Urinary Leakage and Incontinence

Background - importance and magnitude of problem
Diagnostic goals - for overall category

stress urinary incontinence (urethral sphincter incontinence)

• genuine stress urinary incontinence
• intrinsic urethral insufficiency (Type III) with hypermobility
• intrinsic urethral insufficiency (Type III) without hypermobility (pipestem urethra)
• stress induced detrusor instability

• urinary tract infection
• estrogen deficiency
• interstitial cystitis
• detrusor instability
• small capacity/"nervous" bladder
• detrusor hypereflexia
• detrusor sphincter dyssynergia

• cystocoele
• urethral diverticula
• detrusor instability

• stress and urge incontinence
• stress and overflow

intermittant incontinence

overflow incontinence (hypotonic bladder)
• medication induced
• radical pelvic surgery induced
• diabetes mellitus
• diabetes insipidus
• psychogenic water ingestion
CNS impairment
• Alzheimers disease
• delerium
continuous incontinence

congenital anomalies
• ectopic ureter
• short urethra
• urethral diverticula
post surgical/radiation therapy fistulae
• vesical -vaginal fistula
• ureteral-vaginal fistula

Background

The unintentional loss of urine happens once in a while to most women. It is much more frequent after the menopause. When it does occur, it is usually in a small amount and doesn't occur so often as to be a hygiene or activity-limiting problem. If urine loss becomes more frequent or larger in amount, it results in inability to leave the house or maintain much in the way of physical activity. Incontinence is somewhat expensive because of having to buy perineal pads continuously.

Goals

The etiology of the incontinence determines therapy so it is critical to separate between anatomical and functional causes. Anatomically incontinence can be stress incontinence due to detachments of the pelvic structures that support the urethra and bladder, as well as the unusual occurrence of fistulas between the urinary tract and vagina which produce continuous incontinence. Functionally, the detrusor muscle of the bladder may contract spontaneously or there may be impairment anywhere along the neurological reflex arc that controls voiding functions. These disturbances can be from the central nervous system, spine or in the local nerve innervation pathway. A thorough physical exam looking for pelvic support defects, as well as a neurologic exam and urodynamic studies are key in differentiating the causes of urinary incontinence.

Pain with urination

• acute cystitis
  urethritis
  • gonococcal
  • non gonococcal - mycoplasma, ureaplasma
• interstitial cystitis
• bladder calculi
• urethral syndrome
• urethral stenosis
• urethral diverticulum
• Skene's duct infection/cyst
• urethral mucosa prolapse
• atrophic urethritis - estrogen deficiency

Background

Pain with urination is a common complaint and is most often associated with urinary tract infections. Pain with urination usually represents some sort of inflammation of the urethra or bladder.

Goals

The major goal is to separate causes into those associated with urinary tract infection or acute urethritis versus non-infectious causes such as urethral stenosis, diverticulum etc. The initial exam should check for any purulent discharge from the urethra or any cystic formation below the ureteral opening. A look at the estrogenization of the epithelium is also performed. Urine specimens are then obtained to look at microscopically and for culture. If there is no infectious process present and no anatomical problem on exam, the patient may need to have a cystourethroscopy.

Urinary difficulty

• cystocoele
• urinary tract infection
• urethral diverticulum
• urethral syndrome
• urethral stenosis
• urethral tumor
• Skene's duct infection/cyst
• urethral mucosa prolapse
• atrophic urethritis
• postoperative urinary obstruction
• medication induced urinary difficulty

Background

Difficulty in voiding may occur after giving birth, having spinal or epidural anesthesia or after vaginal surgery. Otherwise, it is an uncommon problem in women. Urinary tract infection may cause pain with voiding and the pain then causes voiding difficulty.

Goals

By history, recent trauma or surgery should be ruled out and by examination, cystocele or ureteral diverticulum should be noted. Urinalysis for urinary tract infection is then performed.