History and exam
Key diagnostic factors
common
age over 50 years
The prevalence of stress incontinence peaks in the fifth decade of life, whereas the prevalence of both mixed and urgency incontinence continues to increase with age.[11]
BMI over 25
Excess weight, especially in women with a BMI over 25, increases pressure on pelvic tissues, causing chronic strain, stretching, and weakening of the muscles, nerves, and other pelvic structures.[3]
increased parity
involuntary urine leakage on effort, exertion, sneezing, or coughing
Suggestive of stress incontinence.
involuntary urine leakage accompanied by or immediately preceded by urgency
Suggestive of urgency incontinence.
frequency of urination
Occurs in overactive bladder.
nocturia
Occurs in overactive bladder.
use of drugs that can cause urinary incontinence
Includes drugs with anticholinergic effects, such as antihistamines, antidepressants, and antipsychotics.[11] Calcium-channel blockers and alpha-blockers have also been linked to urinary retention and difficulty in voiding. Diuretics may cause polyuria, frequency, and urgency.[11] Consult your local drug information source for more information on drugs that can cause urinary incontinence.
Other diagnostic factors
common
suggestive bladder diary
A 3-day diary records each void throughout the day and fluid intake. Documentation of incontinence events, times at which they occur, and any associated symptoms or events preceding leakage (i.e., urgency or sneezing).
vaginal bulge/pressure
Pelvic organ prolapse indicates lack of tissue support to vagina and neighboring organs, such as the bladder. An enlarged uterus may cause abnormal voiding or stress incontinence.
urogenital atrophy
uterine prolapse or posterior support weakness
Other forms of prolapse (e.g., uterine prolapse or posterior support weakness such as rectocele) can affect bladder function. They may cause bladder outlet obstruction and resultant incontinence or retention.
long-term residence in a care facility
High correlation with chronic medical comorbidities (e.g., bowel disease, chronic cough [e.g., COPD, asthma], arthritis, diabetes mellitus, and cardiovascular disease [e.g., hypertension, heart failure]) that may be associated with incontinence has been observed.[19] For individuals in a care facility, constipation, cardiovascular disease (especially heart failure), immobility, and wheelchair dependence increases the rate of urinary incontinence.[39] Cognitive impairment and dementia is highly prevalent in older people in care homes with urinary incontinence.[40]
uncommon
diabetes mellitus
excess fluid intake
May be associated with increased urine output.
cognitive impairment on mental state exam
Abnormalities (e.g., memory deficits) may be suggestive of dementia, which is associated with an increased incidence of urinary incontinence in older women.
history of neurologic disease
Neurologic diseases, such as cerebrovascular accidents, multiple sclerosis, and Parkinson disease, may affect the neuronal pathways of the genitourinary system, causing urinary urgency or incontinence, or impair mobility, resulting in functional incontinence.[27]
history of back injury
Suggests possible spinal cord injury as a cause of urinary incontinence.[11]
history of recurrent urinary tract infections
May suggest an inflammatory process of the lower urinary tract caused by bacteria that also causes urinary incontinence.[11]
dysuria
Suggestive of a urinary tract infection as a cause of urinary incontinence.[11]
hematuria
May suggest an alternative lower urinary tract pathology which contributes to urinary urgency, frequency, and urgency incontinence.[11] Importantly, the presence of hematuria without identifiable etiology prompts workup for bladder cancer, especially in women with increased risk factors of age >65 years, tobacco use, occupational exposure, or persistent irritative urinary symptoms (urgency, frequency, dysuria, and incontinence).
post-void dribbling
May suggest an alternative lower urinary tract pathology, such as urethral diverticula, as a cause of urinary incontinence.[11]
pooling of urine in vaginal tract
Suggests a genitourinary fistula as a cause of urinary incontinence.[11]
urethral discharge or tenderness
May suggest urethral diverticulum, carcinoma, or inflammation, which also causes urinary incontinence.[11]
enlarged uterus
A bimanual examination also provides valuable information about the size and conformation of the pelvic organs, if present. Mechanical compression of the bladder by an enlarged, bulky uterus may cause urinary urgency and frequency by constricting the bladder's ability to distend in the already occupied pelvis. Causes mechanical compression of the bladder causing urinary urgency and frequency.
loss of perineal sensation
Suggests disruption of neurologic input to the perineum.
abnormal bulbocavernosus and wink reflexes
Anal reflex is performed by gently stroking the skin lateral to the anus. In normal circumstances, an anal wink, or contraction of the anus, is visualized. Similarly, the clitoro-anal reflex, which involves tapping the clitoris, causes contraction of the bulbocavernosus, ischiocavernosus, and anal sphincter. Abnormal reflexes suggest disruption of the sacral reflex.
weakened sphincter tone
Reflects poor pelvic floor muscle support to urethral sphincter.
fecal impaction
Sign of pelvic floor dysfunction, manifested by anorectal changes.
Risk factors
strong
increasing age
pregnancy
obesity
pelvic organ prolapse
Commonly coexistent condition with urinary incontinence and pelvic floor dysfunction.[34]
postmenopausal status
Menopause and aging are strongly associated with the emergence or worsening of lower urinary tract dysfunction.[35] Estrogen depletion results in atrophy of the superficial and intermediate layers of the urethral mucosal epithelium.[36] This causes atrophic urethritis, diminished urethral mucosal seal, loss of compliance, and irritation, possibly leading to either stress or urgency incontinence.
diuretic use
May cause polyuria, frequency, and urgency.[11]
caffeine consumption
May cause frequency and urgency.[37]
constipation
Women with urinary incontinence are significantly more likely to report bowel symptoms (constipation, fecal incontinence).[17] Constipation with chronic repeated, prolonged defecatory straining efforts contribute to progressive neuropathy and dysfunction.[18] Concomitant urinary incontinence and chronic constipation in young women with longstanding history of urinary incontinence may indicate occult spina bifida.
fecal incontinence
high-impact physical activity
obstructive sleep apnea
long-term residence in a care facility
High correlation with chronic medical comorbidities (e.g., bowel disease, chronic cough [e.g., COPD, asthma], arthritis, diabetes mellitus, and cardiovascular disease [e.g., hypertension, heart failure]) that may be associated with incontinence has been observed.[19] For individuals in a care facility, constipation, cardiovascular disease (especially heart failure), immobility, and wheelchair dependence increases the rate of urinary incontinence.[39] Cognitive impairment and dementia is highly prevalent in older people in care homes with urinary incontinence.[40]
dementia
Associated with increased incidence of urinary incontinence in older women. Types of dementia may include Lewy body disease, vascular dementia, normal pressure hydrocephalus, frontotemporal dementia, and Alzheimer disease.[27] Incontinence may be due to neurologic problems, behavioral problems, or myogenic changes, but also from the cognitive impairment and impaired mobility often seen in dementia.[27]
stroke and other central nervous system/spinal disorders
Parkinson disease
Urinary incontinence may be a direct consequence of neurologic damage caused by Parkinson disease or may be caused indirectly as a result of physical limitations imposed by the disease.[27][29] Urinary dysfunction in Parkinson disease is predominantly associated with detrusor overactivity (urgency, frequency, nocturia, and urge incontinence).[41] External sphincter bradykinesia, which may contribute to urinary obstruction, is rare.[42]
multiple sclerosis
Up to 90% of patients with multiple sclerosis experience neurogenic lower urinary tract symptoms (most commonly detrusor overactivity) over the course of their disease.[43]
weak
white women
A study on different racial/ethnic groups within the US determined that stress and mixed urinary incontinence were significantly less prevalent in black versus white women; however, there was no significant difference in prevalence of urgency urinary incontinence between the groups.[6]
functional impairment
Mobility impairment or sensory impairments (i.e., impaired vision) contributing to mobility limitation are associated with incontinence.[11][27] The relationship between functional impairment and condition is unclear. Possibilities include difficulties in getting to the bathroom and removing clothing, or the condition may be a consequence of general frailty in older patients or an underlying systemic illness, such as cerebrovascular accident.
family history of incontinence
chronic cough
In chronic coughing, the rapid increase in intra-abdominal pressure and impact loading on pelvic musculature and connective tissue can create damage over time.[19]
diabetes mellitus
The pathogenesis of diabetes-induced bladder dysfunction is multifactorial.[49] Diabetes commonly results in overactive bladder and can lead to sensory neurogenic bladder, which predisposes to incontinence.
depression
chronic heart failure
The association between heart failure and urinary symptoms may be directly attributable to worsening heart failure pathophysiology; however, management strategies for heart failure, in particular diuretics, ACE inhibitors, and beta-blockers, may contribute to the risk of developing urinary incontinence.[52] There is also significant overlap in the known risk factors associated with urinary incontinence and heart failure, such as increasing age, and the comorbid illnesses of diabetes, obstructive sleep apnea, obesity, and depression.[53]
smoking
May contribute to chronic coughing and interfere with collagen synthesis.[54]
genitourinary and pelvic surgery
Musculofascial attachments of the bladder to the surrounding pelvic wall can be disrupted during procedure. Nerve damage may also occur during some procedures (e.g., hysterectomy).[55] Additionally, abdominopelvic surgery is associated with an inherent risk of direct urinary tract injury, which may lead to urinary fistula.
radiation exposure
May cause injury to connective tissue, resulting in decreased elasticity and mobility (lead pipe urethra), which may lead to stress incontinence. Decreased bladder compliance from radiation may lead to low bladder capacity and mucosal irritation, resulting in irritative bladder symptoms and urinary urgency.[56] Urinary fistulae may also form after pelvic irradiation.
alcohol consumption
The combination of impaired mobility, confusion associated with alcohol use, and sedation, in conjunction with increased diuresis, can contribute to urinary incontinence.
antihistamine use
Those with anticholinergic effects have been associated with dry mouth, which, in turn, leads to increased fluid intake and the potential for urinary retention through inhibition of the contractile activity of the bladder, leading to incontinence. May also cause sedation.[11]
sedative use
Causes sedation, muscle relaxation, and confusion.[11]
hypnotic use
Causes sedation, muscle relaxation, and confusion.[11]
opioid analgesic use
Has been associated with urinary retention, fecal impaction, sedation, and delirium. May lead to incontinence.[11]
anticholinergic use
Has been associated with dry mouth, which, in turn, leads to increased fluid intake and the potential for urinary retention through inhibition of the contractile activity of the bladder, leading to incontinence. Also causes sedation.[11]
antidepressant use
The anticholinergic action of some antidepressants causes suppression of bladder contraction and alpha-adrenergic-mediated increased bladder neck tone. Resultant increased bladder outlet resistance is manifested by urinary retention, urinary urgency, frequency, and incontinence.[11]
Selective serotonin-reuptake inhibitors (SSRIs) increase cholinergic release resulting in urgency and urgency incontinence.[11]
antipsychotic use
Anticholinergic action of some antipsychotics causes suppression of bladder contraction and alpha-receptor-mediated increased bladder neck tone. Resultant increased bladder outlet resistance is manifested by urinary retention, urinary urgency, frequency, and incontinence. Also causes sedation.[11]
alpha-blocker use
Has been associated with urinary retention and voiding difficulty, which can lead to incontinence.[11]
calcium-channel blocker use
Has been associated with urinary retention and voiding difficulty, which can lead to incontinence.[11]
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