Urinary incontinence
Urinary incontinence: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Incontinence, the uncontrollable passage of urine, can result from a bladder abnormality, a neurologic disorder, or an alteration in pelvic muscle strength. A common urologic sign, incontinence may be transient or permanent and may involve large volumes of urine or scant dribbling. It can be classified as stress, overflow, urge, or total incontinence. Stress incontinence refers to intermittent leakage resulting from a sudden physical strain, such as a cough, sneeze, laugh, or quick movement. Overflow incontinence is a dribble resulting from urine retention, which fills the bladder and prevents it from contracting with sufficient force to expel a urine stream. Urge incontinence refers to the inability to suppress a sudden urge to urinate. Total incontinence is continuous leakage resulting from the bladder’s inability to retain urine.
History and physical examination
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection, prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
Medical causes
Benign prostatic hyperplasia (BPH)
Overflow incontinence is common with BPH as a result of urethral obstruction and urine retention. BPH begins with a group of signs and symptoms known as prostatism: reduced caliber and force of urine stream, urinary hesitancy, and a feeling of incomplete voiding. As obstruction increases, urination becomes more frequent, with nocturia and, possibly, hematuria. Examination reveals bladder distention and an enlarged prostate.
Bladder cancer
The patient commonly presents with urge incontinence and hematuria; obstruction by a tumor may produce overflow incontinence. The early stages can be asymptomatic. Other urinary signs and symptoms include frequency, dysuria, nocturia, dribbling, and suprapubic pain from bladder spasms after voiding. A mass may be palpable on bimanual examination.
Diabetic neuropathy
Autonomic neuropathy may cause painless bladder distention with overflow incontinence. Related findings include episodic constipation or diarrhea (which is commonly nocturnal), impotence and
retrograde ejaculation, orthostatic hypotension, syncope, and dysphagia.
Multiple sclerosis (MS)
Urinary incontinence, urgency, and frequency are common urologic findings in MS. In most patients, visual problems and sensory impairment occur early. Other findings include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer
Urinary incontinence usually appears only in the advanced stages of this cancer. Urinary frequency and hesitancy, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped, nodular prostate are other common late findings.
Prostatitis (chronic)
Urinary incontinence may occur as a result of urethral obstruction from an enlarged prostate. Other findings include urinary frequency and urgency, dysuria, hematuria, bladder distention, persistent urethral discharge, dull perineal pain that may radiate, ejaculatory pain, and decreased libido.
Spinal cord injury
Complete cord transection above the sacral level causes flaccid paralysis of the bladder. Overflow incontinence follows rapid bladder distention. Other findings include paraplegia, sexual dysfunction, sensory loss, muscle atrophy, anhidrosis, and loss of reflexes distal to the injury.
Stroke
Urinary incontinence may be transient or permanent. Associated findings reflect the site and extent of the lesion and may include impaired mentation, emotional lability, behavioral changes, altered level of consciousness, and seizures. Headache, vomiting, visual deficits, and decreased visual acuity are possible. Sensorimotor effects include contralateral hemiplegia, dysarthria, dysphagia, ataxia, apraxia, agnosia, aphasia, and unilateral sensory loss.
Urethral stricture
Eventually, overflow incontinence may occur here. As obstruction increases, urine extravasation may lead to formation of urinomas and urosepsis.
Urinary tract infection (UTI)
Besides incontinence, UTI may produce urinary urgency, dysuria, hematuria, cloudy urine and, in males, urethral discharge. Bladder spasms or a feeling of warmth during urination may occur.
Other causes
Surgery
Urinary incontinence may occur after prostatectomy as a result of urethral sphincter damage.
Special considerations
Prepare the patient for diagnostic tests, such as cystoscopy, cystometry, and a complete neurologic workup. Obtain a urine specimen.
Begin management of incontinence by implementing a bladder retraining program. (See Correcting incontinence with bladder retraining, page 614.) To prevent stress incontinence, teach Kegel exercises to help strengthen the pelvic floor muscles.
If the patient’s incontinence has a neurologic basis, monitor him for urine retention, which may require periodic catheterizations. If appropriate, teach the patient self-catheterization techniques. A patient with permanent urinary incontinence may require surgical creation of a urinary diversion.
Pediatric pointers
Causes of incontinence in children include infrequent or incomplete voiding. These may also lead to UTI. Ectopic ureteral orifice is an uncommon congenital anomaly associated with incontinence. A complete diagnostic evaluation usually is necessary to rule out organic disease.
Geriatric pointers
Diagnosing a UTI in elderly patients can be problematic because many present only with urinary incontinence or changes in mental status, anorexia, or malaise. Also, many elderly patients without UTIs present with dysuria, frequency, urgency, or incontinence.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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