitive
  • Neurologic
  • Psychological
  • Physical impairment
• Pharmacologic
• Metabolic/endocrine
  
  • Hyperglycemia, hypercalcemia, diabetes insipidus
  • ↑↑↑ Fluid intake (psychogenic polydipsia)
• Delirium
• Volume overload
• Stool impaction

Question 11

Name Medications Affecting urinary function (8)

Answer 11

• Frequency
  
  • Diuretics
  • Caffeine/EtOH
• Retention
  
  • Narcotics
  • Anticholinergics
  • Antidepressants
  • Antipsychotics
  • a-Agonists
  • Ca²⁺ - channelblockers

Question 12

Describe HX in the Evaluation of urinary incontinence in women (8)

Answer 12

• Sx: urgency, frequency, dysuria, nocturia, incomplete emptying, dribbling, pelvic bulge/ pressure, medical Hx, hematuria, volume of incontinence
• Level of functional impairment (quality of life)
• Neurologic Hx (DM, stroke, lumbar disk disease)
• Smoking Hx (COPD)
• Voiding diary (3–7 d):
  
  • Daytime and nocturnal voiding frequency and fluid intake (caffeine, EtOH)
  • Incontinence episodes
• Recurrent UTIs, GI Hx (incontinence, constipation)
• OB/GYN Hx (hysterectomy, vaginal repair, pelvic radiotherapy)
• Medication lsit

Question 13

Describe physical exam in the Evaluation of urinary incontinence in women (8)

Answer 13

• General physical exam including mental status
• Pelvic exam:
  
  • Vulvar or vaginal atrophy
  • Assess pelvic organ prolapse
  • Bimanual exam—R/O gyn pathology
  • Rectal exam—anal sphincter tone
  • “Cough test”—visualize leakage from urethra at time of cough with full bladder, and if pelvic organ prolapse, repeat with restoration of vaginal anatomy
• Neurologic exam (S2–4 control micturition):
  
  • Sensation: perineum, sacral derma- tomes of lower extremities
  • Motor: strength and tone of bulbo- cavernosus muscle, levators, external anal sphincter, and lower extremities

Question 14

Describe investigations in the Evaluation of urinary incontinence in women (4)

Answer 14

• PVR
• U/A (R/O UTI)
• Consider serum urea, Cr, glucose, and Ca2+
• Referral to gynecologist or urogynecologist for further testing (i.e., urodynamics, cystoscopy)

Question 15

Describe: Algorithm to assess for SI versus detrusor overactivity (Figure)

Answer 15

Question 16

Describe: Management of stress incontinence (4)

Answer 16

• behavioral approaches:
  
  • lifestyle interventions: weight loss, ↓ caffeine/ uid intake, smoking cessation, D activities/exercise, relief of constipation, timed voiding
  • Pelvic muscle exercises (aka Kegel): strengthen voluntary urethral sphincter and levator ani muscles; 3 repetitions of 8–10 sustained muscle contractions, 3–4 times weekly; not to be done during urination!
  • Biofeedback
• Medical management
  
  • New evidence against estrogen therapy for Rx of SI
• Devices (pessaries)
• Surgical management (refer to gynecologist)

Question 17

Describe: Management of urge incontinence (4)

Answer 17

1. lifestyle modifications: caffeine/fluid reduction, reduce bladder irritants
2. behavioural approaches
   
   • “bladder retraining” (aka bladder drills or timed voiding): schedule to ↑ interval between voids .
   • Pelvic muscle exercises (aka Kegel)
   • biofeedback
3. Medical management:
   
   • Tricyclic antidepressants or anticholinergic agents, selective b-receptor agonist
4. Surgical management and devices: sacral nerve modulation
5. Botox injections into bladder