Urinary Incontinence (Miller)

Question 1

What is the main risk factor for urinary incontinence in men?

Answer 1

Benign prostate hypertrophy (BPH)

Question 2

What are common risk factors for urinary incontinence in women?

Answer 2

Parity (multiple vaginal childbirth deliveries)
Menopause

Question 3

What are some common risk factors for urinary incontinence?

Answer 3

Age (increase with age)
Obesity
Smoking/pulmonary disease (the chronic cough)
Family Hx
PSH of pelvic surgery
Meds
Dementia

Question 4

What is the main reason as to why UIs are underreported?

Answer 4

UI is highly prevalent but sigmatizing which is why it is underreported. Prevalence range (5-72%)

Question 5

Urinary Incontinence (UI)

Answer 5

complaint of involuntary loss or leakage of urine

Question 6

What are the three class of UI?

Answer 6

1. Transient UI - last < 6 months (can be reversed)
2. Chronic UI (4 subtypes)
3. Functional UI - UI due to physical or cognitive impairment

Question 7

What are the 4 subtypes of chronic UI?

Answer 7

1. Stress UI
2. Urge UI
3. Mixed UI
4. Overflow UI

Question 8

Stress UI

Answer 8

leakage of urine with coughing, sneezing, or physical exertion (women)

Question 9

Urge UI

Answer 9

AKA overactive bladder
urine leakage with a sudden compelling desire to void (women and men)

Question 10

Mixed UI

Answer 10

co-existence of stress and urgency

Question 11

Overflow UI

Answer 11

urinary retention from detrusor under-activity or outflow obstruction (more common in men due to BPH)

Question 12

Pathophysiology of Stress UI

Answer 12

Your pelvic floor muscles are weak and no longer support your pelvic organs as they should. This muscle weakness means that you’re more likely to accidentally leak urine when you move around. (coughing, sneezing, laughing)

Question 13

Pathophysiology of Urge UI

Answer 13

AKA overactive bladder is caused by increased connectivity and excitability of both detrusor smooth muscle and nerves (ach released). Increased excitability propagates and generates uninhibited contractions

Question 14

Pathophysiology of Overflow UI

Answer 14

when the bladder becomes so full and distended that urine leaks out

Question 15

What are the 3 common causes of overflow UI

Answer 15

1. blocked urethra
2. bladder weakness (diabetes, alcohol, nerve impairment)
3. enlarged prostate (BPH)

Question 16

DIPPERS assessment

Answer 16

Reversible causes of UI: (usually causes transient UI)
Delirium
Infection
Pharmaceuticals
Psych morbidity
Excess fluid intake
Restricted mobility
Stool impaction

Question 17

Refer to a specialist urologist if there is any:

Answer 17

Bladder pain
Pelvic organ prolapse
Fistula
Neurological symptoms
Malignancy
Recurrent UTI
Post void residual volume >50 mL
Insensible loss

Question 18

Stress UI symptoms

Answer 18

Symptoms with coughing, sneezing, exercise
No nocturia
Small volume leakage on voiding daily (5-10mL)
Positive cough stress test
Post void residual volume < 50mL

Question 19

Urge UI symptoms

Answer 19

Symptoms of urgency
Variable volume loss on voiding diary
Frequency and nocturia typical
Negative cough stress test
Post void residual volume < 50mL

Question 20

Mixed UI symptoms

Answer 20

Symptoms with both physical activity and urgency
Variable volume loss on voiding diary
Positive cough stress test
Post void residual volume < 50 mL

Question 21

What are the 3 incontinence questions you MUST ask if you suspect UI>

Answer 21

1. During the past 3 months, have you leaked urine (even a small amount)?
2. During the past 3 months, when did you leak urine? (choose all that apply)
3. During the past 3 months, when did you leak urine most often? (choose only one)

Question 22

What are two common meds that can cause UI?

Answer 22

Diuretics
Lithium (causes polyuria via induced diabetes insipidus)

Question 23

UI physical exam

Answer 23

Functional assessment (mental status/mobility/BMI)
Abdominal exam (assess mass, palpable bladder, CVA)
Urogenital exam

Question 24

Urological test

Answer 24

Urinalysis with urinary microscopy
Urine culture
+/- post void residual volume (PVR) - measures completeness of emptying
Voiding diary
pad testing (worn for 24 hours; positive when >4g)

Question 25

Urodynamic Studies

Answer 25

According to the American Urogynecologic Society these studies are NOT recommended in the initial workup of an uncomplicated overactive bladder patient.

Indicated if: incontinence dx is uncertain after initial assessment or symptoms do not correlate with physical findings.

Question 26

Functional UI

Answer 26

caused by cognitive, functional or mobility difficulties that impair pt ability to use the bathroom W/O bladder or neurological impairment.

Question 27

Stress UI treatment

Answer 27

There is no recommended pharmacological treatment, but there is recommended conservative management

Appropriate fluid intake
Constipation management
Electrical stimulation
Mechanical devices
Pelvic floor muscles strengthening (training)
Smoking cessation
Weight loss

Can have stress incontinence surgery

Question 28

Urge UI treatment

Answer 28

Antimuscarinics
Intravaginal estrogen
Mirabegron (B3 adrenergic agonist for women with contraindications)

Invasive interventions:
Neuromodulation
Intravesicle Botox injection

Question 29

Overflow UI treatment

Answer 29

Alpha-adrenergic antagonists

Question 30

Invasive treatments for UI

Answer 30

Stress incontinence surgery (stress UI)
Neuromodulation (urge UI)
Intravesicle Botox injection (urge UI)

Question 31

Major UI complications

Answer 31

Poor quality of life (social isolation, sexual dysfunction, poor martial relationships, poor sleep)
Burden to family caregivers
Increased rates of depression (both patients and caregivers)