Urinary incontinence

Question 1

Probability diagnosis

Answer 1

Stress incontinence

Cystitis

Overactive bladder (detrusor instability)

Outflow obstruction e.g. prostatism

Post pelvic surgery

Enuresis

Question 2

Serious disorders not to be missed

Answer 2

Infection:

• Prostatitis
• Chronic UTI

Cancer/tumour:

• Bladder

Other:

• Dementia
• Fistula
• Ectopic urethra

Question 3

Pitfalls (often missed)

Answer 3

Neurogenic: multiple sclerosis, neuropathy, others

Interstitial cystitis (women)

Rarities:

• Bladder calculus
• Post pelvic fracture

Question 4

Masquerades checklist

Answer 4

Diabetes: polyuria

Drugs (see list in history)

Endocrine: diabetes insipidus

Spinal dysfunction incl. cauda equina lesion

Urinary tract infection

Question 5

Is the patient trying to tell me something?

Answer 5

Functional (?psychogenic)

Question 6

Key history

Answer 6

Focus on the;

• duration and patterns of voiding
• bowel function
• drug use
• obstetric and pelvic surgery history.

A voiding diary is helpful to pinpoint the cause.

Use of a severity index questionnaire is very helpful.

Obstructive symptoms in men with detrusor overactivity.

Consider a sleep related problem.

Check drug history:

• diuretics
• alcohol
• sedatives
• antidepressants
• α-adrenergic blockers e.g. prazosin
• caffeine
• psychoactive agents
• anticholinergics
• calcium channel blockers e.g. nifedipine.

Question 7

Key examination

Answer 7

Based on neurological, pelvic and rectal examinations

Question 8

Key investigations

Answer 8

First line:

• urinalysis
• MSU
• KFTs

Consider (based on specialist referral):

• cystoscopy
• cystometry
• urodynamic studies
• selective imaging e.g. ultrasound, micturating cystourethrogram, IVU

Question 9

Diagnostic tips

Answer 9

Classify incontinence into the main categories:

• stress
• urge
• continuous (overflow)