Overview

• Stress Incontinence → increased pressure on bladder [small losses]. Due to weakness of the pelvic floor and sphincter muscles. Most common cause of incontinence in females.
• Urge Incontinence (Overactive Bladder) → strong urge to urinate and often don’t get to toilet in time [large losses]. Due to overactivity of detrusor muscle. Urge = OAB (dx if no involuntary leakage) + involuntary leakage.
  • The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs
• Mixed Stress & Urge Incontinence → both together.
• Overflow Incontinence → chronic urinary retention due to an obstruction to outflow of urine. High voiding detrusor pressure with low peak flow rate along with voiding symptoms (straining, poor flow, incomplete emptying). Can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.
  • Palpable bladder after urination → retention with urinary overflow.
• Dribbling incontinence after having a child with prolonged labour → vesicovaginal fistula (do urinary dye studies - identifies fistula).
• Risk Factors → increased age, postmenopausal, increased BMI, previous pregancies & vaginal deliveries, pelvic organ prolapse, hysterectomy, pelvic floor surgery, neurological conditions, cognitive impairment, diuretic use (if hypertensive).

Making Diagnosis

Clinical Features

• FUN → frequency, urgency, nocturia.

Investigations

• 1st [Bedside]) Urine Dipstick (first investigation) → assess for UTI, DM or microscopic haematuria.
• 1st) Bladder Diary → track fluid intake and episodes of urination and incontinence over at least 3 days.
• 2nd) Urodynamic Testing → measures 3 pressures from inside the rectum and urethra.
  • Thin catheter is inserted into the bladder, and another into the rectum. The two catheters measure the pressures in the bladder and rectum for comparison. Various outcomes are then measured → cystometry, uroflowmetry, leak point pressure, post-void residual bladder volume, video urodynamic tesing.
• Speculum (Sim’s) Examination → exclude pelvic organ prolapse. Ask patient to cough (valsalva manouvere).

Management Plan