Urinary incontinence

Question 1

“A 55-year-old female complains of urinary incontinence. What are the types of urinary incontinence and how are they diagnosed and managed?

2020 stem: A 62 year old lady presenting with urinary incontinence, has to wear pads. Obtain key points on history from the examiner, suggest what examination you would do, what are the possible causes, what investigations and management.”

Answer 1

Impression
This patient is experiencing urinary incontinence, of which there a number of different causes depending on the nature of the incontinence;
- mixed
- stress
- overflow 
- urge

Would want to consider other aetiologies:

• UTI causing similar symptoms
• urogenital fistula (likely in setting of prev repair/trauma)

Question 2

Urinary incontinence - Types

Answer 2

Types of urinary incontinence
- Stress: leakage of urine with increases in intra-abdominal pressure (sneezing, coughing, straining, etc)
Causes: urethral hyper mobility, intrinsic sphincteric insufficiency

• Urge: often used interchangeable with ‘overactive bladder’. a sensation of the need to void is immediately preceding or accompanying involuntary urination of a varying amount. Common in older women, thought to be related to detrusor m overactivity.
  Causes: neurological injuries, idiopathic
• Overflow: continuous urinary leakage or dribbling in the setting of incomplete bladder emptying.
  Causes: detrusor m underactivity, or urinary outlet obstruction
• Mixed: women with features of both stress and urgency (not overflow)

Question 3

Urinary incontinence - History

Answer 3

History
- PC: volume, timing, nature of incontinence (happen when laugh/sneeze? Get sudden urges to go? - do you make it?)
associated sx: nocturia, polyuria, 
- Risk factors: prev pregnancy's (traumatic births), obesity, smoking, prolapse, increasing age
- other: impact on quality of life
- PMHx, PSHx
- Obstetric history, menstrual history
- SNAP

Question 4

Urinary incontinence - Examination

Answer 4

Examination

• General appearance + vital signs
• abdominal examination
• pelvic examination:
• neurological examiantion (esp lower limb, if suspecting underlying neurological condition)
• bladder stress test: standing with full bladder, visualise urethra and ask patient to cough/valsalva and observe any incontinence

Question 5

Urinary incontinence - Investigations

Answer 5

Investigations

• Bedside: urinalysis (UTI), urine MCS, cough stress test, post-void residual measurement (may confirm urinary retention (therefore likely overflow incontinence)
• imaging: bladder scan - for post-void residual urine

Question 6

Urinary incontinence - Management

Answer 6

Management
Is dependent on the underlying cause of the urinary incontinence, aims to reduce symptoms and improve quality of life.

Non-pharmacological (first line treatments)

• weight loss, reduce caffeine/smoking
• avoid/manage constipation
• pelvic floor muscle training (Kegel exercises), bladder training (mainly for stress incontinence)
• functional electrical stimulation (pudendal nerve)
• pessaries for prolapse
• pads and protective garments for persistent incontinence
• pessaries: elevates the bladder and compresses the urethra; may assist for patients with urge incontinence

Pharmacological

• predominantly for urge incontinence, aim to limit bladder overactivity. anticholinergics (Oxybutynin orals or patch medication - can cause dry mouth, constipation)
• Botox injections

Surgical treatment
Used in cases where conservative/pharmacological management has failed
- retropubic suspension (urethral hyper mobility/displacement)
- urethral sling
- supra-pubic catheters
- augmentation cystoplasty