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Volume 5, Number 2, Fall 2001

Parkinson's disease, and dementia.4

Stress incontinence is the most common type of UI in women less than 75 years of age. In 85% of the cases, it results from an increase in abdominal pressure (e.g. Valsalva maneuver) that places "stress" on the bladder and its support structures and leads to "hypermobility" of the bladder neck and the urethra. This can be secondary to aging, hormonal changes, multiple childbirths, hysterectomy, and pelvic surgery. The remaining 15% of cases is due to intrinsic sphnicter deficiency secondary to pelvic/anti-incontinence surgery, pelvic radiation, trauma, and neurogenic disorders.8

Overflow incontinence is rare in women.8 It can be the result of over-distention of the bladder causing constant or frequent dribbling. Causes include bladder outlet obstruction due to stricture, cystocele, and fecal impaction. Another type of overflow UI is acontrac- tile bladder (a.k.a. detrusor hypoactivity or atonic bladder) which can be due to diabetes, multiple scle- rosis, lower spinal cord damage, and/or medications.4

Functional incontinence does not involve the lower urinary tract and is usually the result of physical (e.g. arthritis/stroke) and/or cognitive impairment. Lastly, mixed incontinence is a combination of any two or more of the above causes of persistent inconti- nence. The most common type is urge and stress with typically one type pre-dominating over the other.4

Office Workup A useful screening question to help identify patients with UI is "In the past year, have you ever lost your urine or gotten wet?" If yes, then ask "Have you lost urine on at least 6 separate days?" Once you have established your patient suffers from UI, then inquire about the onset and duration of symptoms, the type of incontinence (urge, stress, mixed, etc.), previous treat- ment, medical conditions, medications, and genitouri- nary history (e.g. previous anti-incontinence surgery). A discussion of how her UI affects her quality of life is also important. A bladder record can be a useful asset to the history and can be completed by the patient during the evaluation.4 It logs the frequency, timing, and the amount of continent and incontinent episodes over a one or two day period. During the initial evalu- ation, it is also important to distinguish between acute/transient versus persistent UI.

Physical examination should include an assess- ment of the patient's mental status and mobility, moni- toring for peripheral edema or evidence of congestive

heart failure, and neurologic evaluation of lumbosacral nerves and observing for any focal findings such as peripheral neuropathy. A pelvic examination should assess paravaginal muscle tone and look for atrophic vaginitis, cystocele, rectocele, tenderness, and mass. A rectal examination should assess sphincter tone (active and resting tone which helps determine the integrity of sacral plexus (S2-S4), fecal impaction, or presence of a mass.4,8

A cough stress test should be performed prior to voiding in the standing position by having the patient cough forcefully. Immediate leakage of urine is diag- nostic for stress urinary incontinence with specificity >90%. Within five minutes of voiding, a post-void residual (PVR) value should be obtained by either catherization or bladder ultrasound. PVR<50 cc is indicative of adequate bladder emptying. PVR<100 cc is adequate in the elderly. PVR 100 cc-200 cc is inad- equate bladder emptying, and the test should be repeated. If the PVR remains in this range, the patient may need to be referred for urologic evaluation. If the PVR is more than 200 cc, the patient should be referred for urologic evaluation. PVR>400 cc suggests overflow UI and usually requires an indwelling cathether for a short time to decompress the bladder.4

Laboratory tests include calcium and glucose levels if polyuria is present and a BUN/Cr if PVR>200 cc. Urine culture and urinalysis should be performed for the initial evaluation looking for heme, glucose, and leukocytes.4 A urinary tract infection can also have an effect on urge UI. During an acute infec- tion, 60% of patients were found to have transient urge UI.9 Simple cystometrics are useful if symptoms are unclear, and the test can be done in the office. It deter- mines bladder capacity and stability and has a 70%- 91% positive predictive value for urge incontinence.10

Management Options Behavioral interventions are always the first line of therapy.4 Simple measures include reducing the amount and timing of fluid intake (e.g., no fluids after 7 pm), avoiding bladder stimulants such as caffeine, using diuretics judiciously and not before bedtime, elevating legs when sitting to help diuresis before going to bed in patients with lower extremity edema, and having easy access to a toilet (e.g., a bedside commode). Other patient dependent interventions to treat urge and/or stress incontinence include bladder training or retraining which involves educating the patient about the physiology of their type of UI and


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