Female urinary incontinence

Classification

Three types — and what the patient describes

• Stress incontinence: urine leakage on coughing, sneezing, lifting, or exercising, without a preceding urge to urinate.
• Urge incontinence: a sudden, almost uncontrollable urge to urinate with urine loss, plus pollakiuria and nocturia.
• Mixed incontinence: both components are present — the question is which component is more bothersome to the patient.
• Frequency: stress incontinence accounts for about half, and the mixed form for about a third of cases.

Types you think of last

• Overflow incontinence: dribbling leakage with chronic retention and large residual urine volume.
• Extraurethral incontinence: constant leakage without urge and without stress — suggests a fistula.
• Nocturia: ask about it specifically — it is more indicative of an urge component than a stress component.

Clinical features

More facts from the study questions

• Stress incontinence accounts for about half of all cases.
• The mixed form accounts for about one third.
• An intrinsic sphincter deficiency is the correlate of a rigid, hypomobile urethra.
• The underlying mechanism of urge incontinence is involuntary contractions of the bladder muscle (detrusor vesicae muscle) during the filling phase.
• Risk factors for stress incontinence include vaginal births, macrosomic infants, obesity and chronic cough.
• The bladder diary is a key, simple diagnostic tool.
• It is kept for two to three days to objectify fluid intake and voiding patterns.
• The stress test (cough provocation) is performed with a comfortably full bladder.
• Immediate, visible urine leakage proves a stress incontinence component.
• Introital or perineal ultrasound is a dynamic examination.

Diagnosis

History

• First: type of urine loss, triggers, amount, pad usage, and the degree of suffering.
• Drinking and voiding habits: fluid intake volume, coffee, micturition frequency, nocturia, and urgency.
• The simplest tool: a bladder and fluid diary for two to three days.

Clinical Examination

• Speculum and palpation: descent per compartment, signs of atrophy, pelvic floor muscle strength according to the Oxford scale.
• Stress test: coughing with a full bladder — visible urine leakage at the same moment proves the stress component.
• Additionally in case of prolapse: elevation test to uncover occult stress incontinence.
• Always included: urine status with dipstick test and post-void residual volume measurement by sonography.

Sonography — Introitus and Perineum

• What is assessed: the mobility of the bladder neck and the urethrovesical angle during straining.
• Funnelling: a funnel-shaped opening of the proximal urethral lumen under stress.
• Mnemonic for the examination: scan before and after bladder emptying because the findings change with bladder filling.
• Advantage over urodynamics: immediately available, radiation-free, without a catheter, and without risk of infection.

Keep learning in the app

Further reading (selection)

1. StatPearls: Urinary Incontinence (NCBI Bookshelf)
2. DocCheck Flexikon, Harninkontinenz

Cross-references