Urinary Incontinence

• Involuntary loss of urine due to dysfunction of bladder storage, outlet control, or both. Classified as stress, urge (overactive bladder), overflow, functional, or mixed types.



• Very common in women after menopause or childbirth. Overflow type occurs more often in men with benign prostatic hyperplasia or neurologic disease.

Clinical Presentation

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  Stress Incontinence: Leakage with increased intra-abdominal pressure (cough, sneeze, laugh); common postpartum or post-menopause.
  
  
  The question stem would likely describe a postmenopausal woman who reports urine leakage when she exercises, laughs, or coughs.

  
  
  



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  Urge Incontinence: Sudden, strong urge to void with inability to reach the toilet in time; caused by overactive detrusor muscle; nocturia is common.
  
  
  The question stem would likely describe a patient who feels an abrupt urge to urinate and cannot make it to the bathroom in time, often awakening several times at night.

  
  
  



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  Overflow Incontinence: Dribbling and incomplete emptying due to bladder outlet obstruction or detrusor underactivity; seen with benign prostatic hyperplasia, neurogenic bladder, or diabetes.
  
  
  The question stem would likely describe an older man with benign prostatic hyperplasia who reports dribbling urine and a sensation of incomplete emptying.

  
  
  



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  Functional Incontinence: Normal bladder function but impaired mobility or cognition (dementia, post-stroke).
  
  
  The question stem would likely describe an elderly nursing home resident with dementia who is unable to reach the bathroom before urinating.

  
  
  



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  Mixed Incontinence: Combination of stress and urge symptoms; common in older women.
  
  
  The question stem would likely describe an older woman with both leakage when coughing and episodes of urgency.

  
  
  

Diagnostics

• Urinalysis and urine culture: First step to rule out urinary tract infection.



• Serum BUN and creatinine: Assess renal function in chronic or severe cases.



• Post-void residual measurement:
  
  
  
  
  
  • Less than 50 mL is normal.
  
  
  
  • Greater than 200 mL suggests overflow incontinence.
  
  
  
  • In older adults, a residual up to about 100 mL can be normal.
  
  
  
  
  
  



• Bladder stress (cough) test: With a full bladder, immediate leakage after a single cough confirms stress incontinence.



• Voiding diary (48–72 hours) and medication review: Identify transient or medication-related causes (e.g., diuretics, anticholinergics, calcium-channel blockers, opioids, alpha-blockers).



• Urodynamic studies: A small catheter measures bladder pressure and urine flow during filling and emptying; used to identify detrusor overactivity, impaired contractility, or outlet obstruction when the diagnosis is uncertain or before surgery.



• Neurologic evaluation: Consider if diabetic neuropathy or spinal cord involvement is suspected.

Treatment

Step 1: Behavioral and Lifestyle Measures

• Bladder training: Scheduled voiding at gradually longer intervals to increase bladder capacity and reduce urgency episodes.



• Timed voiding and fluid management; limit caffeine, alcohol, and bladder irritants.



• Kegel (pelvic floor) exercises for stress incontinence.



• Weight loss and smoking cessation.



• Topical vaginal estrogen for postmenopausal atrophic urethritis or vaginitis contributing to symptoms.

Step 2: Pharmacologic Management (Type-Specific)

• Urge / Overactive bladder:
  
  
  
  
  
  • Antimuscarinic agents (oxybutynin,