Stress, urge, overflow, and mixed urinary incontinence (GYN): Clinical sciences

Urinary incontinence, or the involuntary leakage of urine, is a common and often underreported problem that impacts both physical and psychological well-being. It can adversely impact activities of daily living and diminish quality of life.

Urinary incontinence is associated with the effects of childbirth, urinary tract infections, changes to the pelvic floor, and bladder dysfunction. In addition, it can be secondary to neurologic conditions, diabetes, and medications such as diuretics. The most common types of urinary incontinence are stress, urgency, overflow, and mixed incontinence.

When a patient presents with a chief concern suggesting urinary incontinence, the first step is to obtain a urinalysis and urine culture. If the urinalysis is positive for nitrites, leukocyte esterase, and possibly heme; and if the urine culture is positive, the diagnosis is a lower urinary tract infection. Treat the patient with appropriate antibiotic therapy.

Here is a clinical pearl! If urinary leakage persists after successful treatment of a urinary tract infection, evaluate the patient for other causes of urinary incontinence!

On the other hand, if the urinalysis is negative for nitrites, leukocyte esterase, and heme; and the urine culture is negative, then your patient does not have a urinary tract infection. Proceed with your next step, which is to perform a focused history and physical examination, as well as a simple office evaluation consisting of a urinary cough stress test and a post-void residual, or PVR. A cough stress test is the observation of urine leaking from the urethra when the patient coughs. This 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 the aid of bladder ultrasonography or catheterization. A normal PVR is generally considered to be less than 150 milliliters.

Here’s another clinical pearl! In addition to the office evaluation, a validated urinary incontinence questionnaire and voiding diary are useful tools to assess incontinence symptoms. Also, consider any functional or cognitive impairments that may impact the patient’s ability to maintain continence.

First, let’s talk about stress urinary incontinence. These patients may report a history of loss of urine with physical exertion, sneezing, or coughing. Additionally, the physical examination may reveal pelvic muscle weakness; pelvic organ prolapse, such as a cystocele; and urethral hypermobility. Urethral hypermobility is defined as a displacement angle of the urethra-bladder neck that is greater than thirty degrees from the horizontal 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.

After the history and physical, if the cough stress test is positive for leaking of urine and the PVR is normal, the diagnosis is stress urinary incontinence. Generally, the initial management involves pelvic floor physical therapy, along with behavioral and lifestyle modifications such as fluid management, weight loss if overweight, and bladder training, which includes keeping a voiding diary and timed voiding. Other nonsurgical options include an incontinence pessary to support the urethra, or urethral bulking agents to increase urethral resistance.

Surgical management is an option for patients who decline or do not have success with conservative management. The most common primary surgical procedure for stress urinary incontinence is placement of a midurethral sling. The sling is placed vaginally, and sits below the urethra like a hammock, with the ends secured behind the pubic bone or into the groin.It is placed tension-free and is designed to provide dynamic obstruction to the urethra during physical stress or strain such as coughing, sneezing, or exercise.

Now, let’s consider 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, and vulvovaginal atrophy. If the cough stress test is negative for leaking and the PVR is normal, this supports the diagnosis of 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.