Urinary Incontinence: Causes and Diagnostic Work-Up

Review literature: (Liedl et al, 2005) (Viktrup et al, 2004).

Definition of Urinary Incontinence

The International Continence Society (ICS) defines urinary incontinence as "the complaint of any involuntary loss of urine"

Classification and Causes of Urinary Incontinence

Stress Incontinence:

Stress incontinence is urine leakage, which is associated with increased abdominal pressure and insufficient urethral sphincter mechanism. The main symptom of stress incontinence is the loss of urine on exertion, sneezing or coughing.

Urge incontinence:

Urge incontinence is defined by urinary incontinence due to active detrusor contractions. If a neurological disease is present, urge incontinence is also called detrusor hyperreflexia. The main symptom is involuntary urine loss together with urgency.

Giggle incontinence is a special form of urge incontinence (enuresis risoria): laughter triggers detrusor contractions and causes urge incontinence. Giggle incontinence is most common in children.

Mixed Urinary Incontinence:

Mixed urinary incontinence is the combination of stress incontinence and urge incontinence.

Overflow Incontinence:

In chronic urinary retention, urinary incontinence is causes by an increase of the bladder pressure without detrusor contractions, which exceeds the urinary sphincter pressure.

Extraurethral Urinary Incontinence:

Extraurethral Urinary incontinence is urine leakage via channels independent from the urethra: fistula or malformations such as ectopic ureter.

Enuresis:

Nocturnal enuresis is urinary incontinence of children after the age of 5 years while asleep.

Epidemiology of Urinary Incontinence

Prevalence of Urinary Incontinence:

The prevalence is 4.5% to 53% for women, 1.6% to 24% for men, the prevalence increases with age.

The prevalence of neurogenic bladder disorder (with or without urinary incontinence) increases with age in women from 2% to 19% with a steep increase in women older than 44 years. In men, the prevalence is 1% to 9% with a steep increase in men older than 64 years.

Diagnostic Work-Up in Urinary Incontinence

Medical History:

A thorough history is a powerful tool to differentiate between different forms of urinary incontinence. Important aspects of the history in urinary incontinence: lower urinary tract symptoms, precipitans of urinary incontinence (laugh, cough...), severity of urinary incontinence, bother due to incontinence, previous surgery, number of vaginal childbirth, medications, neurological and urological diseases.

Quantification of Urinary Incontinence:

Severity and time pattern of urinary incontinence can be assessed with a micturition diary over 1–2 days: data of drinking habits, episodes of incontinence, volumes of micturition.

Laboratory Tests in Urinary Incontinence:

Urine sediment, urine culture and determination of creatinine to assess renal function.

Physical Exam:

In addition to a neurological examination, a vaginal and rectal examination in lithotomy position is done.

Important pathological findings: cystocele, rectocele, quantify pelvic organ descensus, decreased anal sphincter tonus, lack of anal reflex or clitoris reflex, visible urinary incontinence due to coughing.

Imaging in Urinary Incontinence:

Abdominal Sonography:

Renal ultrasound: Upper urinary tract obstruction? Signs of renal atrophy or scarring?
Ultrasound of the Bladder: Bladder wall thickness? Post-void residual urine?

Voiding Cysturethrogram:

Voiding cysturethrogram is important for differential diagnosis of urinary incontinence, e.g. to detect extraurethral incontinence, cystocele, hypermobile urethra, opening of the bladder neck under pressing (valsalva maneuver).

Urodynamic Testing in Urinary Incontinence:

Urodynamic testing is the best tool to differentiate between different forms of urinary incontinence. Urodynamic testing is indicated if history, physical examination and imaging are unequivocal.

Cystoscopy:

Cystoscopy is useful for differential diagnosis of lower urinary tract symptoms.

Signs and symptoms

Index

Abbreviations

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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References

Liedl u.a. 2005 LIEDL, B. ; SCHORSCH, I. ; STIEF, C.:: [The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy].
In: Urologe A
44 (2005), Nr. 7, S. W803–18; quiz W819–20
Viktrup u.a. 2004 VIKTRUP, L. ; SUMMERS, K. H. ; DENNETT, S. L.:: Clinical practice guidelines for the initial management of urinary incontinence in women: a European-focused review.
In: BJU Int
94 Suppl 1 (2004), S. 14–22

Deutsche Version: Harninkontinenz

Last update

Dr. med. Dirk Manski
man...@urologielehrbuch.de