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BASICS

  • Urinary incontinence (UI): Involuntary urine loss; common in women; often underreported despite effective treatments.
  • Classification:
  • Transient (<6 months, reversible if cause treated)
  • Chronic (stress, urge, mixed, overflow, functional, continuous)

DESCRIPTION

  • Stress UI: Leakage with increased intra-abdominal pressure (cough, exertion); most common in younger women.
  • Urge UI: Sudden uncontrollable urine loss with urgency; due to overactive bladder (OAB) or detrusor overactivity (DO); most common in older adults.
  • Mixed UI: Combination of stress and urge; most common overall.
  • Overflow UI: Dribbling from chronic retention or inadequate emptying; risk of infections and reflux.
  • Functional UI: Due to cognitive/mobility deficits despite normal urinary system.
  • Continuous UI: Constant leakage due to ectopic ureters or fistulas.

EPIDEMIOLOGY

  • Prevalence: 10-20% in women; up to 77% in nursing homes.
  • Stress UI decreases with age; urge UI increases with age.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Stress UI: Anatomic (urethral hypermobility) or intrinsic sphincter deficiency.
  • Urge UI: Idiopathic or neurogenic detrusor overactivity (MS, SCI).
  • Overflow UI: Detrusor underactivity, bladder outlet obstruction (fibroids, POP).
  • Functional UI: Cognitive impairment, mobility issues, psychological factors.
  • Continuous UI: Ectopic ureters, urogenital fistulas (vesicovaginal, ureterovaginal, urethrovaginal).

RISK FACTORS

  • Advanced age, menopause/vaginal atrophy, obesity, multiparity.
  • Medical conditions: DM, COPD, neuro diseases (stroke, Parkinson’s, MS).
  • Pelvic floor trauma: vaginal birth, surgery, radiation.
  • Lifestyle: smoking, constipation, caffeine, high-impact exercise.

DIAGNOSIS

HISTORY

  • Age of onset (childhood → congenital).
  • Symptom pattern: stress UI → small spurts; urge UI → sudden urge + large leakage.
  • Associated symptoms: pelvic pressure, dyspareunia, nocturia.
  • Surgical history, comorbidities, medications affecting bladder function.
  • Voiding diary, International Consultation on Incontinence Questionnaire (ICIQ).

PHYSICAL EXAM

  • Neuro exam: perineal-sacral sensation, cognition.
  • Pelvic exam: vaginal atrophy, pelvic organ prolapse, pelvic floor muscle function (Oxford Scale).
  • CST: immediate leakage on cough/valsalva with full bladder.
  • Cotton swab test: limited utility.
  • Postvoid residual (PVR) measurement if indicated.

DIFFERENTIAL DIAGNOSIS

  • Nocturnal enuresis, continuous leakage (fistulas, ectopic ureter), postvoid dribbling.
  • Pain causes: interstitial cystitis, STIs.
  • Pelvic organ prolapse, malignancy, functional UI.

DIAGNOSTIC TESTS & INTERPRETATION

  • UA: infection, hematuria, proteinuria.
  • Urine culture if infection suspected.
  • Renal function tests if obstruction suspected.
  • TSH if constipation present.
  • Renal ultrasound if obstruction suspected.
  • Urodynamics and cystoscopy for complicated cases or pre-surgery.

TREATMENT

GENERAL MEASURES

  • Correct reversible causes (infection, constipation).
  • Stress UI: pelvic floor muscle training (PFMT) + behavioral modification.
  • Urge UI: behavior modification, PFMT, medication.
  • Mixed UI: target predominant symptoms.

MEDICATION

  • Stress UI: no FDA-approved meds; topical estrogen may help postmenopausal women with vaginal atrophy.
  • Urge UI: antimuscarinics (oxybutynin, tolterodine, solifenacin), β3-agonists (mirabegron, vibegron).
  • Combination therapy (behavior + meds) more effective.
  • Caution: anticholinergics avoid in narrow-angle glaucoma, urinary retention, cognitive impairment.

MECHANICAL DEVICES

  • Vaginal pessaries and tampons (stress UI, pregnancy, non-surgical candidates).
  • Urethral plugs (limited evidence; risk of UTI, hematuria).

SURGERY (Third Line)

  • Stress UI:
  • Mid-urethral sling (mesh common, high success).
  • Autologous fascia pubovaginal sling, Burch colposuspension.
  • Urge UI:
  • OnabotulinumtoxinA intravesical injection.
  • Neuromodulation (sacral nerve stimulation, posterior tibial nerve stimulation).
  • Bladder augmentation (last resort).

SPECIAL CONSIDERATIONS

  • Geriatrics: Avoid long-term anticholinergics; risk of falls, delirium.
  • Pregnancy: Meclizine and dimenhydrinate safe.

ONGOING CARE

  • Monitor for adverse effects and symptom improvement.
  • Follow-up with specialists as needed.

COMPLICATIONS

  • Skin maceration, social isolation, depression.
  • Sexual dysfunction, impaired quality of life.
  • Increased risk of falls and fractures.

REFERENCES

  • Riemsma R, Hagen S, Kirschner-Hermanns R, et al. Can incontinence be cured? A systematic review of cure rates. BMC Med. 2017;15(1):63.

ICD10

  • R32 Unspecified urinary incontinence
  • N39.3 Stress incontinence (female) (male)
  • N39.41 Urge incontinence

CLINICAL PEARLS

  • UI diagnosis mostly clinical, supported by CST, PVR, UA.
  • Rule out infection and hematuria before treatment.
  • Pelvic floor training is first-line for stress and urge UI.
  • If no improvement in stress UI, consider sling surgery.
  • Anticholinergics and β3-AR agonists useful for urge UI.