Common and may cause significant distress
| Symptoms | Etiology | Treatment | |
|---|---|---|---|
| Stress | • Leaking with Valsalva maneuver (coughing, sneezing, laughing) | • ↓ Urethral sphincter tone | |
| • Urethral hypermobility | • Lifestyle modification | ||
| • Pelvic floor exercises | |||
| • Pessary | |||
| • Pelvic floor surgery | |||
| Urgency | • Sudden, overwhelming, or frequent need to void | • Detrusor overactivity | • Lifestyle modification |
| • Bladder training | |||
| • Antimuscarinic drugs | |||
| Mixed | • Features of stress & urgency incontinence | • Variable treatment depending on predominant symptoms | |
| Overflow | • Constant involuntary dribbling & incomplete emptying | • Impaired detrusor contractility | |
| • Bladder outlet obstruction | • Identification and correction of underlying cause | ||
| • Cholinergic agonists | |||
| • Intermittent self-catheterization |
All patients with urinary incontinence (eg, stress, urgency, mixed) require initial evaluation for urinary retention (eg, postvoid residual) and infection (eg, urinalysis).
First-line treatment for any type of urinary incontinence includes bladder training and pelvic floor muscle (Kegel) exercises.
Cystoscopy is indicated in some patients with urinary symptoms and abnormal urinalysis (eg, hematuria, leukocytes) to evaluate for secondary causes of incontinence (eg, malignancy, infection, interstitial cystitis). This patient has a normal urinalysis, and cystoscopy is not part of the routine workup for uncomplicated urinary incontinence.
New-onset incontinence should prompt investigation for reversible causes. If reversible causes are not found, further testing includes evaluation for stress incontinence (eg, Valsalva maneuver with full bladder) and overflow incontinence (eg, postvoid residual). Urodynamic testing is usually unnecessary unless there is diagnostic uncertainty (eg, mixed incontinence) or consideration for surgical intervention.
<aside> 💡 cystoscopy may be indicated in patients with a suspected urethral diverticulum or vesicovaginal fistula, it is not used in initial evaluation of urinary incontinence due to cost and invasiveness.
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Hyperglycemia can lead to polyuria due to glucosuria-induced osmotic diuresis. However, polyuria does not necessarily cause incontinence. Although longstanding, poorly controlled diabetes mellitus can lead to incontinence due to autonomic neuropathy (usually overflow incontinence), it is unlikely in this patient who has had a short episode of glucocorticoid-induced diabetes mellitus.
Urethral instability refers to involuntary fluctuations in the urethral pressure with or without urinary incontinence. This can occur even in normal individuals.
(Choices C and D) A continence pessary is used to treat stress urinary incontinence (SUI) and symptomatic pelvic organ prolapse (eg, anterior vaginal wall bulge); it works by stabilizing the pelvic floor in its anatomic position and compressing the urethra against the pubic symphysis. Midurethral sling procedures are performed for SUI due to urethral hypermobility. Although this patient has anterior vaginal wall prolapse and prior SUI managed with a midurethral sling, her current urinary symptoms do not suggest SUI (as they are unrelated to laughing or exercise) and are consistent with new-onset urgency incontinence.