Internal Medicine

0521779407-21 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 18:59

Urinary Incontinence 1493

■Urinalysis (with urine culture when UA positive for red and/or white

cells)

■Uroflow to evaluate voiding dysfunction – outpatient and non-

invasive (minimum volume voided 150 ml for proper interpretation)

■Post void residual (by catheterization or bladder scan)

■Blood tests: urea, creatinine, electrolytes when indicated

Specific Tests

■Urodynamic testing to assess severity of stress incontinence (Val-

salva leak point pressure), identification of detrusor overactivity,

and assessment of detrusor voiding function. Surface patch elec-

tromyogram for neurogenic bladder and in patients suspected of

outlet obstruction.

■Cystoscopy to exclude etiology for urge incontinence (tumor, stone,

etc.) or for assessment of urethral sphincter (indirect). The procedure

can be followed by a stress test in supine and/or standing position

to demonstrate stress incontinence.

■Imaging studies: voiding cystourethrogram in standing position to

assess impact of gravity on urethral support and bladder base. Upper

tract studies (i.e., CT or IVP) rarely needed unless hematuria or asso-

ciated high-grade bladder prolapse.

differential diagnosis

■Pseudo-incontinence

➣Vaginal voiding (well documented on the post-void film of the

cystourethrogram)

➣Post-void dribbling from a urethral diverticulum

Classification

■Stress urinary incontinence (urinary leakage secondary to an

increase in abdominal pressure with cough, sneezing, laughing, etc.)

■Risk factors for stress incontinence

➣Aging

➣Hormonal changes

➣Traumatic delivery

➣Parity

➣Pelvic surgery

■Urge incontinence (urinary leakage associated with an abrupt desire

to void – urgency that cannot be suppressed)

■Overflow incontinence – from overdistention of the bladder

■Total incontinence usually from extra-urethral sources (ectopic

ureter or vesico-vaginal fistula)