Urinary incontinence classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Classification

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

Stress incontinence

Stress urinary incontinence (SUI) occurs when the intraabdominal pressure on the bladder exceeds the resistance provided by the urethra. The symptoms include loss of urine with coughing, laughing, sneezing, exercising or other movements that increase intraabdominal pressure and thus increase pressure on the bladder. The pathophysiology is related to pelvic floor muscle and tissue weakness and changes in the intrinsic "water seal" function of the urethra. Physical changes resulting from pregnancy, childbirth, prior pelvic surgery and menopause may lead to stress incontinence in women while in men it may occur following a prostatectomy.

The urethra is supported by fascia of the pelvic floor. If the fascial support is weakened, as it can be in pregnancy and childbirth, the urethra can move downward at times of increased abdominal pressure, resulting in stress incontinence. There are many different theories as to why SUI actually occurs. Two of the classic concepts are changes in abdominal pressure transmission and loss of the normal suburethral support

Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels resulting in changes in urethral function. Urine analysis, cystometry and postvoid residual volume are normal.

Urge incontinence

Urge incontinence describes incontinence associated with a sudden urge to void. This urge is not the typical sense that one has of a need to void but is a pathologic sense of an extreme need to void which is difficult to ignore. Typically patients describe a sudden urge to urinate but before they can get to the toilet urine starts to leak out. Often the entire bladder may empty leading to a large volume of urine loss. Classically urge incontinence was thought to be due to abnormal sudden bladder contractions which the patient could not control. However, when observing these patients during urodynamics, some of them do not have these abnormal bladder contractions (detrusor overactivity) but instead seem to have an early sensation of the need to void (detrusor hypersensitivity). Patients with urinary tract infections or other inflammatory conditions of the bladder may develop urge incontinence. In some cases when the underlying cause is treated, for example with a UTI, the urge incontinence will resolve. Urge incontinence may also coexist with other symptoms of the overactive bladder syndrome − urinary frequency, urgency and nocturia.

• Idiopathic Detrusor Overactivity − describes urge incontinence with no clear etiology
• Neurogenic Detrusor Overactivity − describes urge incontinence in a patient with neurologic disease. In many neurologic diseases loss of normal bladder inhibition may occur which can lead to urge incontinence

Medical professionals describe such a bladder as "unstable," "spastic," or "overactive." Urge incontinence may also be called "reflex incontinence" if it results from overactive nerves controlling the bladder.

Some patients with urge incontinence may have triggers that lead to it. Many will complain of urge incontinence after washing their hands or hearing running water (as when washing dishes or hearing someone else taking a shower), after feeling a chill, or when they get close to their home and are fumbling for the keys to get in the house.

Involuntary bladder contractions can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson's disease, Alzheimer's Disease, stroke, and injury−−including injury that occurs during surgery−−can all harm bladder nerves or muscles.

Overflow incontinence or Hypotonic

Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan − hence the general name overflow incontinence. Overflow incontinence occurs when the patient's bladder is always full so that it frequently leaks urine. Weak bladder muscles, resulting in incomplete emptying of the bladder, or a blocked urethra can cause this type of incontinence. Autonomic neuropathy from diabetes or other diseases (e.g Multiple sclerosis) can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the detrusor muscle (allowing for urinary retention). Additionally, tumors and kidney stones can block the urethra. In men, benign prostatic hypertrophy (BPH) may also restrict the flow of urine. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. Also overflow incontinence in women can be from increased outlet resistance from advanced vaginal prolapse causing a "kink" in the urethra or after an anti−incontinence procedure which has overcorrected the problem.

Early symptoms include a hesitant or slow stream of urine during voluntary urination. Anticholinergic medications may worsen overflow incontinence.

Functional incontinence

Functional incontinence occurs when a person does not recognize the need to go to the toilet, recognize where the toilet is, or because of disability is unable to get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, or being in a situation in which one is unable to reach a toilet. People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer's Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.

Other types of incontinence

Stress and urge incontinence often occur together in women. Combinations of incontinence − and this combination in particular − are sometimes referred to as "mixed incontinence."

"Transient incontinence" is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow. Incontinence can often occur while trying to concentrate on a task and avoiding using the toilet.

Type of Incontinence	Gender	Pathophysiology	Urinary signs and symptoms						Risk factors	Associated findings
			Urgency	Frequency	Dribbling of urine	Amount of incontinence	Nocturia	Residual volume
Stress incontinence	F > M	Weakness of the urethral sphincter Weakness of the pelvic floor muscles	−	−	+	Small volume	±	< 50 ml	Genitourinary surgical procedures Multiple childbirths	Patient recognizes which activities promote incontinence Incontinence with a cough, sneezing, straining
Urge incontinence (detrusor instability)	F > M	Detrusor overactivity Increased parasympathetic drive to the bladder (S2−S4)	+	+	−	Small to large volume	++	< 50 ml	Stroke Alzheimer's disease Parkinson's disease Benign prostatic hyperplasia	A variable amount of urine loss; ranging from small volumes to complete emptying of the bladder
Overflow incontinence	M > F	Overdistension of the bladder Impaired bladder contractility Bladder outlet obstruction (BOO)	−	−	+	Small volume	+	> 200 ml	Benign prostatic hyperplasia Fecal impaction	Poor bladder emptying
Functional incontinence	M=F	Inability to reach the toilet to urinate Environmental barriers Physical barriers	−	−	+	Variable volume	+	< 50 ml	Altered mental status	Immobility Lower urinary tract deficits
Mixed incontinence (urge and stress)	M=F	Combined urge and stress incontinence	+	±	+	Variable volume	±	Variable	Neurologic disorders Urogenital procedures Multiple childbirths	Patient able to determine the pre−dominant symptoms