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
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 - increased bladder contractions during the filling phase
- Ultrasonography and cystoscopy can be used to determine anatomic abnormalities
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
Phenytoin is an anticonvulsant and is not used in enuresis.
Pramipexole is a dopamine agonist used in the treatment of restless leg syndrome.
Hyoscyamine is an anti-spasmodic used to treat overactive bladder.
Monotherapy with anticholinergic drugs, such as oxybutynin, is not effective in treating monosymptomatic nocturnal enuresis. However, anticholinergic agents may be useful in children with nocturnal enuresis and daytime incontinence. In such children, anticholinergic therapy may be used in combination with desmopressin to increase bladder capacity during sleep.
Refer for a cystoscopy
Conservative therapy for stress incontinence should be attempted prior to any evaluation, such as cystoscopy, that might indicate the need for surgical correction.
Recommend Kegel exercises
Refer for surgical correction
See A for explanation.
Recommend hormone replacement therapy
There is no indication in the history for hormone replacement therapy and no vaginal atrophy was noted on pelvic examination.
Intravaginal estrogen cream (Premarin cream)
Intravaginal estrogen is indicated for women with vaginal atrophy that is contributing to stress incontinence.
Terazosin is indicated for men with urinary incontinence caused by urethral obstruction due to benign prostatic hyperplasia.
Intravaginal miconazole cream (Monistat cream)
Duloxetine is effective in reducing the number of stress incontinence episodes in women.
oxybutynin chloride (Ditropan)
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.
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.
TMP-SMX is indicated for urinary tract infections that may cause secondary enuresis, but it is not used in primary enuresis.