4-90
Allow to air dry and apply a sterile dressing.
GU: Urinary Incontinence
CAPT Leo Kusuda, MC, USNIntroduction: Incontinence, the inability to voluntarily control the flow of urine, is only a social nuisance
in most cases. If the incontinence is not due to infection, and a physical exam including gross motor and
sensory (numbness or muscle weakness) exam is normal, serious complications are unlikely. Incontinence is
fairly common in women. Daytime incontinence in men is highly abnormal and suggests significant underlying
disease.
Subjective: Symptoms
Uncontrollable loss of urine.
Focused History: Do you leak urine when you cough, lift heavy objects or jump up and down? Do you go to
the bathroom often to prevent urine leaking out? (affirmative answers suggest stress incontinence) When you
have to go to the bathroom is the urge strong? Do you have a hard time holding your urine when you get the
urge? When you leak, is it a lot? (affirmative answers suggest urge incontinence) Do you have a hard time
emptying your bladder even though you feel like you have to? After you go to the bathroom do you feel like
you still have to go again? After you go to the bathroom do you leak? (affirmative answers suggest urinary
retention, which may be accompanied by overflow incontinence). Do you feel constantly wet? Do you feel
that the wetness or dripping may be coming from your vagina? (affirmative answers suggest fistula or hole
between the bladder or ureter and the vagina). Patients may have mixed diagnoses, such as mixed urge
and stress incontinence.
Objective: Signs
Using Basic Tools: Wet clothing; trauma or irritation to the vagina; neurologic deficits: difficulty walking,
numbness in the perineum or increased deep tendon reflexes.
Using Advanced Tools: Lab: Urinalysis: moderately to strongly positive leukoesterase should be considered
an infection. Moderate to strongly positive heme should be considered an infection initially, but may be cancer,
urinary tract stone or other condition. Urinary catheterization (see Procedures) for suspected retention.
Assessment:
Differential Diagnosis - stress incontinence, urge incontinence, mixed incontinence, and retention as
described above.
Trauma, with or without fistula - continuous leakage in the setting of trauma suggests laceration of the vagina
and bladder either from a foreign body or bone fragment. Trauma frequently causes fistula formation.
Compression of the spinal cord from disk disease, spinal tumors and brain disease (e.g., stroke).
Multiple sclerosis or other neural tissue disease.
Renal obstruction with overflow incontinence.
Plan:
Treatment
Primary:
Treat any urinary tract infection (see Urinary Tract Infection section).
Treat specific type of incontinence:
Stress Incontinence: Empty bladder frequently. Wear diaper or tampon. Practice Kegel exercises (tighten the
muscles around the vagina 40-160 times per day).
Urge Incontinence: Mild: Hyoscyamine 0.375 mg po bid, Urised 1 po qid or Flavoxate 1 po bid
Moderate/Severe: Ditropan 5 mg 3-4x/day
Mixed Stress and Urge Incontinence: Imipramine 10-25 mg po q hs
Retention with Overflow Incontinence: Patients with significant symptoms, especially those suspected to
have overflow incontinence, should have a catheter passed into the bladder per urethra to determine if there