PANCE Blueprint Genitourinary (5%)

Incontinence

Patient will present as → a 68-year-old woman who presents to your office with leakage of urine when she sneezes, laughs, or coughs. She reports that these symptoms strictly occur during the day and never at night. She denies any subjective fever, dysuria, or hematuria. Pelvic examination is notable for a protrusion from the anterior vagina. (Stress incontinence)

Alternative presentation → a mother and her 6-year-old son come to the office with a concern that he continues to have nighttime wetting several times a week. He is the second child of three. He is in the first grade and struggling with his performance. He has had no medical problems. There is no history of developmental delay, and he was the product of a normal uncomplicated pregnancy and delivery. Since the birth of the third child, his behavior has been problematic. The examination of other body systems is normal. He does not have laboratory evidence of a urinary tract infection. (enuresis)

There are five major types of incontinence - affects  30% of elderly women and 15% of elderly men

1. Urge incontinence (detrusor overactivity)

  • Most common in elderly and nursing home patients
  • Overactive detrusor muscle results in increased frequency and involuntary loss of urine
  • Sudden urge to urinate (e.g., patients are unable to make it to the bathroom), a loss of large volumes of urine with small postvoid residual, and nocturnal wetting
  • Diagnostic study of choice is a urodynamic study

2. Stress incontinence (weakness of pelvic floor)

  • Occurs mostly in women (after multiple deliveries of children)
  • Weakness of the pelvic diaphragm (pelvic floor) leads to loss of bladder support (with resultant hypermobility of the bladder neck). This causes the proximal urethra to descend below the pelvic floor so that an increase in intra-abdominal pressure is transmitted mostly to the bladder (instead of an equal transmission to the bladder and urethra)
  • Involuntary urine loss (only in spurts) during activities that increase intra-abdominal pressure (cough, laugh, sneeze, exercise); small postvoid volume
  • Rule out infection with a urinalysis

3. Overflow incontinence (impaired detrusor contractility) cannot empty bladder - high postvoid volume

  • Common in diabetic patients and patients with neurologic disorders
  • Inadequate bladder contraction (due to impaired detrusor contractility) or a bladder outlet obstruction leads to urinary retention and subsequent overdistention of the bladder. Bladder pressure increases until it exceeds urethral resistance, and urine leakage occurs
  • Causes include neurogenic bladder (diabetic patients, lower motor neuron lesions), medications (anticholinergics, α-agonists, and epidural/spinal anesthetics), obstruction to urine flow (BPH, prostate cancer, urethral strictures, severe constipation with fecal impaction)
  • Nocturnal wetting, frequent loss of small amount of urine; large postvoid residual (usually exceeds 100 mL)

4. Functional incontinence - occurs in patients who have normal voiding systems, but who have difficulty reaching the toilet because of physical or mental disabilities

  • Symptoms include increased urinary volume and the inability to timely urinate

5. Mixed incontinence (combo of stress and urge) - most common

 

Nocturnal enuresis is defined as involuntary urination in sleep without urologic or neurologic causes after the age of 5 years, at which time bladder control would normally be expected.

  • The prevalence of enuresis decreases with increasing age. Thus, 82% of 2-year-old children, 49% of 3-year-old children, 26% of 4-year-old children, and 15% to 25% of 5-year-old children still wet beds on a regular basis.

Urinalysis to rule out UTI

  • Postvoid residual urine volume to identify urinary retention
    • overflow has a high PVR
    • stress and urge have a normal low PVR
  • Urodynamic studies can identify bladder contractions
    • stress - normal bladder contractions
    • urge - decreased bladder contractions
  • Ultrasonography and cystoscopy can be used to determine anatomic abnormalities

 

The only mandatory laboratory evaluation for children with enuresis is urinalysis. The following are all important abnormalities that may be associated with enuresis:

  • The presence of white blood cells in the urine as a result of a urinary tract infection
  • Low urine specific gravity as a result of diabetes insipidus
  • Proteinuria
  • Hematuria as a result of renal disease
  • Glucosuria as a result of diabetes mellitus
  • Urine culture, CBC, IVP, and cystometric evaluation should be performed only if specific indications suggest the need. Posterior urethral valves (especially in boys) may be associated with enuresis

1. Urge incontinence (detrusor overactivity) is treated with bladder-training exercises (the goal is to increase the amount of time between voiding)

  • If this is unsuccessful, medications include anticholinergics (oxybutynin) and TCAs (imipramine)

2. Stress incontinence (weakness of pelvic floor) is treated with Kegel exercises (multiple contractions of pelvic floor muscles as if patient were interrupting flow of urine) to strengthen pelvic floor musculature

  • Vaginal estrogens
  • Use of a pessary
  • Surgery (there are various options, and a popular option is a mid-urethral sling)

3. Overflow incontinence (impaired detrusor contractility)

Treatment is primarily medical: intermittent self-catheterization is the best management

  • cholinergic agents (e.g., bethanechol) to increase bladder contractions
  • α-blockers (e.g., terazosin, doxazosin) to decrease sphincter resistance

4. Functional incontinence is treated with scheduled voiding times

5. Mixed - (combo of stress and urge) most common

  • Lifestyle modifications and pelvic floor exercises are first-line
  • If unresponsive to first-line treatments then therapy is based on the predominant symptoms

Treatment of enuresis is aimed at alleviation of the symptoms of nocturnal enuresis rather than cure of the condition

  • Imipramine is no longer recommended for the treatment of enuresis in most children because of the potential for complications
  • Desmopressin is useful in achieving dry nights, but patients often revert to pretreatment levels when the medication is discontinued
  • A behavior modification program is the treatment of choice, including buzzer or bell and pad, positive reinforcement, charting of progress to increase confidence and self-esteem, urinating before bedtime, avoiding liquids after the evening meal, and avoiding psychological trauma through blame or belittling of the child

IM_MED_FunctionalIncontinence_v2.1_ Functional incontinence is a form of urinary incontinence that occurs in patients who have normal voiding systems, but who have difficulty reaching the toilet because of physical or mental disabilities. Symptoms include increased urinary volume and the inability to timely urinate. The treatment for functional incontinence includes scheduled voiding times.

Functional Incontinence Picmonic

IM_MED_OverflowIncontinence_v1.3_ Overflow incontinence is a form of urinary incontinence that is characterized by an involuntary, continuous loss of small amounts of urine due to a full bladder. Symptoms include increased urinary retention, involuntary urine dribble and urinary frequency. Treatment options include medication such as bethanechol, catheterization and sacral neuromodulation.

Overflow Incontinence Picmonic

IM_MED_StressIncontinence_V1.2_ Stress incontinence is described by urine leaking with movement, and patients may state leakage occurs with coughing or sneezing, or with increased intra-abdominal pressure. Stress incontinence develops when there is laxity of the pelvic floor muscles, which leads to urethral sphincter insufficiency.

Stress Incontinence Picmonic

urge-incontinence_5038_1466711871 Urge incontinence symptoms include a strong urge to void, but they are typically unable to void quickly enough. Nocturia is a common complaint, as is increased urinary frequency, with subsequent small volume voids of urine. This all takes place because of increased detrusor muscle activity, which has numerous etiologies. Treatment includes avoiding caffeine and alcohol. Pharmacologic therapy includes anticholinergics and mirabegron, while other treatment modalities include botox injections and sacral neuromodulation.

Urge Incontinence Picmonic

Question 1
A 68 year-old woman comes to the office for evaluation of urinary incontinence. For the past few months, she has had an intense urgency to urinate, followed by leakage of urine. Which of the following is the most appropriate intervention for this patient?
A
Intravaginal estrogen cream (Premarin cream)
Hint:
Intravaginal estrogen is indicated for women with vaginal atrophy that is contributing to stress incontinence.
B
Terazosin (Hytrin)
Hint:
Terazosin is indicated for men with urinary incontinence caused by urethral obstruction due to benign prostatic hyperplasia.
C
Oxybutynin (Ditropan)
D
Intravaginal miconazole cream (Monistat cream)
Hint:
Duloxetine is effective in reducing the number of stress incontinence episodes in women.
Question 1 Explanation: 
Urge incontinence is caused by detrusor overactivity that causes urinary leakage. Antimuscarinics, such as oxybutynin, are prescribed to relax the pelvic muscles.
Question 2
The most definitive treatment for primary enuresis is
A
oxybutynin chloride (Ditropan)
Hint:
Oxybutynin chloride is used for bladder spasms. It cannot be used for children under 5 years of age and is not indicated in primary enuresis.
B
imipramine (Tofranil)
Hint:
Imipramine is an older form of treatment that is moderately effective, but many patients relapse when therapy is stopped. This is no longer considered the treatment of choice.
C
trimethoprim-sulfamethoxazole (Bactrim)
Hint:
TMP-SMX is indicated for urinary tract infections that may cause secondary enuresis, but it is not used in primary enuresis.
D
desmopressin (DDAVP)
Question 2 Explanation: 
Intranasal desmopressin is effective in 50% of patients treated and is the treatment of choice.
Question 3
A 40 year-old female G5P5 complains of small quantities of urine leaking when she coughs, sneezes, or laughs. Her genitourinary examination is unremarkable and her urinalysis is normal. At this time, which of the following is the most appropriate management plan?
A
Refer for a cystoscopy
Hint:
Conservative therapy for stress incontinence should be attempted prior to any evaluation, such as cystoscopy, that might indicate the need for surgical correction.
B
Recommend Kegel exercises
C
Refer for surgical correction
Hint:
See A for explanation.
D
Recommend hormone replacement therapy
Hint:
There is no indication in the history for hormone replacement therapy and no vaginal atrophy was noted on pelvic examination.
Question 3 Explanation: 
Strengthening the pelvic muscles by Kegel exercises and emptying the bladder frequently may resolve the problem.
Question 4
A 7-year-old boy wets the bed on most nights. Which of the following is the preferred pharmacological agent to decrease the incidence of bedwetting?
A
Imipramine (Tofranil)
B
Phenytoin (Dilantin)
Hint:
Phenytoin is an anticonvulsant and is not used in enuresis.
C
Pramipexole (Mirapex)
Hint:
Pramipexole is a dopamine agonist used in the treatment of restless leg syndrome.
D
Hyoscyamine (Urised)
Hint:
Hyoscyamine is an anti-spasmodic used to treat overactive bladder.
Question 4 Explanation: 
Imipramine is an anticholinergic and when given before bedtime has been shown to decrease the incidence of bedwetting.
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