Urinary Incontinence

Differential Overview

❑ 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.

Clinical Findings

Cystitis  Urinary frequency, urgency, and burning are hallmarks. Perineal sensation and reflexes are preserved. It may result from bacterial infection or interstitial cystitis.

Benign prostatic hypertrophy  Hypertrophy may produce problems with urine retention or overflow of a chronically full (palpably distended) bladder. Prostate size on rectal examination correlates imperfectly with bladder outlet obstruction.

Pelvic floor relaxation  It is usually due to prior childbirth, to aging in women, or to prior prostate surgery in men. Urine loss occurs with laughing, coughing, sneezing, and lifting. On pelvic examination, a cystocele is found during Valsalva. Symptoms are often exacerbated in the elderly by diuretic use.

Drugs  Many drugs exacerbate incontinence, including decongestants and tricyclic antidepressants (with anticholinergic activity), diuretics, theophylline, and alcohol (which overwhelms bladder capacity), alpha-agonists (which increase sphincter tone), and calcium channel blockers (which decrease bladder smooth muscle contractility).

Prostatitis  Deep pelvic/perineal pain is accompanied by a sense of urgency.

Diabetes  Incontinence occurs without warning. There are usually associated signs of neuropathy, such as erectile dysfunction and peripheral or autonomic neuropathy. Glycosuria with increased urine volume also contributes.

Cough  Immediate leakage occurs with stress, and delayed leakage is caused by involuntary bladder contractions.

Multiple sclerosis  Incontinence occurs with detrusor spasticity with functional outlet obstruction or reflex incontinence. Associated findings include patchy numbness, hyperreflexia, and optic neuritis.

Spinal cord compression  Compression is associated with sensory and motor findings in the legs. Voluntary sphincter control and perineal sensation are reduced, but sacral reflexes may remain intact.

Decreased cortical inhibition  Socially inappropriate urination may occur in patients with Alzheimer dementia, Parkinson disease, stroke, or brain tumor.

Vesicovaginal fistula  Occurring most often after childbirth trauma, there is leakage of urine through the vagina.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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