Approach to urinary incontinence (GYN): Clinical sciences

Watch video only
Urinary incontinence refers to the involuntary leakage of urine. This is a common problem that impacts both physical and psychological well-being.
Often, patients do not disclose symptoms of urinary incontinence due to feelings of embarrassment, but these symptoms can adversely impact daily activities and diminish quality of life.
Underlying causes of incontinence include pregnancy, childbirth, urinary tract infections, changes to the pelvic floor, or bladder dysfunction.
It’s also associated with medical conditions such as diabetes or certain neurologic disorders, as well as physical immobility, or cognitive impairment.
There are several categories of urinary incontinence including stress, urgency, mixed, overflow, and functional urinary incontinence.When a patient presents with a chief concern suggesting urinary incontinence, the first step is to perform a focused history and physical examination and obtain an hCG to assess for pregnancy.
If the hCG is positive you have a diagnosis. Urinary incontinence is common in pregnancy, mostly during the second and third trimesters due to increased pressure on the bladder and pelvic floor.
Also, pregnant patients are at increased risk for asymptomatic bacteriuria and urinary tract infections, which can cause urinary leakage.
After assessing for pregnancy, the next step is to assess for a urinary tract infection by obtaining a urinalysis. Now, it might come back positive for nitrites and leukocyte esterase, and possibly heme or blood.
In this case, the patient will likely report an acute onset of incontinence. They may also report associated symptoms of dysuria, urinary frequency or urgency, and gross hematuria.
The physical examination might reveal suprapubic tenderness. So, consider a lower urinary tract infection and send the urine for culture.
If the culture is positive, you have made your diagnosis of a lower urinary tract infection.Here is a clinical pearl! If urinary leakage persists after successful treatment of a urinary tract infection, evaluate the patient for other types of urinary incontinence.
On the other hand, if the urinalysis is negative for nitrites, leukocyte esterase, and heme or blood; assess for common causes of urinary incontinence.Let’s start with stress urinary incontinence.
The patient will report loss of urine with physical exertion, sneezing, or coughing. They may have risk factors for stress incontinence including previous pregnancy, constipation, or obesity.
The physical examination may demonstrate pelvic organ prolapse, such as a cystocele; or pelvic muscle weakness. In this case, consider stress urinary incontinence and perform a cough stress test, post void residual or PVR, and test for urethral hypermobility.
Let’s take a moment to discuss these tests. A cough stress test is simply the observation of the leaking of urine from the urethra when the patient coughs.
It can be performed while the patient is supine or standing and may require a full bladder. A PVR involves the measurement of residual urine in the bladder after the patient voids.
This can be done with bladder ultrasonography or catheterization. A normal PVR is generally considered to be less than 150 milliliters.
Finally, a test for urethral hypermobility is performed by measuring the displacement of the angle of the urethra-bladder neck from the horizontal position when the patient performs a Valsalva maneuver.
In the past, this was done by placing a cotton-tipped swab into the urethra, known as a Q-tip test; but actually the cotton-tipped swab is not necessary, and it may also be uncomfortable for the patient.
Instead, the measurement can be made by direct visualization or palpation. Urethral hypermobility is present if the angle is greater than 30 degrees from the horizontal.
Now, if there is leaking of urine with the cough stress test, a normal PVR, and possible evidence of urethral hypermobility, the testing supports the diagnosis of stress urinary incontinence.Here’s another clinical pearl!
Often, a simple office evaluation is sufficient to make the diagnosis of urinary incontinence. A voiding diary or a validated urinary incontinence questionnaire are useful tools to confirm your findings.
Additionally, complex urodynamic testing and cystourethroscopy are helpful if the diagnosis is unclear, a treatment plan is not successful, or a preoperative evaluation is needed.Next, let’s talk about urgency urinary incontinence.
The primary symptom here is the strong sudden urge to urinate resulting in an involuntary leakage of urine. The history may also reveal the use of bladder irritants such as caffeine or alcohol; medications such as diuretics; or medical conditions that cause bladder dysfunction, like multiple sclerosis and certain types of spinal cord injuries.
The physical exam may reveal pelvic muscle weakness or vulvovaginal atrophy. If you see these findings, consider urgency urinary incontinence and perform a cough stress test and a PVR.
If the cough stress test is negative for leaking and the PVR is normal, the diagnosis is urgency urinary incontinence. Here’s a high yield fact to keep in mind!
An overactive bladder, or OAB, is also characterized by a strong urge to urinate, but it can be present with or without incontinence.
So, all urgency incontinence is a form of OAB, but not all OAB is urgency incontinence.Okay, time to switch to mixed urinary incontinence.
Many patients have symptoms of both stress and urgency urinary incontinence and will report the strong sudden need to urinate as well as the loss of urine with physical exertion, sneezing, or coughing.
The physical exam may demonstrate pelvic organ prolapse, pelvic muscle weakness, or vaginal or vulvar atrophy. With these findings, consider mixed urinary incontinence and perform a cough stress test, PVR, and test for urethral hypermobility.
The stress test might be positive, the PVR will be normal, and there could be urethral hypermobility. These findings support your diagnosis of mixed urinary incontinence.Time for one more clinical pearl!
Many patients with urinary incontinence also have pelvic organ prolapse. Both diagnoses are associated with prior pregnancy, pelvic floor muscle weakness, and a decreased estrogenic state.
Keep in mind that the prolapse may not necessarily be the source of incontinence. Sometimes, pelvic organ prolapse can cause a kink in the urethra, which may actually mask underlying stress urinary incontinence or may cause overflow incontinence.
When evaluating for incontinence in a patient with pelvic organ prolapse, be sure to reduce the prolapse manually during your examination.
Next, let’s consider overflow urinary incontinence. The patient may report leaking or dribbling of urine, incomplete bladder emptying, and nocturia, as well as urinary frequency or a weak stream.
They may have a history of diabetes, a neurologic disorder, pelvic surgery, or pelvic radiation. The physical exam may demonstrate pelvic organ prolapse or neurologic findings that reflect damage to sacral segments two to four.
These findings include impaired motor and sensory function of the lower extremities or the absence of an anal wink. In this case, the cough stress test might be positive or negative, but the PVR will be elevated.
The elevated PVR confirms the diagnosis of overflow incontinence.Here’s a clinical pearl! Overflow urinary incontinence results from detrusor muscle underactivity or bladder outlet obstruction.
Detrusor underactivity is often related to an underlying nerve injury or neurologic condition as seen with diabetes, a cerebrovascular accident, multiple sclerosis, or Parkinson disease.
Bladder outlet obstruction could be secondary to pelvic organ prolapse, prior pelvic surgery or radiation, or a tumor.Finally, let’s go over functional urinary incontinence.
Many patients may have physical impairment, immobility, or cognitive or psychiatric impairment that impacts the ability to remain continent.
In these cases, patients have intact urinary function but are unable to reach the toilet in a timely fashion. This is functional urinary incontinence; so, when assessing a patient for incontinence, remember to consider both physical and cognitive function.After assessing for common causes of urinary incontinence, consider and assess for alternative diagnoses.
Possible diagnoses include a fistula, such as a vesicovaginal fistula where there’s a communication between the bladder and vagina; certain medications; pelvic organ prolapse; and urethral diverticulum.
Alright, as a quick recap… Urinary incontinence, the involuntary leaking of urine, is a common problem that can affect a patient’s physical and emotional well-being.
Common types of incontinence include stress urinary incontinence, urgency urinary incontinence, mixed urinary incontinence, overflow urinary incontinence, and functional urinary incontinence.
Also consider other possible diagnoses such as a fistula, medications, pelvic organ prolapse, or a urethral diverticulum.