Urinary incontinence resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maneesha Nandimandalam, M.B.B.S.[2]

Overview

Urinary incontinence is defined as an involuntary leakage of urine. The causes can be temporary or permanent. Most common reversible causes include dementia, delirium, infections, atrophic vaginitis, psychological, drugs, stool impaction. It is broadly classified into 5 types based on the characteristics on the urinary incontinence.

Causes

Life Threatening Causes

• Cerebrovascular accident

• Idiopathic parkinson's disease
• Infection
• Limbic encephalitis
• Metastatic prostate cancer
• Mitochondrial parkinson's disease
• Multiple sclerosis
• Parkinson disease
• Pelvic cancer
• Prostate cancer
• Schaefer-stein-oshman syndrome
• Spinal cord neoplasm
• Spinal fracture
• Stroke
• Toxic mushrooms
• Tumor
• Wilms tumor
• Wohlwill-andrade syndrome

Common Causes

• Bladder Cancer
• Botulinum toxin
• Delerium
• Drugs: Bethanechol chloride, Meropenem, Tiagabine
• Infection
• Inflammation
• Multiparity
• Neuropathic bladder dysfunction
• Neurologic
• Obesity
• Obstetric/gynecologic surgery
• Outlet obstruction
• Pelvic surgery
• Polyuria
• Postpartum
• Pregnancy
• Prostate surgery
• Restricted mobility
• Sphincteric atony
• Stool impaction
• Tumor
• Vaginitis
• Vesicovaginal fistula

Diagnosis

The approach to the diagnosis of Urinary incontinence is based on a step-wise approach strategy. Below is an algorithm summarising the identification and diagnosis of different types of Urinary incontinence . The algorithm is developed and modified according to American Urological Evaluation (AUA) Guidelines. Shown below is an algorithm summarizing the diagnosis of Urinary incontinence according to The American Urological Association guidelines.

Patients presenting with symptoms of urinary incontinence

Look for temporary causes Dementia, delirium Infections Atrophic vaginitis Psychological Drugs Stool impaction

Look for chronic incontinence History and physical exam including a cough test for stress incontinence Review voiding dairy Do all the lab work Measure post void residual urine volume

Based on all the findings arrive at a diagnosis

"Urge incontinence" ❑Urgency ❑ Frequency ❑Nocturia ❑ Cough stress test: May show delayed leakage after cough ❑ PVR urine< 50ml ❑Variable vol loss seen in voiding dairy

Overflow incontinence ❑No urgency ❑Absence of symptoms on physical activity ❑ Cough stress test:No leakage ❑ PVR urine> 200ml ❑Voiding dairy: varies

Stress incontinence ❑Symptoms seen on coughing, sneezing, exercise, increased intra-abdominal pressure ❑ No nocturia ❑ Cough stress test:Leakage coincides with cough ❑ PVR urine< 50ml ❑Voiding dairy: Small volume leakage

Functional incontinence ❑Cognitive dysfunction, immobility seen ❑ Cough stress test:No leakage ❑ PVR urine: Varies ❑Voiding dairy: Sometimes a pattern seen with incontinence

Mixed incontinence ❑Symptoms with physical activity, urgency noted ❑ Cough stress test:May show leakage ❑ PVR urine<50ml ❑Voiding dairy: Varies

Treatment

Treatment for different types of urinary incontinence

Stress incontinence ❑Lifestyle modifications like weight loss, smoking cessation, decreasing fluid intake, treating constipation if present ❑Pelvic floor muscle (Kegel) exercises that will strengthen the pelvic floor musculature ❑Supervised pelvic floor therapy ❑Vaginal weighted cones ❑Biofeedback ❑

Urge incontinence ❑behavioral therapy (controlling fluid intake, prompted voiding, constipation management, etc.) ❑Electrical stimulation ❑ Pelvic floor muscle strengthening (Kegel and floor muscle exercises) ❑Weight loss ❑ PVR urine< 50ml ❑Variable vol loss seen in voiding dairy

Overflow incontinence ❑Clean intermittent catheterization ❑Indwelling urethral catheter ❑ Relieving the obstruction ❑

D04

D05

If above modalities failed

Pharmacologic management ❑ Antimuscarinics (e.g., darifenacin, solifenacin, oxybutynin,tolterodine) ❑Topical vaginal estrogen

Pharmacologic management ❑ Alpha-adrenergic antagonists (e.g. terazosin, tamsulosin)

E04

E05

❑Pessaries placement ❑Midurethral sling surgical procedure

❑Surgical management like neuromodulation

❑Surgical management like neuromodulation

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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