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Urinary Incontinence: Causes and Diagnostic Workup

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 the involuntary loss of urine associated with urgency (increased daytime frequency or nocturia in the absence of urinary tract infection or other detectable disease) or detrusor overactivity.

Mixed Urinary Incontinence:

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

Giggle urinary incontinence:

Giggle incontinence is a situational urinary incontinence associated with laughter (enuresis risoria) and occurs predominantly in children.

Coital urinary incontinence:

Coital urinary incontinence is a situational urinary incontinence associated with sexual intercourse or orgasm.

Overflow Incontinence in Chronic Urinary Retention:

Chronic urinary retention is the inability to empty the bladder despite the ability to pass some urine. This may result in the frequent passage of small amounts of urine or urinary incontinence and a distended bladder.

Extraurethral Urinary Incontinence:

Extraurethral Urinary incontinence is urine leakage via channels independent from the urethra: vesicovaginal fistula, urethrovaginal 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 5% to 20% for women and 3% to 10% for men, increasing with age and comorbidity.

Diagnostic Workup in Urinary Incontinence

Medical History:

A thorough medical history is a powerful tool to differentiate between different forms of urinary incontinence. Important aspects are 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, and neurological and urological diseases.

Severity of Urinary Incontinence:

Documentation of drinking quantities, micturition volumes, incontinence episodes and pad changes with a micturition diary helps to quantify urinary incontinence. A time period of 24 to 48 hours is usually sufficient.

Laboratory Tests in Urinary Incontinence:

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

Physical Exam:

In addition to a neurological examination, a vaginal and rectal examination is done in the lithotomy position. Significant pathological findings are cystocele or rectocele, quantification of the pelvic floor insufficiency, anal sphincter tone and anal reflex, clitoral or bulbocavernous reflex, provocation of incontinence with pressure, coughing, or heel impact test.

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 Cystourethrography:

Voiding cystourethrography (VCUG) is often done in combination with urodynamics to diagnose cystocele, hypermobile urethra, rotation of the urethra, opening of the bladder neck under stress, and to exclude other forms of incontinence (extraurethral incontinence).

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 used to assess bladder capacity, sphincter function, and for differential diagnosis.

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