Urology Book

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Urinary IncontinenceAka: Incontinence

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  1. Epidemiology
    1. Increased prevelance with age
      1. Age 44 year women: 17%
      2. Age 75 year women: 27%
    2. High Incidence in female athletes
      1. Female Varsity Athletes: 32%
      2. Female Basketball players: 68%
  2. Physiology
    1. Physiology of urination and Bladder control
      1. Detrussor muscle (bladder) control
        1. Parasympathetic innervation
        2. Beta adrenergic control
      2. Internal urethral sphincter
        1. Alpha adrenergic control
      3. External urethral sphincter
        1. Somatic or voluntary control
    2. Incontinence is not a normal part of aging
      1. Age predisposes to incontinence
      2. Age does not cause incontinence
  3. Pathophysiology
    1. Disorders of Urinary Storage
      1. Detrussor Hyperactivity
        1. Urge Incontinence
      2. Sphincter incompetence
        1. Urge Incontinence
        2. Stress Incontinence
    2. Disorders of Urine Emptying
      1. Detrussor hypoactivity
        1. Overflow Incontinence
      2. Urethral Sphincter obstruction
        1. Overflow Incontinence
  4. Types of Urinary Incontinence
    1. Low Pressure Urethra (Type 3)
      1. Urethral tone loss (<60 cm H20)
      2. Causes: trauma, surgery
    2. Overflow Incontinence (Urinary Retention)
      1. Bladder overdistention with Urinary Retention
      2. Post-void residual >200 cc of urine
      3. Less common in women
      4. Causes: Neuropathy, BPH, or pelvic mass
      5. Requires evaluation for tumor mass
    3. Urge Incontinence (Overly sensitive bladder)
      1. Loss of large bladder volumes (contrast with stress)
      2. Associated with urinary urgency, frequency, nocturia
      3. Causes: CNS, Cystitis, Bladder Cancer, stones
    4. Stress Incontinence (Loss of pelvic support at urethra)
      1. Loss of small bladder volumes (contrast with urge)
      2. Occurs with coughing, sneezing, lifting
      3. Causes: Urethral hypermobility, Sphincter damage
    5. Functional Incontinence
      1. Normal bladder with decreased access to toilet
  5. Differential Diagnosis: (Mneumonic: "DIAPPERS")
    1. Delirium
    2. Infection or Inflammation
      1. Recurrent Urinary Tract Infection
      2. Infectious Vaginitis
      3. Interstitial Cystitis
      4. Carcinoma-in-situ of the bladder
    3. Atrophic urethritis or Atrophic Vaginitis
    4. Pharmaceuticals
      1. Diuretics
      2. Sedative-Hypnotic Medications
      3. Antipsychotic medications
      4. Muscle relaxants
      5. Sympathetic blockers
    5. Psychological causes
    6. Excessive urine output (e.g. Diabetes Mellitus)
    7. Restricted Mobility (i.e. difficult ambulation)
    8. Stool Impaction
  6. Exam
    1. Spontaneous loss of urine
      1. Detrussor Instability
      2. Urge Incontinence
    2. Provocation with cough, valsalva, or bearing down
      1. Suggests Stress Incontinence
      2. Perform Pelvic exam, lifting anterior vaginal wall
        1. Changes bladder neck position
        2. Retest with cough or valsalva
    3. Spontaneous uncontrolled large volume bladder emptying
      1. Suggests Urge Incontinence
  7. Diagnosis
    1. See Provoked Full Bladder Stress Test
    2. Urodynamic Testing (Cystometrography)
      1. Indicated for incontinence not due to stress or urge
  8. Evaluation
    1. Rule-out reversible cause
      1. Medication adverse effects
      2. Atrophic Vaginitis
      3. Benign Prostatic Hyperplasia (BPH)
      4. Polyuria
        1. Medication
        2. Diabetes Mellitus
      5. Fecal Impaction
      6. Urinary Tract Infection
      7. Functional Incontinence
        1. Limited mobility
        2. Altered Level of Consciousness
    2. Rule-out Overflow Incontinence
      1. Check post-void residual if indicated by history
    3. Consider neurologic or post-surgical cause
      1. See Low Pressure Urethra
    4. Distinguish Urge Incontinence from Stress Incontinence
      1. If secondary cause is unlikely
  9. Management: General
    1. Management is per specific incontinence cause
    2. Make toilets more accessible
      1. Higher toilets
      2. Well lit floors
      3. Change bedroom to be close to bathroom
      4. Consider bedside commode
    3. Wear clothes that are removed easily
    4. Use moderation in fluid intake
    5. Lose weight (if obese)
    6. Smoking Cessation
    7. Avoid Diuretics
      1. Avoid Alcohol
      2. Avoid caffeine
  10. Resources
    1. Help for Incontinent People
      1. Phone: (864) 579-7900
    2. AUA Step By Step Incontinence Treatment
      1. http://www.drylife.org/drylife.html
    3. Bladder Control in Women
      1. http://www.niddk.nih.gov/health/urolog/uibcw/

Urinary Incontinence (C0042024)

Definition (MSH)Involuntary loss of URINE, such as leaking of urine. It is a symptom of various underlying pathological processes. Major types of incontinence include URINARY URGE INCONTINENCE and URINARY STRESS INCONTINENCE.
Definition (CSP)failure of voluntary control of the vesical and urethral sphincters, with constant or frequent involuntary passage of urine.
Definition (NCI)(in-KAHN-tih-nens) Inability to control the flow of urine from the bladder (urinary incontinence) or the escape of stool from the rectum (fecal incontinence).
ConceptsDisease or Syndrome (T047)
ICD9788.3, 788.30
EnglishAbsence of bladder continence, Bladder incontinence, Bladder: incontinent, Incontinence, Incontinence of urine, INCONTINENCE URINARY, Involuntary urination, Lack of bladder control, Leaking of urine, Loss of bladder control, Unable to control bladder, Unable to hold fluids, Unable to hold urine, Unable to prevent bladder emptying, URINARY BLADDER INCONTINENCE, URINARY INCONTINENCE, URINATION INVOLUNTARY, Urine incontinence, Weak bladder
Spanishausencia de continencia urinaria, incontinencia de orina, incontinencia urinaria, incontinencia vesical, vejiga: incontinente
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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