Gynecology Topic 34. Urinary incontinence

I. Urinary Incontinence

Definition and Classification

• Urinary incontinence: involuntary loss of urine.
• Main types: stress, urge, mixed, overflow, continuous/bypass, irritative/transient.

II. Diagnosis

History: Leakage Pattern

• Cough, laugh, lifting, exercise → stress urinary incontinence.
• Sudden urgency before leakage → urge incontinence / overactive bladder.
• Dribbling + weak stream/incomplete emptying → overflow.
• Constant leakage despite normal voiding → fistula/bypass incontinence.
• Frequency, nocturia, urgency, dysuria, hematuria.
• Ask about childbirth, pelvic surgery/hysterectomy, radiation, neurologic disease, diabetes, medications, caffeine and alcohol.
• Bladder diary if symptoms are unclear.

Examination and Basic Tests

• Pelvic examination: prolapse, atrophy, masses, fistula, infection, urethral mobility.
• Neurologic signs if suspected.
• Cough stress test with full bladder: observed urethral leakage → stress incontinence.
• Urinalysis + urine culture → Exclude UTI/hematuria.
• Postvoid residual (PVR): high PVR, especially >200 mL → retention/overflow concern.

Special Tests

• Urodynamics/cystometry: unclear or complex symptoms, high PVR, suspected neurogenic bladder, or before selected surgery.
• Cystoscopy/dye test/imaging: hematuria, recurrent UTI, suspected fistula, tumor, stone or ureteral injury.

III. General Management

For All Patients

• Bladder training and timed/scheduled voiding.
• Fluid intake planning; reduce evening fluids if nocturia.
• Reduce caffeine, alcohol and bladder irritants.
• Kegel exercises / pelvic floor muscle training ± physiotherapy/biofeedback.
• Weight loss if overweight/obese.
• Treat chronic cough/constipation and review medications.

IV. Stress Urinary Incontinence

Clinical Picture

• Leakage with increased intra-abdominal pressure: coughing, sneezing, laughing, lifting, exercise.
• No detrusor contraction and usually no urgency before leakage.
• Mechanism: weak pelvic floor/bladder-neck support, urethral hypermobility or sphincter deficiency.
• Risk factors: childbirth trauma, prolapse, menopause/atrophy, obesity, chronic cough/constipation.

Treatment

• First-line: pelvic floor muscle training/Kegels, weight loss, treat cough/constipation.
• Topical vaginal estrogen may help postmenopausal atrophy symptoms.
• Duloxetine: possible medical option, limited by adverse effects; not first-line.
• Surgery if conservative treatment fails: mid-urethral sling; alternatives include Burch colposuspension or urethral bulking.

V. Urge Urinary Incontinence / Overactive Bladder

Clinical Picture

• Sudden urge to void with leakage due to involuntary detrusor contraction.
• OAB: urgency ± frequency/nocturia ± urge incontinence, without UTI or obvious pathology.
• Causes: idiopathic, neurologic disease, UTI/cystitis, stones, tumors, obstruction, urogenital atrophy.
• Dysuria/hematuria suggests irritative pathology rather than idiopathic OAB.

Treatment

• Behavioral: bladder training, timed voiding, urge suppression, fluid/caffeine modification.
• Medical: antimuscarinics, e.g. oxybutynin/tolterodine/solifenacin; β3-agonist, e.g. mirabegron.
• Refractory: botulinum toxin or neuromodulation in specialist care.

VI. Overflow Urinary Incontinence

Clinical Picture

• Continuous or intermittent leakage/dribbling due to incomplete bladder emptying.
• Bladder overdistention + detrusor underactivity or bladder outlet obstruction.
• High PVR, classically >200 mL.
• Causes: diabetic or neurologic bladder, spinal cord disease, severe prolapse/outlet obstruction, anticholinergics/opioids/sedatives.

Treatment

• Catheterization / intermittent self-catheterization → Ensure bladder drainage.
• Treat underlying cause → Stop causative drugs, treat obstruction/prolapse/stricture, manage diabetes/neurologic disease.
• Cholinergics are rare/specialist-use options.

VII. Continuous / Bypass Incontinence

Fistula-Type Leakage

• Constant leakage independent of activity or urge; voluntary voiding may remain normal.
• Cause: vesicovaginal, urethrovaginal or ureterovaginal fistula.
• Etiology: obstructed labor/obstetric trauma, pelvic surgery especially hysterectomy, radiation, malignancy, inflammation.
• Diagnosis: dye testing, cystoscopy and imaging as needed.
• Treatment: surgical repair after infection/inflammation is controlled.

VIII. Mixed and Irritative Incontinence

Practical Points

• Mixed incontinence: stress + urge symptoms; treat the predominant/bothersome component first.
• Irritative/transient incontinence: UTI, stone, cancer, atrophic vaginitis, catheter irritation, medications.
• Frequency, urgency, dysuria or hematuria → urinalysis and investigate/treat the underlying cause.