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BASICS

  • UI Types: stress, urge, mixed, overflow, functional.
  • Stress UI: uncommon in men; often post-prostate surgery or trauma.
  • Urge UI: caused by detrusor overactivity; commonly associated with bladder outlet obstruction (BPH).
  • Overflow UI: bladder overdistension from poor contraction or obstruction.
  • Functional UI: caused by mobility or environmental barriers.

EPIDEMIOLOGY

  • 12.4% prevalence of UI in US community-dwelling adult men.
  • Moderate to severe UI seen in 4.5%, with urge UI being most common.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Bladder abnormalities: detrusor overactivity β†’ urge UI.
  • Outlet abnormalities: sphincteric damage (surgery, radiation), neurologic disease.
  • BPH compresses urethra β†’ urinary flow obstruction.
  • Mixed UI: combination bladder and outlet issues.
  • Stress UI: weakened urethral sphincter or pelvic floor.

RISK FACTORS

  • Age, diabetes, BPH, hypertension, depression, neurologic disease.
  • History of UTIs, pelvic trauma, prostate surgery.
  • Polypharmacy.

DIAGNOSIS

HISTORY

  • Use 3 Incontinence Questions tool.
  • Assess voiding symptoms, incontinence pattern, severity, timing.
  • Review medications, surgeries, comorbidities.
  • Screen for red flags: pain, hematuria, recurrent infections, fistulas.

PHYSICAL EXAM

  • Abdominal: suprapubic tenderness or mass.
  • Genitourinary: external genitalia, digital rectal exam (DRE) of prostate.
  • Musculoskeletal & neurologic: assess for neurogenic bladder causes.

DIFFERENTIAL DIAGNOSIS

  • Transient causes (infection, meds, constipation).
  • Urge, stress, mixed, overflow, functional UI.

DIAGNOSTIC TESTS

  • Urinalysis and culture (exclude infection).
  • Postvoid residual (PVR) measurement (β‰₯100 mL β†’ voiding dysfunction; >200 mL β†’ overflow UI).
  • Voiding diary, pad test (low sensitivity).
  • Uroflowmetry.
  • PSA as clinically indicated.
  • Imaging and cystoscopy selectively.

TREATMENT

GENERAL MEASURES

  • Behavioral modification: bladder training, timed voiding.
  • Pelvic floor muscle training (PFMT) aids stress UI recovery post-prostatectomy.
  • Weight loss recommended.
  • Manage constipation, limit caffeine intake.
  • Use of pads or external sheaths.

MEDICATION

  • Urge UI:
  • Antimuscarinic agents (oxybutynin, tolterodine, darifenacin, solifenacin, trospium, fesoterodine).
  • Ξ²3-adrenergic agonist (mirabegron) as alternative or adjunct.
  • Stress UI: no FDA-approved meds; topical estrogen may help postmenopausal urgency.
  • Combination therapy preferred for mixed UI.
  • Monitor side effects; caution in bladder outlet obstruction and high PVR.

SECOND LINE

  • Tricyclic antidepressants (imipramine).
  • Desmopressin for occasional short-term relief.
  • Botulinum toxin intradetrusor injections (not FDA-approved).
  • Duloxetine for mixed UI.

MECHANICAL DEVICES

  • Pelvic floor rehab (Kegel exercises) recommended for stress and urge UI.

SURGERY

  • Stress UI:
  • Urethral bulking agents (modest success).
  • Male sling procedures (promising short/intermediate outcomes).
  • Artificial urinary sphincter (gold standard; high continence rates, revision may be needed).
  • Urge UI:
  • Sacral nerve stimulation.
  • Augmentation cystoplasty.
  • Botulinum toxin injection.

SPECIAL CONSIDERATIONS

  • Geriatrics: anticholinergics and tricyclics may impair cognition.
  • Monitor blood pressure with mirabegron.

ONGOING CARE

  • Follow up with symptom severity indices (M-ISI, ICIQ-UI short form, Sadvik questionnaire).
  • Monitor for complications.

COMPLICATIONS

  • Dermatitis, candidiasis, skin breakdown.
  • Social isolation, sexual dysfunction, weight gain.

REFERENCES

  1. Khandelwal C, Kistler C. Diagnosis of urinary incontinence. Am Fam Physician. 2013;87(8):543-550.

ICD10

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

CLINICAL PEARLS

  • Consider comorbidities as contributors to UI; treat secondary causes.
  • Always check PVR; >100 mL suggests voiding dysfunction; >200 mL suggests overflow UI.
  • Pelvic floor rehab beneficial in males.
  • Surgical options highly effective for stress UI refractory to conservative therapy.