Diagnosis of Incontinence
Incontinence Diagnosis: Book Excerpts
Diagnostic Tests for Incontinence: Online Medical Books
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INCONTINENCE OF URINE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the volume of urine large or small? If the volume of urine released is small, stress incontinence and vesicovaginal fistula should be considered. If the amounts released are large, one should consider a neurologic condition or an enlarged prostate with bladder neck obstruction as the cause.
- Are there abnormalities on the neurologic examination? Neurologic disorders to be considered are spastic neurogenic bladder due to multiple sclerosis, spinal cord tumor, and spinal cord trauma, as well as incompetent sphincter due to cauda equina syndrome, spinal stenosis, poliomyelitis, diabetic neuropathy, and tabes dorsalis.
- Are there hyperactive reflexes? This helps distinguish the disorders of the spinal cord and parasagittal area, such as spastic neurogenic bladder due to multiple sclerosis, spinal cord tumor, spinal cord trauma, and parasagittal meningioma.
- Are the reflexes hypoactive? Hypoactive reflexes suggest poliomyelitis, cauda equina syndrome, spinal stenosis, diabetic neuropathy, and tabes dorsalis.
- Is there an enlarged bladder or prostate? If an enlarged bladder or prostate is palpated, one should consider overflow incontinence from bladder neck obstruction, prostatic hypertrophy, and tuberculosis of the bladder.
DIAGNOSTIC WORKUP
Routine laboratory tests include a CBC, a urinalysis, a urine culture and sensitivity, a chemistry panel, and a VDRL test. An intravenous pyelogram and a voiding cystogram may be helpful. A Q-tip test or stress test may be helpful in diagnosing stress incontinence. The bladder may be catheterized for residual urine, or abdominal ultrasonography may be employed to evaluate residual urine. Fifty milliliters or more is considered abnormal. Cystoscopy may also be necessary to determine if there is chronic bladder inflammation or bladder neck obstruction. Office cystometrography can be considered, but it is usually best to refer the patient to a urologist for cystometric studies. Prostatic size can be determined by transrectal prostatic ultrasonography.
The simplest and most cost-effective approach is to refer the patient to a neurologist if there are abnormalities on the neurologic examination, or refer the patient to a urologist if there are not. If there is stress incontinence and a cystocele is found on vaginal examination, the patient should be referred to a gynecologist. It is not cost-effective to begin ordering MRIs or CT scans of the brain and spinal cord without the assistance of these specialists.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ENURESIS:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the bed-wetting frequent or only occasional? Frequent bed-wetting should signify pathology in the urogenital tract or endocrine system. If the bed-wetting is infrequent, one should consider epilepsy.
- Are there abnormalities found on the urogenital examination? There are many causes of enuresis that can be found on a simple examination, such as phimosis, balanitis, meatal stricture, vulvitis, or intestinal worms.
- Are there abnormalities on the urinalysis? Urinalysis alone is usually not adequate, and a urine culture should be done to rule out cystitis and pyelonephritis. The simple examination of the urine sediment for bacteria is also helpful. Sugar in the urine may indicate diabetes mellitus, but it may also indicate Fanconi's syndrome.
- Is there polyuria? Polyuria might indicate diabetes insipidus, diabetes mellitus, hyperthyroidism, and hypoparathyroidism.
- Are there abnormalities on the neurologic examination? Here one would be looking for cerebral palsy and congenital anomalies of the spinal cord.
Finally, if the neurologic examination, urogenital examination, and urinalysis are normal, perhaps the patient has a simple neurosis or situational maladjustment.
DIAGNOSTIC WORKUP
Patients who are suspected of having a urologic condition as the cause of their enuresis should have a urinalysis, intravenous pyelogram, and voiding cystogram with a urine culture and colony count. Referral to a urologist for cystometric testing may be required. If there is polyuria, a glucose tolerance test, a thyroid profile, and tests for calcium phosphorus, alkaline phosphatase, and parathyroid hormone level should be done. If epilepsy is suspected, an EEG should be ordered. If the neurologic examination is abnormal, referral to a neurologic specialist would be in order. If all the studies and examinations are within normal limits, a referral to a psychiatrist or psychologist may be in order. However, the child may have simple enuresis, in which case all that is required is to reassure the parents that the child will grow out of it by puberty.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INCONTINENCE OF FECES:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the stool volume small or large? A small volume of stool should suggest anal fissure; hemorrhoids, diarrhea, or postoperative incontinence from a fistulectomy; or other types of surgery in the perirectal area.
- Is the incontinence intermittent? Intermittent incontinence suggests epilepsy or organic brain syndrome.
- Are there hyperactive reflexes in the lower extremities? Presence of hyperactive reflexes in the lower extremities should suggest a spinal cord tumor or trauma to the spinal cord, multiple sclerosis, a parasagittal meningioma, transverse myelitis, and syringomyelia.
- Are there hypoactive reflexes in the lower extremities? The presence of hypoactive reflexes in the lower extremities should suggest tabes dorsalis, a cauda equina tumor, spinal stenosis, and other conditions of the lumbar spine and lumbosacral area.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, chemistry panel, and VDRL test. A sigmoidoscopy and barium enema are needed to exclude malignancy. The anorectal area should be carefully inspected for lesions and the sphincter competence determined by a digital exam. If these findings are normal, it would be wise to consult a neurologist. If one is not available, further workup may be done.
If there are hyperactive reflexes with cranial nerve signs, a CT scan or MRI of the brain should be done. If there are hyperactive reflexes of all four extremities with no cranial nerve signs, MRI of the cervical spine should be done. With hyperactive reflexes of the lower extremities only, MRI of the thoracic cord should be done. If there are hypoactive reflexes in the lower extremities, MRI or CT scan of the lumbar spine should be done. If increased intracranial pressure has been excluded, a spinal tap may be done to help diagnose multiple sclerosis or tabes dorsalis. Anorectal manometry and defecography may be used to detect anal and rectal muscle dysfunction.
If the general physical examination and neurologic examination are negative, psychogenic causes should be considered, and cystometric studies might be helpful. The patient should be referred to a psychiatrist.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
STRESS INCONTINENCE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
In most cases, the diagnosis will be obvious. You can ask the patient to cough during a vaginal examination, and the urine will trickle out. If that does not establish the diagnosis, have the patient drink a lot of water and not void until he or she returns to the office. Then you can have him or her cough in the recumbent or erect position, and the urine will be released. This is called the stress test. In the Q-tip test, a Q-tip is inserted in the tip of the urethra, and the patient is asked to cough or strain. The Q-tip will move at least 30 degrees above the horizontal in cases of stress incontinence. For further discussion of incontinence, see
page 264
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Incontinence:
Differential Diagnosis
(In a Page: Signs and Symptoms)
Transient, acute incontinence (DIAPPERS)
-
Delirium
-
Infections of urinary tract
-
Atrophic urethritis or vaginitis
-
Pharmaceuticals [e.g., diuretics, sedatives, anxiolytics, alcohol, β-blockers (cause urethral relaxation), ACE inhibitors (chronic cough increases abdominal pressure), antidepressants, antipsychotics]
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Psychiatric conditions (e.g., depression)
-
Endocrine disorders (e.g., hypercalcemia, hyperglycemia)
-
Restricted mobility or (urinary)
-
Retention
-
Stool (fecal impaction)
Persistent, chronic incontinence - Stress incontinence
–Loss of urine upon increases in intra-abdominal pressure (e.g., laughing, coughing, change in position, exercise)
–Women <60 years after vaginal births
–Urethral trauma (e.g., prostate surgery)
- Urge incontinence (“overactive bladder”)
–Strong urge to urinate before reaching the toilet; usually in people >60
–Commonly associated with reversible causes, increased fluid intake, or poor bladder contractility
–Idiopathic causes, neurologic causes, hyperreflexia, neuropathies, poor bladder contractility, increased sphincter relaxation, and reversible causes (e.g., UTI, increased fluid intake)
-
Overflow incontinence
–Outlet obstruction: BPH, GU prolapse, tumors
–Bladder contractility dysfunction: Neurologic disorder (e.g., diabetic or alcoholic neuropathy), sacral spinal cord lesions, anticholinergic medications
-
Functional incontinence
–Normal urinary system affected by external factors (e.g., age, mental status decline, poor mobility)
-
Mixed incontinence
–Combined elements of stress and urge incontinence is common in older females
–Combined elements of overflow and urge incontinence are most common in men and frail nursing-home patients
Workup and Diagnosis
-
History should include whether the patient has problems holding urine versus emptying bladder; leakage of urine with cough, exercise, sneezing, laughing, lifting; frequency of urination; nocturnal urination; strong urge to urinate; loss of urine before reaching toilet; hesitancy, dribbling, slow stream, incomplete voiding, dysuria; bowel habits (e.g., constipation); medications; fluid intake; and medical and surgical history
-
Physical exam should include full neurologic and mental status examinations, assessment of physical frailness (e.g., use of walking aids, dysfunction secondary to stroke), abdominal exam (e.g., lower quadrant distension, pregnancy, fecal impaction), and genital and rectal exam (evaluate for cystocele, vaginal atrophy, strength of pelvic muscles in women; rectal tone, abnormalities of glans penis and prostate in men)
-
Cough stress test: Immediate leakage indicates stress incontinence; delayed leakage indicates urge incontinence
-
Voiding diaries may be used to track urinary habits
-
Initial labs may include electrolytes, calcium, glucose, urinalysis, and urine culture
-
Measurement of postvoid residual volume by catheterization and/or pelvic ultrasound (>100 mL of residual urine is abnormal)
-
Specialized urodynamic tests are reserved for ambiguous results or treatment failure
>
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Source: In a Page: Signs and Symptoms, 2004
Enuresis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Urinary tract infection (UTI)
–Most common cause of new onset, secondary enuresis
–Common pathogens: E. coli (85%), Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, and other gram-negatives
-
Primary nocturnal enuresis
–Normal in children up to 8 years
–Often there is a strong family history
–Affected family members may not achieve night-time continence until adolescence
-
Dysfunctional voiding
–Unstable (uninhibited) bladder of childhood
–Infrequent voiding
–Neurogenic bladder
-
Psychosocial stress
-
Chronic constipation
–Often associated with encopresis
-
Chronic kidney disease
-
Nephrogenic diabetes insipidus (DI)
-
Central DI
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Diabetes mellitus (DM)
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Ectopic ureter
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Posterior urethral valves
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Urethral stricture
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Developmental delay
-
Neurologic disease
–Tethered cord
–Spina bifida
–Spinal tumors
–Spinal dysraphism
-
Sexual abuse
-
Prostatic tumor or abscess
-
Hydrocolpos or hematocolpos
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Osteomyelitis of vertebral body with compression of the spinal cord
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Spinal epidural abscess
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Obstructive sleep apnea
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Giggle micturition
Workup and Diagnosis
-
History
–Primary vs secondary; daytime vs night-time
–Previous urinary tract infection or renal disease
–Poor growth, recurrent dehydration
–“Curtsying” or urinary withholding/delay maneuvers
–Stooling frequency
–Psychosocial stressors, social withdrawal, poor performance in school (depression or sexual abuse)
–Developmental delay
-
Family history: Primary nocturnal enuresis, polyuria; early infant death (suggests nephrogenic DI)
-
Symptoms
–Fever, flank pain (UTI), dysuria, urgency, frequency (cystitis or dysfunctional voiding)
–Fatigue and polyuria (renal disease)
–Headache or vision changes (intracranial process)
-
Physical exam
–Affect, developmental assessment, growth parameters (height/weight), blood pressure
–Pallor (e.g., due to anemia of renal failure)
–Neuro: Reflexes, anal wink, sensation, strength
–Spinal exam (hair tufts, clefts suggest spina bifida)
–GU exam
-
Labs: Urinalysis, urine culture, chemistry panel
-
Additional evaluation based on the clinical situation
–Spinal MRI for sacral dimple or hair cleft
–Ultrasound/VCUG for UTI or other kidney /bladder
disease
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Source: In A Page: Pediatric Signs and Symptoms, 2007
INCONTINENCE, URINARY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
First, exclude stress incontinence with a pad test. Perineal pads are weighed before and after walking and stress for 30 minutes. An increase in weight identifies urine loss. Catheterization and examination, smear, and culture of the urine are essential at the outset. Cystoscopy and cystometric studies are often needed. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals.
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Source: Differential Diagnosis in Primary Care, 2007
ENURESIS (BEDWETTING):
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
From the above discussion it should be obvious that simple bedwetting prior to age 6 may not require a workup at all. After that age a careful examination of the urine, including smear and culture for bacteria, should be done. An intravenous pyelogram and voiding cystogram are usually necessary. If these suggest a congenital lesion or are negative, cystoscopy may need to be done. An x-ray film for spina bifida and a sleep EEG are probably worthwhile if urologic investigation is negative.
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Source: Differential Diagnosis in Primary Care, 2007
Enuresis:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child's daily fluid intake. Does he drink much after supper? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur at home and away from home? Ask the parents how they've tried to manage the problem, and have them describe the child's toilet training. Observe the child's and parents' attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.
Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child's gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Urinary incontinence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
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.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Fecal incontinence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern — for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool sample. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See
Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Neurogenic bladder:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The patient’s history may include a condition or disorder that can cause neurogenic bladder, incontinence, and disruptions of micturition patterns. Voiding cystourethrography evaluates bladder neck function, vesicoureteral reflux, and continence.
Urodynamic studies help evaluate how urine is stored in the bladder, how well the bladder empties, and the rate of movement of urine out of the bladder during voiding. These studies consist of four components:
❑ Urine flow study (uroflow) shows diminished or impaired urine flow.
❑ Cystometry evaluates bladder nerve supply, detrusor muscle tone, and intravesical pressures during bladder filling and contraction.
❑ Urethral pressure profile determines urethral function with respect to the length of the urethra and the outlet pressure resistance.
❑ Sphincter electromyelography correlates the neuromuscular function of the external sphincter with bladder muscle function during bladder filling and contraction. This evaluates how well the bladder and urinary sphincter muscles work together.
❑ Retrograde urethrography reveals the presence of strictures and diverticula. This test may not be performed on a routine basis.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Enuresis:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child’s daily fluid intake. Does he drink much after supper? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur both at home and away from home? Ask the parents how they have tried to manage the problem, and have them describe the child’s toilet training. Observe the child’s and parents’ attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.
Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child’s gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
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 can control urination occasionally, 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 (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies and childbirths she has had.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious signs of inflammation or an anatomic defect. Have female patients bear down, and 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.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fecal incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, at night or with diarrhea. Note the frequency, consistency, and volume of stools passed within the last 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation, page 334.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary Incontinence:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Voiding history. It is important to fully characterize the patient’s problem by taking a detailed history, including the duration of the symptoms, timing of voluntary or involuntary voiding, amounts voided involuntarily, and the relationship to voluntary voiding. Focus on the following areas:
1. Need for pads or diapers (measure of severity)
2. Loss of urine with coughing or laughing (suggests stress type)
3. Inability to hold urine after having the urge to urinate (suggests urge type)
4. Pain or discomfort (suggests infection or inflammation) (Chapter 10.1)
5. Inability to fully empty bladder (suggests obstruction)
6. Decreased urinary stream (suggests obstruction)
7. What impact does UI have on the patient’s life?
8. What does the patient think is going on?
B. Major medical problems. Does the patient have any known condition that is associated with UI? These include diabetes, heart failure, menopause, and neurologic problems. Does the patient have other genitourinary symptoms? In female patients, be sure to take a detailed obstetric history.
C. Medication history. Since medications are a major cause of incontinence, a thorough medication history is essential. Offending agents include diuretics, older antidepressants, antihypertensives, narcotics, and alcohol.
D. Special concern. Central and nephrogenic diabetes insipidus can present with UI because of increased urine output (many liters per day). These patients frequently have a concomitant polydypsia that closely matches their water loss (Chapter 14.5). Consider this diagnosis when the patient gives a history of voiding large volumes of urine.
Physical examination
The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):
A. General. Is the patient physically capable of getting to the toilet?
B. Mental status. Can the patient understand and act on the urge to void?
C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.
D. Abdominal examination. Is the bladder distended?
E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?
F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urinary Incontinence:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Cystitis
❑ Benign prostatic hypertrophy
❑ Pelvic floor relaxation
❑ Drugs
❑ Prostatitis
❑ Diabetes
❑ Cough
❑ Multiple sclerosis
❑ Spinal cord compression
❑ Decreased cortical inhibition
❑ Vesicovaginal fistula
Diagnostic Approach
On examination, test for stress-induced leakage with a full bladder, palpate for bladder distension after voiding, and check for post-void residual. Do a pelvic examination looking for pelvic floor laxity, atrophic vaginitis, urethritis, or pelvic mass, and a rectal examination for tone, fecal impaction, and prostate nodule. Check perineal sensation and neurosacral reflexes including volitional anal contraction, anal wink (anal contraction in response to a light scratch of the perineal skin), and bulbocavernosus reflex (anal contraction in response to a light squeeze of the penis or clitoris). An intact reflex arc but absent perineal sensation suggests a cord lesion or multiple sclerosis.
Urge incontinence: Due to detrusor overactivity. Urine loss is accompanied by a strong desire to void. Incontinence is preceded by a warning of seconds to minutes. Leakage is periodic but frequent, and nocturnal incontinence is common. Voluntary control of the anal sphincter is intact, and sacral sensation and reflexes are preserved. The post-void residual is low. It is usually a result of detrusor instability caused by stroke, Alzheimer dementia, brain tumor, Parkinson disease, bladder outlet obstruction, spinal cord lesion, or interstitial cystitis.
Reflex incontinence: Due to an excessive pressure response to bladder filling. Voiding occurs without stress or warning. Sacral reflexes are preserved, but voluntary sphincter control and perineal sensation are impaired. Post-void residual is increased. Usually caused by a spinal cord lesion, incontinence may be mimicked by cortical damage with decreased awareness of signals to void.
Stress incontinence: Due to failure of the sphincter to remain closed during bladder filling. Incontinence of small amounts of urine occurs with increased abdominal pressure (e.g., coughing, laughing, sneezing). Stress-induced detrusor instability is suggested by a 5 to 15 second delay between stress and leakage, and by nocturnal leakage.
Overflow incontinence: Due to impaired detrusor contractility and/or bladder outlet obstruction. There is frequent leakage of small amounts of urine, hesitancy, decreased flow, and incomplete emptying. The post-void residual is increased, and the bladder is palpable. Common mechanisms include bladder outlet obstruction caused by benign prostatic hypertrophy or urethral stricture; decreased detrusor tone due to a herniated disc; or peripheral neuropathy caused by diabetes, pernicious anemia, tabes, or cauda equina.
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Source: Field Guide to Bedside Diagnosis, 2007
Neurogenic bladder:
Diagnosis
(Handbook of Diseases)
The patient’s history may include a condition or disorder that can cause neurogenic bladder, incontinence, and disruptions of micturition patterns. The following tests will help evaluate the patient’s bladder function:
❑ Voiding cystourethrography evaluates bladder neck function, vesicoureteral reflux, and continence.
❑ Urodynamic studies help evaluate how urine is stored in the bladder, how well the bladder empties, and the rate of movement of urine out of the bladder during voiding. These studies consist of four components:
– Urine flow study (uroflow) shows diminished or impaired urine flow.
– Cystometry evaluates bladder nerve supply, detrusor muscle tone, and intravesical pressures during bladder filling and contraction.
– Urethral pressure profile determines urethral function with respect to the length of the urethra and the outlet pressure resistance.
– Sphincter electromyelography correlates the neuromuscular function of the external sphincter with bladder muscle function during bladder filling and contraction. This evaluates how well the bladder and urinary sphincter muscles work together.
❑ Retrograde urethrography reveals the presence of strictures and diverticula. This test may not be performed on a routine basis.
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Source: Handbook of Diseases, 2003
Urinary incontinence:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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 has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), 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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary Incontinence:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Maturational Delay
Most commoncause of primary urinary incontinence is lag in maturation of normal inhibitingmechanism of urine control. There is often family history of incontinence.Many children may achieve daytime controlbut still experience incontinence during sleep.This is a diagnosis of exclusion inan otherwise normal child who has no evidence of organic disease,no history of stress-related or psychologic disturbance, and normalUA and urine culture.At 5–10 yrs of age, spontaneouscure rate of nocturnal enuresis is about 15%/yr. Stress-Related Causes
Stress is frequent cause of secondary incontinence.Examples of stress-related factors are illness, separation, birthof sibling, attending new school, death of family member, divorcein family, and other personal and family problems. Once problemis recognized, proper support and counseling usually help with itsresolution.
Urinary Tract Disorders
Urinary Tract Infection
May causenighttime and daytime incontinence.Other common findings include fever,dysuria, urinary frequency, abdominal or flank pain, and vomiting.Positive urine culture confirms diagnosis(see Chap. 15, Dysuria). Dysfunctional Voiding Disorders
Voidingdysfunction occurs in many children who do not have known organiccause (e.g., neurologic disorder, injury, or malformation).Although some children have small-capacitybladder and experience urgency and often incontinence, others havehyperreflexic bladder with uninhibited detrusor contractions duringfilling. Still others have large hypotonic bladder that does notempty completely with voiding.Failure to empty bladder results inchronically distended bladder that is prone to urinary tract infectionand overflow incontinence.Urinary urodynamic testing is helpfulin determining abnormality in each case. Lower Urinary Tract Obstruction
Can producebladder distension and overflow incontinence. Poor urinary streamwith dribbling and excessive straining with urination are prominentfeatures.Specific causes include posterior urethralvalves, urethral duplication, or urethral cyst.Combination of tests including renalU/S, intravenous urography, and voiding cystourethrographyusually can confirm diagnosis. Retrograde urethrography is generallyrequired for adequate evaluation of urethral duplication. Ectopic Ureter in Girls
Ectopicureter may empty into bladder neck, urethra, vagina, or, rarely,uterus with continuous leakage of small amount of urine. Child hasnormal voiding habits but is frequently wet.Because of frequent occurrence of completeureteral duplication and associated renal parenchymal dysplasiain segment drained by ectopic ureter, renal U/S, intravenousurography, and voiding cystourethrography are useful in evaluation.If diagnosis remains uncertain afterthese studies, but ectopic ureter is still suspected, magnetic resonanceurography may be diagnostic. Cystoscopy can help identify ureteralorifice if it is in urethra, whereas vaginoscopy may be needed ifureter empties into vagina. Neurologic Disorders
Mental Retardation
Although children with mild mental retardationmay have voluntary control of urination, they may have incontinencefor behavioral reasons, while those with severe retardation usuallylack voluntary control of urination.
Neurogenic Bladder
Lower extremityweakness, gait disturbance, fecal incontinence, decreased or absent perianalsensation, and lack of normal anal sphincter tone are common findingsin children with neurogenic bladder.Bladder size can be small, normal,or large, but usually it is small with thick wall.Evaluation of urinary tract may includerenal U/S, voiding cystourethrography, and urodynamic testing.Spinal dysraphism, a common cause ofneurogenic bladder in children, includes myelomeningocele, congenitaldermal sinus, diastematomyelia, and tethered cord syndrome.Myelomeningoceleand dermal sinus tract are visible on physical exam.Diastematomyelia is the splitting ofspinal cord at 1 or more vertebral levels, usually by bony or fibrousspur in spinal canal. The bone spicule may be detectable on spineradiography, but MRI is definitive imaging procedure.Tethering of spinal cord maintainsabnormally low position of cord and prevents its normal ascent.Lipoma, dermoid cyst, or dermal sinus tract are associated lesions,and MRI is diagnostic. Other causes of neurogenic bladderare sacral agenesis, spinal cord injury, and spinal cord tumors.Failure to palpate sacrum and coccyxsuggest sacral agenesis. Radiography of lumbosacral spine showsabsence of sacral segments.History of trauma exists with spinalcord injury.Tumors affecting spinal cord are discussedin Chap. 5, Back Pain. Abdominal or Pelvic Mass
Abdominal or pelvic mass (fecal impaction,mesenteric cyst, presacral teratoma) that impinges on bladder cancause urinary incontinence during running, laughing, coughing, orlifting. Abdominal or pelvic U/S is most useful screeningtest.
Polyuria
Childrenwith diabetes mellitus may have incontinence, especially at night,if they have persistent hyperglycemia that is difficult to control.Other causes of polyuria are diabetes insipidus and psychogenicpolydipsia.Diabetes insipidus is associated withdefect in urine-concentrating ability. Random sample of urine withspecific gravity of >1.028 rules out concentration defect.Even specific gravity of >1.020 on random or early-morningurine sample is evidence of good concentrating ability and againstconcentrating defect.Children with persistent polyuria mayhave structural and functional changes in bladder, which contributeto voiding dysfunction.See Chap.47, Polyuria and Polydipsia. Primary Psychologic Disturbance
Urine incontinence occurs in some childrenwith primary psychologic problems (e.g., depression, a severe personalityor behavioral disorder, or psychosis). History, physical exam, clinicalobservation, and psychologic testing are diagnostic.
Diagnostic Approach
Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fecal Incontinence:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Maturational Delay or Developmental Conflict
Some childrenexperience maturational delay in developing bowel control. Others havenever been toilet trained.Sometimes developmental conflicts resultin fecal incontinence.History and normal physical exam arediagnostic. Stress-Related Factors
Stress iscommon cause of secondary fecal incontinence. Stress-related factorsinclude illness, separation, birth of sibling, attending new school,death of family member, parental divorce, or any other personalor family upset.History and normal physical exam arediagnostic. Constipation
Chronicconstipation from functional fecal retention is thought to be majorcause of encopresis, which is defined as fecal incontinence notresulting from illness or organic disorder.Most cases of encopresis occur in school-agedchildren, who soil their underclothes.See Chap.9, Constipation. Neurologic Disorders
Childrenwith mild mental retardation may have delay in achieving bowel control, whilesome with severe retardation never achieve control.Spinal dysraphism, spinal cord injury,or spinal cord tumor can be associated with fecal incontinence.History andphysical exam, including rectal and neurologic exams, screen forthese disorders. Often there is history of lower extremity weakness,impaired sensation, and lack of bladder or bowel control. Strength,tone, sensation, and reflexes of lower extremities; back; anal sphinctertone; perianal sensation; and gait should be particularly examined.Spine radiography, CT, and MRI locateand define extent of lesion. Primary Psychologic Disturbance
Childrenwith severe behavioral disorders or psychosis may develop fecalincontinence.History (including psychosocial historyof child and family), physical exam, clinical observation of child,and psychologic testing are diagnostic. Diagnostic Approach
In childwith normal physical exam, most common causes of fecal incontinenceare maturational delay, developmental conflict, stress-related factors,and constipation. If primary psychologic disturbance exists, furtherevaluation should be performed by clinical psychologist or psychiatrist.History and physical exam can screenfor a neurologic disorder. Relaxed anal sphincter tone, decreasedperianal sensation, lower extremity weakness, and urinary incontinencesuggest spinal cord lesion. Combination of spine radiography, CT,and MRI is usually diagnostic.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Enuresis:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child's daily fluid intake. Does he drink much after dinner? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur at home and away from home? Ask the parents how they've tried to manage the problem, and have them describe the child's toilet training. Observe the child's and parents' attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.
Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child's gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
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 can occasionally 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 has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), 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. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.
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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Fecal incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
INCONTINENCE, URINARY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
First, exclude stress incontinence with a pad test. Perineal pads are
weighed before and after walking and stress for 30 minutes. An increase in
weight identifies urine loss. Catheterization and examination, smear, and
culture of the urine are essential at the outset. Cystoscopy and cystometric
studies are often needed. Surgical repair of a cystocele or a
parasympathomimetic drug in cases of a flaccid neurogenic bladder and
propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic
neurogenic bladders may be all that is necessary. A neurologist and
urologist often need to cooperate in the diagnosis and treatment of these
unfortunate individuals.
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Source: Differential Diagnosis in Primary Care, 2007
ENURESIS (BEDWETTING):
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
From the above discussion it should be obvious that simple bedwetting
prior to age 6 may not require a workup at all. After that age a careful
examination of the urine, including smear and culture for bacteria, should
be done. An intravenous pyelogram and voiding cystogram are usually
necessary. If these suggest a congenital lesion or are negative, cystoscopy
may need to be done. An x-ray film for spina bifida and a sleep
electroencephalogram (EEG) are probably worthwhile if urologic investigation
is negative.
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Source: Differential Diagnosis in Primary Care, 2007
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