Urinary Incontinence - Diagnosis and Management Summary
Very common (25% young women → 75% of older women). Most women do not seek help.
• Stress (leakage with coughing, laughing, etc.)
• Urge (loss of urine preceded by feeling of urgency)
• Mixed (most common, stress + urge)
• Functional (impaired mobility/cognition/neurologic).
• History: Review meds (anticholinergics, diuretics, etc.), bowel habits, caffeine/EtOH use, 72h voiding diary.
• Physical exam: check for prolapse, fistula, diverticulum; cough stress test (can be supine, but standing w/ full bladder ↑sensitivity); urethral mobility (w/pt bearing down, displacement >30˚ or movement >2cm); rectal exam (fecal impaction, sphincter tone); neuro exam.
• Diagnostics: UA/cx, PVR (if suspect overflow, abnl >150cc), specialized urodynamic studies not indicated in initial eval of uncomplicated UI.
• All types: bladder training (timed voiding, use PCOI handout), lifestyle interventions (eg weight loss, ↓fluid/caffeine intake) and pelvic floor muscle exercises (eg Kegels, use PCOI handout, consider referral to pelvic floor PT).
• Stress/mixed: Pessaries (mixed data, best for women who wish to avoid therapy/behavioral therapy, refer to urogyn for fitting), vaginal estrogen (in post-menopausal women w/ vaginal atrophy), and surgeries/procedures (eg midurethral sling, urethral bulking agents).
• Urgency: antimuscarinics (numerous side effects), beta-agonists (eg mirabegron, avoid w/uncontrolled HTN, ESRD, liver disease), and intravesicular botox
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