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Urinary incontinence

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Howard B. Goldman M.D. [2], Center for Female Pelvic Medicine and Reconstructive Surgery Glickman Urologic and Kidney Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH

Synonyms and keywords: Incontinence, urine; loss of bladder control; uncontrollable urination; urination – uncontrollable; incontinence – urinary; bladder incontinence

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Urinary incontinence: Unintentional loss of urine. Inability to hold urine in the bladder due to loss of voluntary control over the bladder (detrusor) muscle and/or urinary sphincters resulting in the involuntary passage of urine. In this article, the term “incontinence” will be used to mean urinary incontinence. See also fecal incontinence.

Classification

Urinary incontinence can be broadly classified into 5 major types. They are stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, functional incontinence.

Causes

Urinary incontinence is commonly caused by conditions affecting bladder integrity, including infections, neoplasms, surgical procedures, and internal sources of trauma, such as nutrition and water intake. It can also be caused by congenital and acquired neurological, muscular, and renal conditions.

Pathophysiology

Continence and micturition involve a balance between outlet (urethra) and bladder detrusor muscle activity. Lower urinary tract function is often divided into filling and voiding phases. Normally as the bladder fills the detrusor is compliant – stretching and increasing the volume it holds – without any unpleasant sensation and the outlet is closed. At a socially acceptable time and place to void the bladder (detrusor) contracts and the outlet relaxes and flow ensues. Any perturbation in that balance can lead to voiding dysfunction or incontinence. Abnormal detrusor muscle activity or hypersensitivity of the bladder can lead to urge incontinence. An incompetent outlet can lead to stress incontinence. A bladder that cannot contract may lead to overflow incontinence.

Differential diagnosis

Urinary incontinence may have different etiologies depending upon the underlying dysfunction. The various types of urinary incontinence should be differentiated from each other and also urinary incontinence should be differentiated from other conditions like stroke, multiple sclerosis, parkinson’s disease, fecal impaction, rectal prolapse etc.

Epidemiology and demographics

Risk Factors

Screening

Natural history, complications and prognosis

Common complications of urinary incontinence include increased risk of falling and fractures, urinary tract infection, sleep disorders, depression. The prognosis associated with urinary incontinence depends on the underlying cause and associated conditions such as accurate diagnosis, and proper treatment.

Diagnosis

Diagnostic study of choice

History and symptoms

Physical Examination

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

Laboratory findings

Electrocardiogram

X-ray

Echocardiography and ultrasound

CT scan

MRI

Other imaging findings

Other diagnostic studies

Medical therapy

Medications can reduce many types of urine leakage. Some drugs inhibit contractions of an overactive bladder. Others relax muscles, leading to more complete bladder emptying during urination. Some drugs tighten muscles at the bladder neck and urethra, preventing leakage. And some, especially hormones such as estrogen, are believed to cause muscles involved in urination to function normally.In vaginal atrophy – topical or vaginal estrogens; tolterodine, oxybutynin, propantheline, darifenacin, solifenacin, trospium in urge incontinence, imipramine in mixed and stress urinary incontinence, pseudoephedrine and duloxetine in stress urinary incontinence

References

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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Classification

The approach to the diagnosis of Urinary incontinence is based on a step-wise approach strategy. Below is an algorithm summarising the identification and diagnosis of different types of Urinary incontinence . The algorithm is developed and modified according to American Urological Evaluation (AUA) Guidelines. Shown below is an algorithm summarizing the diagnosis of Urinary incontinence according to The American Urological Association guidelines.[1]

 
 
 
 
Patients presenting with symptoms of urinary incontinence
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for temporary causes
  • Dementia, delirium
  • Infections
  • Atrophic vaginitis
  • Psychological
  • Drugs
  • Stool impaction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for chronic incontinence
  • History and physical exam including a cough test for stress incontinence
  • Review voiding dairy
  • Do all the lab work
  • Measure post void residual urine volume
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Based on all the findings arrive at a diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
“Urge incontinence”
❑Urgency
❑ Frequency
❑Nocturia
❑ Cough stress test: May show delayed leakage after cough
❑ PVR urine< 50ml
❑Variable vol loss seen in voiding dairy
 
Overflow incontinence
❑No urgency
❑Absence of symptoms on physical activity
❑ Cough stress test:No leakage
❑ PVR urine> 200ml
❑Voiding dairy: varies
 
Stress incontinence
❑Symptoms seen on coughing, sneezing, exercise, increased intra-abdominal pressure
❑ No nocturia
❑ Cough stress test:Leakage coincides with cough
❑ PVR urine< 50ml
❑Voiding dairy: Small volume leakage
 
Functional incontinence
❑Cognitive dysfunction, immobility seen
❑ Cough stress test:No leakage
❑ PVR urine: Varies
❑Voiding dairy: Sometimes a pattern seen with incontinence
 
Mixed incontinence
❑Symptoms with physical activity, urgency noted
❑ Cough stress test:May show leakage
❑ PVR urine<50ml
❑Voiding dairy: Varies


Stress incontinence

Stress urinary incontinence (SUI) occurs when the intraabdominal pressure on the bladder exceeds the resistance provided by the urethra. The symptoms include loss of urine with coughing, laughing, sneezing, exercising or other movements that increase intraabdominal pressure and thus increase pressure on the bladder. The pathophysiology is related to pelvic floor muscle and tissue weakness and changes in the intrinsic “water seal” function of the urethra. Physical changes resulting from pregnancy, childbirth, prior pelvic surgery and menopause may lead to stress incontinence in women while in men it may occur following a prostatectomy.

The urethra is supported by fascia of the pelvic floor. If the fascial support is weakened, as it can be in pregnancy and childbirth, the urethra can move downward at times of increased abdominal pressure, resulting in stress incontinence. There are many different theories as to why SUI actually occurs. Two of the classic concepts are changes in abdominal pressure transmission and loss of the normal suburethral support

Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels resulting in changes in urethral function. Urine analysis, cystometry and postvoid residual volume are normal.

Urge incontinence

Urge incontinence describes incontinence associated with a sudden urge to void. This urge is not the typical sense that one has of a need to void but is a pathologic sense of an extreme need to void which is difficult to ignore. Typically patients describe a sudden urge to urinate but before they can get to the toilet urine starts to leak out. Often the entire bladder may empty leading to a large volume of urine loss. Classically urge incontinence was thought to be due to abnormal sudden bladder contractions which the patient could not control. However, when observing these patients during urodynamics, some of them do not have these abnormal bladder contractions (detrusor overactivity) but instead seem to have an early sensation of the need to void (detrusor hypersensitivity). Patients with urinary tract infections or other inflammatory conditions of the bladder may develop urge incontinence. In some cases when the underlying cause is treated, for example with a UTI, the urge incontinence will resolve. Urge incontinence may also coexist with other symptoms of the overactive bladder syndrome − urinary frequency, urgency and nocturia.

  • Idiopathic Detrusor Overactivity − describes urge incontinence with no clear etiology
  • Neurogenic Detrusor Overactivity − describes urge incontinence in a patient with neurologic disease. In many neurologic diseases loss of normal bladder inhibition may occur which can lead to urge incontinence

Medical professionals describe such a bladder as “unstable,” “spastic,” or “overactive.” Urge incontinence may also be called “reflex incontinence” if it results from overactive nerves controlling the bladder.

Some patients with urge incontinence may have triggers that lead to it. Many will complain of urge incontinence after washing their hands or hearing running water (as when washing dishes or hearing someone else taking a shower), after feeling a chill, or when they get close to their home and are fumbling for the keys to get in the house.

Involuntary bladder contractions can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson’s disease, Alzheimer’s Disease, stroke, and injury−−including injury that occurs during surgery−−can all harm bladder nerves or muscles.

Overflow incontinence or Hypotonic

Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan − hence the general name overflow incontinence. Overflow incontinence occurs when the patient’s bladder is always full so that it frequently leaks urine. Weak bladder muscles, resulting in incomplete emptying of the bladder, or a blocked urethra can cause this type of incontinence. Autonomic neuropathy from diabetes or other diseases (e.g Multiple sclerosis) can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the detrusor muscle (allowing for urinary retention). Additionally, tumors and kidney stones can block the urethra. In men, benign prostatic hypertrophy (BPH) may also restrict the flow of urine. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. Also overflow incontinence in women can be from increased outlet resistance from advanced vaginal prolapse causing a “kink” in the urethra or after an anti−incontinence procedure which has overcorrected the problem.

Early symptoms include a hesitant or slow stream of urine during voluntary urination. Anticholinergic medications may worsen overflow incontinence.

Functional incontinence

Functional incontinence occurs when a person does not recognize the need to go to the toilet, recognize where the toilet is, or because of disability is unable to get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, or being in a situation in which one is unable to reach a toilet. People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer’s Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.

Other types of incontinence

Stress and urge incontinence often occur together in women. Combinations of incontinence − and this combination in particular − are sometimes referred to as “mixed incontinence.”

“Transient incontinence” is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow. Incontinence can often occur while trying to concentrate on a task and avoiding using the toilet.

Type of Incontinence Gender Pathophysiology Urinary signs and symptoms Risk factors Associated findings
Urgency Frequency Dribbling of urine Amount of incontinence Nocturia Residual volume
Stress incontinence F > M − − + Small volume ± < 50 ml
Urge incontinence

(detrusor instability)

F > M + + − Small to large volume ++ < 50 ml
  • A variable amount of urine loss; ranging from small volumes to complete emptying of the bladder
Overflow incontinence M > F − − + Small volume + > 200 ml
  • Poor bladder emptying
Functional incontinence M=F
  • Inability to reach the toilet to urinate
  • Environmental barriers
  • Physical barriers
 − − + Variable volume + < 50 ml
Mixed incontinence

(urge and stress)[2]

M=F
  • Combined urge and stress incontinence
 + ± + Variable volume ± Variable
  • Patient able to determine the pre−dominant symptoms

References

  1. ↑ Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L (October 2017). “Urinary Incontinence in Women: A Review”. JAMA. 318 (16): 1592–1604. doi:10.1001/jama.2017.12137. PMID 29067433.
  2. ↑ Barry, Michael J.; Link, Carol L.; McNaughton-Collins, Mary F.; McKinlay, John B. (2007). “Overlap of different urological symptom complexes in a racially and ethnically diverse, community-based population of men and women”. BJU International. 0 (0): 070916224627012–???. doi:10.1111/j.1464-410X.2007.07191.x. ISSN 1464-4096.

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Pathophysiology

Urinary incontinence in adults

Continence and micturition involve a balance between outlet (urethra) and bladder detrusor muscle activity. Lower urinary tract function is often divided into filling and voiding phases. Normally as the bladder fills the detrusor is compliant – stretching and increasing the volume it holds – without any unpleasant sensation and the outlet is closed. At a socially acceptable time and place to void the bladder (detrusor) contracts and the outlet relaxes and flow ensues. Any perturbation in that balance can lead to voiding dysfunction or incontinence. Abnormal detrusor muscle activity or hypersensitivity of the bladder can lead to urge incontinence. An incompetent outlet can lead to stress incontinence. A bladder that cannot contract may lead to overflow incontinence.[1][2][3][4][5][6][7]

Urinary incontinence in children

Urination, or voiding, is a complex activity. The bladder is a balloon like muscle that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord, and the brain.

The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.

A baby’s bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system develops. The child’s brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.

Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.

Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in girls as in boys.

Incontinence is also called enuresis
  • Primary enuresis refers to wetting in a person who has never been dry for at least 6 months.
  • Secondary enuresis refers to wetting that begins after at least 6 months of dryness.
  • Nocturnal enuresis refers to wetting that usually occurs during sleep (nighttime incontinence).
  • Diurnal enuresis refers to wetting when awake (daytime incontinence).
Points to remember
  • Urinary incontinence in children is common.
  • Nighttime wetting occurs more commonly in boys.
  • Daytime Wetting is more common in girls.
  • After age 5, incontinence disappears naturally at a rate of 15 percent of cases per year.
  • Treatments include waiting, dietary modification, moisture alarms, medications, and bladder training.

References

  1. ↑ “pdfs.semanticscholar.org” (PDF).
  2. ↑ Brown JS, Bradley CS, Subak LL, Richter HE, Kraus SR, Brubaker L, Lin F, Vittinghoff E, Grady D (May 2006). “The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence”. Ann. Intern. Med. 144 (10): 715–23. PMC 1557357. PMID 16702587.
  3. ↑ Videla FL, Wall LL (June 1998). “Stress incontinence diagnosed without multichannel urodynamic studies”. Obstet Gynecol. 91 (6): 965–8. PMID 9611005.
  4. ↑ DuBeau CE, Kuchel GA, Johnson T, Palmer MH, Wagg A (2010). “Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence”. Neurourol. Urodyn. 29 (1): 165–78. doi:10.1002/nau.20842. PMID 20025027.
  5. ↑ “Diagnosis of Urinary Incontinence – American Family Physician”.
  6. ↑ Frank C, Szlanta A (November 2010). “Office management of urinary incontinence among older patients”. Can Fam Physician. 56 (11): 1115–20. PMC 2980426. PMID 21075990.
  7. ↑ Imam KA (2004). “The role of the primary care physician in the management of bladder dysfunction”. Rev Urol. 6 Suppl 1: S38–44. PMC 1472846. PMID 16985854.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Jyostna Chouturi, M.B.B.S [2] Luke Rusowicz-Orazem, B.S.

Overview

Urinary incontinence is commonly caused by conditions affecting bladder integrity, including infections, neoplasms, surgical procedures, and internal sources of trauma, such as nutrition and water intake. It can also be caused by congenital and acquired neurological, muscular, and renal conditions.

Causes

Life Threatening Causes

Common Causes

Causes by Organ System

Cardiovascular Cerebrovascular accident, Foix-alajouanine syndrome, Stroke
Chemical/Poisoning Alcohol, Artificial sweeteners, Botulinum toxin, Bromophos, Carbamates, Corn syrup, Demeton-s-methyl, Diuretics, Ethion, Fensulfothion, Fenthion, Food additives, Monocrotophos, Msg, Sulfite, Terbufos, Tetraethyl pyrophosphate, Toxic mushrooms
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Aldicarb, Aldomet and phenoxybenzamine interaction, Ambenonium, Amines, Amodopa and phenoxybenzamine interaction, Antihistamines, Azinphos-methyl, Bethanechol chloride, Cypermethrin, Cystocele, Diazinon, Dichlorvos, Dicrotophos, Dioxathion, Distigmine, Disulfoton, Diuretics, Donepezil, Malathion, Meropenem, Methidathion, Methiocarb, Methomyl, Methyldopa and phenoxybenzamine interaction, Neostigmine, Parathion, Polyuria, Prazosin, Profenofos, Salicylate, Tiagabine
Ear Nose Throat No underlying causes
Endocrine Adult polyglucosan body disease, Congenital disorder of glycosylation, Hormone replacement therapy, Menopause, Primary polydipsia, Transthyretin amyloidosis
Environmental No underlying causes
Gastroenterologic Adult polyglucosan body disease, Congenital disorder of glycosylation, Constipation, Fecal impaction, Sphincter weakness, Sphincteric atony, Stool impaction
Genetic Autosomal dominant leukodystrophy , Basal ganglia calcification, Chromosome 11, Chromosome 13, Deletion 11p, Duplication of urethra, Ehlers-danlos syndrome, Lipomyelomeningocele, Meningocele, Pelizaeus-merzbacher disease, Sacral defect , Schaefer-stein-oshman syndrome, Spina bifida, Wagr syndrome, Wohlwill-andrade syndrome, Wolfram’s disease
Hematologic Autosomal dominant leukodystrophy , Diabetes mellitus
Iatrogenic Hormone replacement therapy, Hysterectomy, Obstetric surgery, Pelvic surgery, Prostate surgery, Prostatectomy, Vaginal surgery
Infectious Disease Infection, Schistosoma haematobium, Tropical spastic paraparesis, Urinary tract infection
Musculoskeletal/Orthopedic Autoimmune myelopathy, Foix-alajouanine syndrome, Immobility, Intervertebral disc herniation, Lipomyelomeningocele, Pelvic cancer, Pelvic fracture, Pelvic surgery, Quadriplegia, Restricted mobility, Spastic paraplegia , Spinal cord injury, Spinal cord neoplasm, Spinal fracture, Spinal muscular atrophy , Spondylitis, Sports injuries, Tethered spinal cord syndrome, Vertebral fracture
Neurologic Autonomic neuropathy, Autonomic seizure, Basal ganglia calcification, Binswanger disease, Brain failure, Cauda equina syndrome, Cerebral palsy, Cerebrovascular accident, Combat stress reaction, Convulsions, Delerium, Dementia, Epilepsy, Grand mal seizures, Hydrocephalus, Idiopathic parkinson’s disease, Immobility, Limbic encephalitis , Meningocele, Mitochondrial parkinson’s disease, Multiple sclerosis, Nerve conditions, Neurogenic bladder, Neurogenic diabetes insipidus, Neuropathic bladder dysfunction, Normal pressure hydrocephalus, Obstructive nephropathy, Olivopontocerebellar atrophy, Paraplegia, Parkinson disease , Pudendal nerve entrapment, Quadriplegia, Restricted mobility, Shy-drager syndrome, Spastic paraplegia , Spina bifida, Spinal muscular atrophy , Wohlwill-andrade syndrome
Nutritional/Metabolic Artificial sweeteners, Caffeine, Carbonated drinks, Citrus fruits, Coffee, Corn syrup, Diabetes mellitus, Obesity, Spicy foods, Sugary foods, Tea
Obstetric/Gynecologic Childbirth, Hysterectomy, Menopause, Multiparity, Obstetric surgery, Postpartum, Pregnancy, Urethrocoele, Uterine prolapse, Vaginal surgery, Vaginitis, Vesicovaginal fistula
Oncologic Bladder cancer, Metastatic prostate cancer, Pelvic cancer, Prostate cancer, Spinal cord neoplasm, Tumor, Wilms tumor
Ophthalmologic Olivopontocerebellar atrophy
Overdose/Toxicity Alcohol, Caffeine, Citrus fruits, Msg
Psychiatric Anxiety, Binswanger disease, Combat stress reaction, Delerium, Depression, Stress incontinence
Pulmonary Andrade’s syndrome, Obstructive sleep apnea
Renal/Electrolyte Nephrolithiasis, Primary polydipsia, Wilms tumor
Rheumatology/Immunology/Allergy Andrade’s syndrome, Autoimmune myelopathy, Autonomic neuropathy, Spondylitis, Transthyretin amyloidosis
Sexual Sexual intercourse
Trauma Cauda equina syndrome, Detrusor instability, Pelvic fracture, Spinal cord injury, Spinal fracture, Sports injuries, Urethrocoele, Uterine prolapse, Vertebral fracture
Urologic Bladder cancer, Bladder fistula, Bladder spasms, Bladder stones, Congenital bladder conditions, Detrusor instability, Duplication of urethra, Enlarged prostate, Enuresis, Epispadias, Infrequent voiding, Metastatic prostate cancer, Neurogenic bladder, Neurogenic diabetes insipidus, Neuropathic bladder dysfunction, Outlet obstruction, Overactive bladder, Prostate cancer, Prostate hyperplasia, Prostate surgery, Prostatectomy, Stress incontinence, Structural problems, Urethral diverticulum, Urinary tract infection, Urinary tract malformation, Urine retention, Vesicovaginal fistula
Miscellaneous Aging, Inflammation

Causes in Alphabetical Order

References

  1. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X

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Differentiating Urinary incontinence from other Diseases

Differentiating Urinary incontinence from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2], Syed Hassan A. Kazmi BSc, MD [3]

Overview

Urinary incontinence may have different etiologies depending upon the underlying dysfunction. The various types of urinary incontinence should be differentiated from each other for optimal management.

Differential diagnosis of urinary incontinence

The following table differentiates the various types of urinary incontinence:[1][2][3][4][5][6][7][8]

To review differential diagnosis of urge urinary incontinence, click here.

To review differential diagnosis of stress urinary incontinence, click here.

To review differential diagnosis of functional urinary incontinence, click here.

To review differential diagnosis of overflow urinary incontinence, click here.

To review differential diagnosis of mixed urinary incontinence, click here.

Category Diseases Type of incontinence Clinical manifestations Lab Findings Gold standard Associated findings
Symptoms Signs
Loss of consciousness Fever Pelvic pain Urinary symptoms Blood Pressure Neurological deficit Urine residue UA Other
Urge Stress Overflow Functional Dysuria Frequency Dribbling Nocturia
Neurological diseases Stroke[9] + + − ± + − − ± + + ++ ↑/↓ + < 50 ml Pyuria ± NA Imaging
Alzheimer’s disease[10][11] + + + + − − ± ± + + ++ Nl + < 50 ml Pyuria ± NA Clinical manifestations
Parkinson’s disease[12][13] + − − − − − − ± + + ++ Nl to ↓ + < 50 ml Nl NA Clinical manifestations
Traumatic spinal cord injury[14] + + − − − − − − − + ± Nl to ↓ + < 50 ml Nl NA MRI of spine
Normal pressure hydrocephalus[15] − − + − − − − − − + + Nl + > 200 ml Nl NA Cerebrospinal fluid (CSF) removal test
  • Slowly progressive gait abnormalities (Magnetic gait)
  • Cognitive deterioration (Dementia)
Multiple sclerosis[16] + − + − − − − + + − + Nl to ↓ + > 200 ml Nl NA MRI of brain and spine
  • Optic neuritis 
  • Sensory and motor abnormalities
  • Relapses and remission
Category Diseases Urge Stress Overflow Functional Loss of consciousness Fever Pelvic pain Dysuria Frequency Dribbling Nocturia Blood Pressure Neurological deficit Urine residue UA Other Gold standard Additional findings
Urogenital disorders Benign prostatic hyperplasia[17] + + + − − − + ± + ++ + Nl to ↑ − > 200 ml Hematuria Elevated PSA (less than 4 ng/dL) Digital rectal examination
Genitourinary surgical procedures[18][19] + + − − − − ± + + + + Depends on underlying disease − < 50 ml Nl NA Clinical manifestations
Multiple childbirths[20][21] + + − − − − ± − + + + Nl − < 50 ml Nl NA Clinical manifestations
  • Increased risk in vaginal delivery
  • More common in obese patients
Uterine fibroids[22] + − + − − − + − − + + Nl − > 200 ml Nl NA Clinical manifestations+ imaging
Uterine prolapse[23] + + − − − − + − + + ± Nl − < 50 ml Nl NA Pelvic examination
Vesicovaginal fistula[24] − − + − − − − + + + + Nl − < 50 ml Nl NA Pelvic examination
Bladder cancer[25] + − + − − ± − + + + + Nl − > 200 ml Hematuria NA Biopsy
Gastrointestinal diseases Fecal impaction[26] − − + − − − + + − + + Nl − > 200 ml Pyuria ↑ K+ Digital rectal examination
Rectal prolapse[27] − − + − − − + − − + + Nl − > 200 ml Pyuria NA Pelvic examination
Category Diseases Urge Stress Overflow Functional Loss of consciousness Fever Pelvic pain Dysuria Frequency Dribbling Nocturia Blood Pressure Neurological deficit Urine residue UA Other Gold standard Additional findings

References

  1. ↑ “pdfs.semanticscholar.org” (PDF).
  2. ↑ Brown JS, Bradley CS, Subak LL, Richter HE, Kraus SR, Brubaker L, Lin F, Vittinghoff E, Grady D (May 2006). “The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence”. Ann. Intern. Med. 144 (10): 715–23. PMC 1557357. PMID 16702587.
  3. ↑ Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE (March 2008). “What type of urinary incontinence does this woman have?”. JAMA. 299 (12): 1446–56. doi:10.1001/jama.299.12.1446. PMID 18364487.
  4. ↑ Videla FL, Wall LL (June 1998). “Stress incontinence diagnosed without multichannel urodynamic studies”. Obstet Gynecol. 91 (6): 965–8. PMID 9611005.
  5. ↑ DuBeau CE, Kuchel GA, Johnson T, Palmer MH, Wagg A (2010). “Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence”. Neurourol. Urodyn. 29 (1): 165–78. doi:10.1002/nau.20842. PMID 20025027.
  6. ↑ “Diagnosis of Urinary Incontinence – American Family Physician”.
  7. ↑ Frank C, Szlanta A (November 2010). “Office management of urinary incontinence among older patients”. Can Fam Physician. 56 (11): 1115–20. PMC 2980426. PMID 21075990.
  8. ↑ Imam KA (2004). “The role of the primary care physician in the management of bladder dysfunction”. Rev Urol. 6 Suppl 1: S38–44. PMC 1472846. PMID 16985854.
  9. ↑ Gibson J, Thomas LH, Harrison JJ, Watkins CL (March 2018). “Stroke survivors’ and carers’ experiences of a systematic voiding programme to treat urinary incontinence after stroke”. J Clin Nurs. doi:10.1111/jocn.14346. PMID 29517816. Vancouver style error: initials (help)
  10. ↑ Lee, Hsiang-Ying; Li, Ching-Chia; Juan, Yung-Shun; Chang, Yu-Han; Yeh, Hsin-Chih; Tsai, Chia-Chun; Chueh, Kuang-Shun; Wu, Wen-Jeng; Yang, Yuan-Han (2016). “Urinary Incontinence in Alzheimer’s Disease”. American Journal of Alzheimer’s Disease & Other Dementiasr. 32 (1): 51–55. doi:10.1177/1533317516680900. ISSN 1533-3175.
  11. ↑ Drennan, Vari M.; Rait, Greta; Cole, Laura; Grant, Robert; Iliffe, Steve (2013). “The prevalence of incontinence in people with cognitive impairment or dementia living at home: A systematic review”. Neurourology and Urodynamics. 32 (4): 314–324. doi:10.1002/nau.22333. ISSN 0733-2467.
  12. ↑ Lemack, Gary E; Dewey, Richard B; Roehrborn, Claus G; O’Suilleabhain, Padraig E; Zimmern, Philippe E (2000). “Questionnaire-based assessment of bladder dysfunction in patients with mild to moderate Parkinson’s disease”. Urology. 56 (2): 250–254. doi:10.1016/S0090-4295(00)00641-5. ISSN 0090-4295.
  13. ↑ Dubow JS (May 2007). “Autonomic dysfunction in Parkinson’s disease”. Dis Mon. 53 (5): 265–74. doi:10.1016/j.disamonth.2007.02.004. PMID 17656188.
  14. ↑ Schurch, B.; Stöhrer, M.; Kramer, G.; Schmid, D.M.; Gaul, G.; Hauri, D. (2000). “BOTULINUM-A TOXIN FOR TREATING DETRUSOR HYPERREFLEXIA IN SPINAL CORD INJURED PATIENTS: A NEW ALTERNATIVE TO ANTICHOLINERGIC DRUGS? PRELIMINARY RESULTS”. The Journal of Urology. 164 (3): 692–697. doi:10.1016/S0022-5347(05)67283-7. ISSN 0022-5347.
  15. ↑ Ghosh, Sayantani; Lippa, Carol (2014). “Diagnosis and Prognosis in Idiopathic Normal Pressure Hydrocephalus”. American Journal of Alzheimer’s Disease & Other Dementiasr. 29 (7): 583–589. doi:10.1177/1533317514523485. ISSN 1533-3175.
  16. ↑ Bosch, JLH Ruud; Groen, Jan (1996). “Treatment of refractory urge urinary incontinence with sacral spinal nerve stimulation in multiple sclerosis patients”. The Lancet. 348 (9029): 717–719. doi:10.1016/S0140-6736(96)04437-6. ISSN 0140-6736.
  17. ↑ Peters, T.J.; Donovan, J.L.; Kay, H.E.; Abrams, P.; de la Rosette, J.J.M.C.H.; Porru, D.; Thuroff, J.W. (1997). “The International Continence Society “Benign Prostatic Hyperplasia” Study: The Bothersomeness of Urinary Symptoms”. The Journal of Urology. 157 (3): 885–889. doi:10.1016/S0022-5347(01)65075-4. ISSN 0022-5347.
  18. ↑ Altman, Daniel; Granath, Fredrik; Cnattingius, Sven; Falconer, Christian (2007). “Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study”. The Lancet. 370 (9597): 1494–1499. doi:10.1016/S0140-6736(07)61635-3. ISSN 0140-6736.
  19. ↑ Prabhu, Vinay; Sivarajan, Ganesh; Taksler, Glen B.; Laze, Juliana; Lepor, Herbert (2014). “Long-term Continence Outcomes in Men Undergoing Radical Prostatectomy for Clinically Localized Prostate Cancer”. European Urology. 65 (1): 52–57. doi:10.1016/j.eururo.2013.08.006. ISSN 0302-2838.
  20. ↑ Barbosa L, Boaviagem A, Moretti E, Lemos A (May 2018). “Multiparity, age and overweight/obesity as risk factors for urinary incontinence in pregnancy: a systematic review and meta-analysis”. Int Urogynecol J. doi:10.1007/s00192-018-3656-9. PMID 29754281.
  21. ↑ Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (November 2013). “A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women”. BJOG. 120 (12): 1548–55. doi:10.1111/1471-0528.12367. PMID 23786421.
  22. ↑ Dragomir, Anca D.; Schroeder, Jane C.; Connolly, AnnaMarie; Kupper, Larry L.; Cousins, Deborah S.; Olshan, Andrew F.; Baird, Donna D. (2010). “Uterine Leiomyomata Associated with Self-Reported Stress Urinary Incontinence”. Journal of Women’s Health. 19 (2): 245–250. doi:10.1089/jwh.2009.1396. ISSN 1540-9996.
  23. ↑ de Boer TA, Salvatore S, Cardozo L, Chapple C, Kelleher C, van Kerrebroeck P, Kirby MG, Koelbl H, Espuna-Pons M, Milsom I, Tubaro A, Wagg A, Vierhout ME (2010). “Pelvic organ prolapse and overactive bladder”. Neurourol. Urodyn. 29 (1): 30–9. doi:10.1002/nau.20858. PMID 20025017.
  24. ↑ Reisenauer C (August 2015). “Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center”. Arch. Gynecol. Obstet. 292 (2): 245–53. doi:10.1007/s00404-015-3760-8. PMID 26001626.
  25. ↑ Porter, M; Penson, D (2005). “HEALTH RELATED QUALITY OF LIFE AFTER RADICAL CYSTECTOMY AND URINARY DIVERSION FOR BLADDER CANCER: A SYSTEMATIC REVIEW AND CRITICAL ANALYSIS OF THE LITERATURE”. The Journal of Urology. 173 (4): 1318–1322. doi:10.1097/01.ju.0000149080.82697.65. ISSN 0022-5347.
  26. ↑ Loening-Baucke, V. (1997). “Urinary Incontinence and Urinary Tract Infection and Their Resolution With Treatment of Chronic Constipation of Childhood”. PEDIATRICS. 100 (2): 228–232. doi:10.1542/peds.100.2.228. ISSN 0031-4005.
  27. ↑ González-Argenté, Xavier F.; Jain, Anil; Nogueras, Juan J.; Davila, Willy G.; Weiss, Eric G.; Wexner, Steven D. (2001). “Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse”. Diseases of the Colon & Rectum. 44 (7): 920–925. doi:10.1007/BF02235476. ISSN 0012-3706.
Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Epidemiology and Demographics

Urinary incontinence in adults

Men experience incontinence twice as often as women, and the structure of the male urinary tract accounts for this difference. But both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.

While urinary incontinence affects older men more often than younger men, the onset of incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages.

Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine – water and wastes removed by the kidneys – in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.

Urinary incontinence in children

In the United States, at least 13 million people have problems holding urine until they can get to a toilet. This loss of urinary control is called “urinary incontinence” or just “incontinence.” Although it affects many young people, it usually disappears naturally over time, which suggests that incontinence, for some people, may be a normal part of growing up. Recent studies in Japan show that an increasing number of children are wetting their beds and even wearing diapers full time, well into elementary school.

No matter when it happens or how often it happens, incontinence causes great distress. It may get in the way of a good night’s sleep and is embarrassing when it happens during the day. That’s why it is important to understand that occasional incontinence is a normal part of growing up and that treatment is available for most children who have difficulty controlling their bladders.

Babies are never considered incontinent, as they cannot physically attain bowel and bladder control and incontinence is a loss of pre-existing control.

References

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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Nasrin Nikravangolsefid, MD-MPH [2]


Overview

Common complications of urinary incontinence include increased risk of falling and fractures, urinary tract infection, sleep disorders, depression. The prognosis associated with urinary incontinence depends on the underlying cause and associated conditions such as accurate diagnosis, and proper treatment.

Complications

Prognosis

  • The prognosis associated with urinary incontinence depends on the underlying cause and associated conditions such as accurate diagnosis, and proper treatment.

References

  1. ↑ Minassian VA, Yan X, Lichtenfeld MJ, Sun H, Stewart WF (2012). “The iceberg of health care utilization in women with urinary incontinence”. Int Urogynecol J. 23 (8): 1087–93. doi:10.1007/s00192-012-1743-x. PMC 3905313. PMID 22527544.
  2. ↑ Shaw C, Tansey R, Jackson C, Hyde C, Allan R (2001). “Barriers to help seeking in people with urinary symptoms”. Fam Pract. 18 (1): 48–52. doi:10.1093/fampra/18.1.48. PMID 11145628.
  3. ↑ Minassian VA, Stewart WF, Hirsch AG (2008). “Why do stress and urge incontinence co-occur much more often than expected?”. Int Urogynecol J Pelvic Floor Dysfunct. 19 (10): 1429–40. doi:10.1007/s00192-008-0647-2. PMID 18528608.
  4. ↑ Dooley Y, Lowenstein L, Kenton K, FitzGerald M, Brubaker L (2008). “Mixed incontinence is more bothersome than pure incontinence subtypes”. Int Urogynecol J Pelvic Floor Dysfunct. 19 (10): 1359–62. doi:10.1007/s00192-008-0637-4. PMID 18491026.
  5. ↑ Gibson W, Hunter KF, Camicioli R, Booth J, Skelton DA, Dumoulin C; et al. (2018). “The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda”. Neurourol Urodyn. 37 (1): 501–509. doi:10.1002/nau.23295. PMID 28471525.
  6. ↑ Hu TW, Wagner TH (2005). “Health-related consequences of overactive bladder: an economic perspective”. BJU Int. 96 Suppl 1: 43–5. doi:10.1111/j.1464-410X.2005.05654.x. PMID 16086679.

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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | MRI | Echocardiography or Ultrasound | Other Diagnostic Studies

Treatment

Treatment

Non pharmacological treatment | Medical Therapy | Surgery | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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