INCONTINENCE OF URINE

Ask the Following Questions:

1. 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.
2. 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.
3. 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.
4. Are the reflexes hypoactive? Hypoactive reflexes suggest poliomyelitis, cauda equina syndrome, spinal stenosis, diabetic neuropathy, and tabes dorsalis.
5. 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.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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