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

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Introduction0:00–0:49

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.

Urinalysis/Lower urinary tract infection0:49–1:28

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!

Focused H&P1:28–2:45

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.

Stress urinary incontinence2:45–5:01

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.

Urgency urinary incontinence5:01–7:06

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.The initial management of urgency incontinence includes pelvic floor physical therapy, along with behavioral and lifestyle modifications such as bladder training, weight loss if overweight, and fluid management; management of underlying medical conditions; or addressing medication issues.
Other nonsurgical management options include pharmacotherapy with antimuscarinic agents or topical estrogen. Here’s a clinical pearl!
Antimuscarinic agents block parasympathetic muscarinic receptors in the bladder in order to inhibit involuntary detrusor contractions.
Also keep in mind that estrogen receptors are found in the vagina, bladder, urethra, and pelvic floor muscles, so topical estrogen therapy can improve vaginal and pelvic floor atrophy as well as bladder function.
Other medications, such as beta agonists and Botox A injections work by relaxing the detrusor muscle and increasing bladder capacity.Next, let’s discuss overflow incontinence.

Overflow incontinence7:06–9:03

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. Again, the initial management includes behavioral or lifestyle modifications, and management of underlying conditions or medications.
Nonsurgical therapy includes a pessary to reduce an obstructing cystocele, intermittent catheterization for patients with sacral nerve damage, or sacral nerve stimulation.
Surgical intervention might include a prolapse repair…to reduce an obstruction of the urethra or bladder neck. 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 talk about patients who may have both stress and urgency incontinence.

Mixed urinary incontinence9:03–10:45

They usually report a history of a strong sudden urge to urinate, as well as loss of urine with physical exertion, sneezing, or coughing.
The physical exam may reveal pelvic muscle weakness, pelvic organ prolapse, and vulvovaginal atrophy. The cough stress test might be positive for leaking, and the PVR will be normal.
This combination of symptoms and findings is consistent with mixed urinary incontinence. For the initial management, refer the patient to pelvic floor physical therapy; offer behavioral and lifestyle modifications such as bladder training, weight loss if overweight, and fluid management; and manage underlying medical conditions and medications.
Nonsurgical interventions include a pessary, urethral bulking agents, and pharmacotherapy with antimuscarinic agents or topical estrogen.
Finally, consider surgical interventions such as a midurethral sling procedure. Here’s a final clinical pearl!
Generally, an incontinence diagnosis is made by history, physical exam, and simple office tests. However, multichannel urodynamic testing, also known as complex cystometrics, is indicated if the diagnosis is unclear, symptoms do not correlate with objective findings, initial treatment is unsuccessful, or there is a history of prior incontinence surgery.
Alright, as a quick recap… Urinary incontinence, or the involuntary leaking of urine, is a common and often underreported problem that impacts both physical… and psychological well-being.

Review10:45–12:01

The most common types of incontinence are stress, urgency, overflow, and mixed incontinence. They can be diagnosed by history, physical exam, and simple office tests such as a cough stress test and PVR.
Initial management for urinary incontinence includes conservative measures such as pelvic floor physical therapy, bladder training, weight loss if overweight, and fluid management; management of underlying medical conditions; or addressing medication issues.
In addition, stress incontinence can be treated with urethral bulking agents, pessaries, or surgery; while urgency urinary incontinence can also be treated with pharmacotherapy.
Additional treatment options for overflow incontinence include pessaries, catheterization, sacral nerve stimulation, or surgical intervention.
Finally, management of mixed incontinence involves a combination of those