Urinary Incontinence [epidemiology, Pathophysiology, Types, Diagnosis]

Question 1

What are the 3 broad sub-types of Urinary Incontinence?

Answer 1

1. Urge Incontinence
2. Stress Incontinence
3. Overflow Incontinence

There can be a ‘Mixed’ type Incontinence [Stress + Urge] and a Functional Incontinence [from lack of patient mobility]

There is also Total Incontinence, Neurogenic Lower Urinary Tract Dysfunction and Enuresis risoria [in laughing babies]

Question 2

What can be the broad undelying reasons for the 3 subtypes of Urinary Incontinence? and reasons leading to its development?

Answer 2

1. Urge Incontinence: overactive detrussor muscle, sphincter dysfunction or overactive bladder [leading to premature initiation of micturition reflex]
2. Stress Incontinence: urethral hypermobility [poor pelvic floor musclesm connective tissue disorders, childbirth causing damage to levator ani muscle and/or S2-S4 nerve roots]; Intrinsic Sphincter deficiency [aging, obesity, trauma, prostate surgery]; Increase in abdominal pressure [laughing, sneezing, coughing, exercising]
3. Overflow Incontinence: impaired Detrussor muscle contractility [Neurogenic bladder in MS; Neuropathy and Polyuria in DM; Spinal Cord Injury; Anti-cholinergic medication adverse effects], Bladder outlet obstruction [BPH], both leading to chronically distended bladder and leaking when intravesicular pressure > outlet resistance

Stress incontinence is caused by urethral dysfunction, while urge incontinence is caused by bladder dysfunction. Mixed incontinence is a combination of both

Question 3

What is Urinary Incontinence?

Answer 3

The involuntary leaking/loss of urine that is out of patients voluntary control

Question 4

What is the epidemiological background of UI?

Answer 4

Increased risk with increasing age

Women more likely affected by UI, especially multiparous women who have had vaginal deliveries [more likely stress, urge or mixed]. Until age 80 women twice as likely, after 80 incidence is equal

Men, especially later stages of BPH present with UI [more commonly urge incontinence]

Question 5

What are the broad etiologies for UI?

Answer 5

1. Anatomical Anomalies: Masses or fistulae development, malignancy blocking urethra or on bladder wall
2. Neurogenic Disorders: Spinal cord and Cerebral pathologies can both cause either urine retention or UI
3. Recurrent Infections: can lead to asynchrony between bladder neck and external urinary sphincter
4. Multiple Pregnancies: multiparous women undergoing vaginal deliveries, post-menopausal women due to weakening of pelvic floor muscles and/or atrophic vagina and atrophic urethra [decrease in estrogen causing degradation of muscles]
5. Obesity: increases abdominal pressures and can lead to weaker pelvic floor muscles

Question 6

4 main procedures and multiple sub-procedures

What is the procedure of diagnosis for someone presenting with UI?

Answer 6

a. Initial Evaluation for all patients presenting with UI:
1. Focused history taking
2. Inquire about symptoms associated with voiding
3. Asses for barriers to voiding in patients with mobility issues
4. Recording fluid intake and mucturition for 3-5 days using a void diary and reassesing

b. Physical Examination
1. Lower abdomen and Urinary Stress Test
2. Digital Rectal Exam [fecal impaction, prostatomegaly, masses, decreased anal spincter tone]
3. Pelvic Exam [prolapse, vaginal atrophy, masses, vaginitis]
4. Cardiovascular Exam [for CHF assessment]
5. Neurologic Exam [motor function and sacral dermatomes assessement; Anal-wink Reflex, Bulbocavernous Reflex; cognitive testing]

c. Urinalysis [if inconclusive]
1. Nitrates and/or leukocyte esterase positive: possible UTI
2. Isolated hematuria: possible enlarged prostate, pelvic organ prolapse or malignancy [microscopic evaluation necessary, not just dipstick]
3. Glycosuria: Diabetes screening

d. PVR using Ultrasound [if inconclusive]
1. Elevated PVR suggestes overflow incontinence either due to underactive Detrussor muscles/bladder wall contractility or urethral obstruction]

Question 7

What are the usual RED FLAGS for initial evaluation of UI patients?

Answer 7

1. Associated pain
2. Persistent Hematuria or Proteinuria
3. Elevated PVR volume
4. Symptoms suggesting obstruction
5. Suspected Fistuale
6. Pevic Organ Prolapse
7. Recurrent UTIs
8. Incontinence after radiation, radical pelvic surgery or previous incontinence surgery

Refer to urologist

Question 8

What are some Acute and Chronic causes of UI?

Answer 8

Acute causes: DIAPPERS.These causes are reversible and patients are re-evaluated after treatment
1. Delirium/confusion
2. Infection
3. Atrophic vaginitis/urethritis
4. Pharmaceuticals
5. Psychiatric esp. depression
6. Excessive output esp. hyperglycemia, hypercalcemia, CHF
7. Restrictive mobility
8. Stool impaction

Chronic Causes:
1. Local: back, bowel, gyneologic, bladder surgery, constipation, pevic organ prolapse
2. Systemic: CHF, chronic cough [makes stress incontinence worse], neurological diseases

Question 9

When should we perfom any Renal evaluation? What do we use to evaluate?

Answer 9

When we see signs of renal pathology or impairement associated with UI or urinary retention like hematuria, neurogenic incontinence signs, elevated PVR, comorbid renal disease in history.

Evaluation methods:
1. Renal Ultrasound [assessment for hydronephrosis or malignancy cause obstruction]
2. Creatinine and BUN levels [elevated in overflow UI in chronic retention cases leading to CKF]

Question 10

What evaluations do we use if we spot any RED FLAGS in UI assessment?

Answer 10

1. Micturating Cystourethrogram: detects vesicoureteral reflux, morphological anomalies like diverticula and obstructions
2. Urodynamic studies: determines Detrussor muscle and sphincter functions
3. Cystoscopy: evaluation for tumours and vesicourectal or vesicovaginal fistulae
4. Ultrasound Pelvis: in suspection of pelvic floor dysfunction [transperineal or transvaginal]
5. MRI: assessment for pelvic floor defects, urinary tract obstructions and masses]
6. CT with IV contrast: suspection of anatomical abnormalities like masses, bladder wall thickening

Question 11

Presenting Signs of Urge Incontinence [result of Urinary Stress Test and PVR]?

Answer 11

Strong, sudden sense of urgency, followed by involuntary leakage

Urinary Stress Test: may have delayed leakage [bladder spasms after 5-15 sec of stress test conductance]

PVR: <50 ml

Question 12

Presenting signs of Stress Incontinence [result of Urinary stress Test and PVR]?

Answer 12

Complaints about leakage after exercise, lifting things from ground, laughing, coughing, sneezing

Urinary Stress Test: positive, leakage with coughing

PVR: <50 ml

Question 13

Presenting signs of Overflow Incontinence [Urinary Stress Test and PVR results]?

Answer 13

1. Frequent, involuntary intermittent/continuous dribbling of urine in the absence of an urge to urinate
2. Occurs only when the bladder is full
3. Often occurs with changes in position

Urinary Stress Test: no leakage

PVR: >200 ml