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Urinary incontinence

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Stress Incontinence

  • Pelvic floor weakness: Commonly due to childbirth, menopause, or aging; leakage occurs with increased intra-abdominal pressure, such as coughing or sneezing.
  • Urethral hypermobility: Results from weakened pelvic floor muscles and ligaments, leading to stress incontinence.
  • Intrinsic sphincter deficiency: Loss of urethral sphincter function, often due to surgery or trauma, causing stress incontinence.
  • Obesity: Increased abdominal pressure contributes to stress incontinence.
  • Chronic cough: Can exacerbate stress incontinence by repeatedly increasing intra-abdominal pressure.

Urge Incontinence

  • Overactive bladder syndrome: Characterized by urgency, frequency, and nocturia; may be idiopathic or due to detrusor overactivity.
  • Neurological conditions: Diseases like multiple sclerosis, Parkinson’s disease, or stroke can lead to detrusor overactivity and urge incontinence.
  • Urinary tract infection (UTI): Can cause irritation and urgency, leading to transient urge incontinence.
  • Bladder outlet obstruction: Such as benign prostatic hyperplasia (BPH), leading to overflow and urge incontinence.
  • Bladder stones or tumors: Can irritate the bladder, causing urge incontinence.
  • Atrophic urethritis/vaginitis: Often seen in postmenopausal women, causing urgency and urge incontinence.
  • Medications: Diuretics, alpha-blockers, or anticholinergics can contribute to urge incontinence.

Overflow Incontinence

  • Bladder outlet obstruction: Often due to BPH or urethral stricture, leading to chronic urinary retention and overflow incontinence.
  • Diabetic neuropathy: Causes impaired bladder sensation and contractility, leading to incomplete emptying and overflow incontinence.
  • Spinal cord injury: Can disrupt the normal reflexes of bladder emptying, leading to overflow incontinence.
  • Medications: Drugs like anticholinergics, opioids, and calcium channel blockers can cause urinary retention and overflow incontinence.
  • Chronic constipation: Can cause mechanical obstruction of the bladder neck, leading to overflow incontinence.
  • Severe pelvic organ prolapse: May cause mechanical obstruction and overflow incontinence.

Functional Incontinence

  • Cognitive impairment: Dementia or delirium can cause a lack of awareness or inability to reach the toilet in time, leading to incontinence.
  • Mobility issues: Conditions like arthritis or stroke that impair mobility can lead to incontinence due to difficulty reaching the toilet.
  • Environmental factors: Lack of access to a toilet, such as in institutional settings, can lead to functional incontinence.
  • Depression: May reduce the motivation to maintain continence, contributing to functional incontinence.
  • Medications: Sedatives, hypnotics, or antipsychotics can impair awareness or mobility, leading to incontinence.
  • Severe constipation: Can lead to functional incontinence by causing discomfort and urgency.
  • Severe frailty: In older adults, frailty may lead to a combination of factors resulting in functional incontinence.

Key Points in History 🥼

Onset and Duration

  • Onset: Acute onset may suggest infection, trauma, or a new medication, whereas chronic onset suggests an underlying condition such as BPH or pelvic floor dysfunction.
  • Duration: Short-term incontinence may be related to reversible causes, while long-term incontinence often indicates a chronic issue.
  • Precipitating factors: Ask about events or changes that coincided with the onset, such as childbirth, surgery, or the start of new medications.
  • Progression: Determine if symptoms are worsening, which can indicate progression of the underlying condition.
  • Pattern: Assess whether incontinence occurs during stress (e.g., coughing, sneezing), urgency, or is continuous, to help determine the type.

Associated Symptoms

  • Urinary symptoms: Frequency, urgency, dysuria, or hematuria may suggest UTI, bladder stones, or bladder cancer.
  • Pelvic pain: Chronic pelvic pain can be associated with pelvic organ prolapse, interstitial cystitis, or endometriosis.
  • Neurological symptoms: Numbness, weakness, or other neurological signs may suggest a spinal cord or peripheral nerve issue.
  • Menopausal symptoms: In postmenopausal women, vaginal dryness or atrophy may contribute to incontinence.
  • Bowel symptoms: Constipation or fecal incontinence may coexist with urinary incontinence, particularly in pelvic floor dysfunction.
  • Sexual dysfunction: May be associated with pelvic floor disorders or psychological factors.
  • Weight changes: Rapid weight gain or loss can affect pelvic floor strength and contribute to incontinence.
  • Systemic symptoms: Fever, malaise, or weight loss may suggest an underlying systemic disease such as diabetes or malignancy.
  • Psychological symptoms: Depression, anxiety, or stress can exacerbate or contribute to incontinence.
  • Mobility issues: Consider any musculoskeletal problems that could impair access to the toilet, leading to functional incontinence.
  • Medication use: Recent use of diuretics, sedatives, or anticholinergics can influence bladder function and contribute to incontinence.

Background

  • Past medical history: Document any history of urological, neurological, or gynecological conditions that could influence incontinence.
  • Medication history: Review current medications, especially those known to affect bladder function, such as diuretics, anticholinergics, or sedatives.
  • Surgical history: Previous pelvic, spinal, or urological surgeries may contribute to incontinence.
  • Family history: Consider any familial patterns of incontinence, which may suggest inherited conditions or predispositions.
  • Obstetric history: In women, document pregnancies, childbirths, and any complications, as these can impact pelvic floor strength.
  • Social history: Assess lifestyle factors such as alcohol use, smoking, and physical activity, which can impact incontinence.
  • Psychological history: Include any history of mental health issues, as these can affect the perception and management of incontinence.
  • Functional status: Determine the patient’s baseline mobility and any recent changes, as these can influence incontinence.
  • Bowel habits: Chronic constipation or fecal incontinence may coexist with urinary incontinence and influence management strategies.
  • Environmental factors: Consider factors such as access to toilet facilities, which can influence functional incontinence.

Possible Investigations 🌡️

Laboratory Tests

  • Urinalysis: To assess for infection, hematuria, or other abnormalities that might contribute to incontinence.
  • Urine culture: If a UTI is suspected based on symptoms or urinalysis findings.
  • Post-void residual (PVR) volume: Measurement via ultrasound to assess for incomplete bladder emptying, particularly in overflow incontinence.
  • Urodynamic studies: To evaluate bladder function, including detrusor activity, bladder compliance, and sphincter function.
  • Serum creatinine: To assess renal function, particularly in patients with suspected overflow incontinence or chronic retention.
  • Blood glucose: To rule out diabetes as a contributing factor to incontinence, particularly in patients with polyuria.
  • Prostate-specific antigen (PSA): In men, to assess for prostate pathology that may contribute to incontinence.
  • Serum electrolytes: To assess for electrolyte imbalances that may influence bladder function.
  • Thyroid function tests: To rule out hyperthyroidism, which can contribute to frequency and urgency.
  • CBC: To assess for anemia or infection, which might exacerbate symptoms of incontinence.

Imaging Studies

  • Pelvic ultrasound: To evaluate the bladder, uterus, and ovaries in women, and the prostate in men, for structural abnormalities.
  • Cystoscopy: Indicated if there is suspicion of bladder pathology such as stones, tumors, or chronic inflammation.
  • MRI spine: To assess for spinal cord or nerve root compression in patients with neurological symptoms or suspected overflow incontinence.
  • X-ray of the abdomen and pelvis: To evaluate for bladder stones or severe constipation contributing to overflow or functional incontinence.
  • Voiding cystourethrogram (VCUG): To assess for vesicoureteral reflux or urethral abnormalities contributing to incontinence.
  • CT urogram: May be indicated to assess for upper urinary tract pathology in patients with hematuria or complex presentations.
  • Uroflowmetry: To measure the flow rate during urination, useful in evaluating bladder outlet obstruction or detrusor underactivity.
  • Electromyography (EMG) of the pelvic floor: To assess for neuromuscular causes of incontinence, particularly in patients with pelvic floor dysfunction.
  • Bladder diary: A non-invasive tool to track fluid intake, urination patterns, and episodes of incontinence over several days.

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Medicine of older adult