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Notes by Sarah Mehrtens

www.askdoctorclarke.com

Incontinence- History Taking

Important points in Hx

HPC  Stress? accidents when coughing/sneezing/laughing- “do you ever leak when

you don’t intend to?”  Urge? “Do you every not make it to the toilet in time?”  Daytime Frequency? >8times a day  Urgency?  Nocturia (>1 a night)/ Enuresis?  Haematuria?  Dysuria?  Fluid intake  Prioritize symptoms & disruption on life

  Faecal urgency/ incontinence?  Prolapse symptoms: dragging sensation/ sensation of lump/ worse at end of

day/standing up? Frequency? Difficulty bowels, e.g. put a finger in? Disruptingsex/ bleeding/ discharge?

O&G Hx  Any other menstrual probs/ pelvic pain/ abnormal discharge?  Obs: details

PMH  Childhood enuresis  Diabetes/ neuro conditions

  Recent weight change/ coughing conditions?  Post menopausal? HRT?

ExaminationGeneral: weight, chest problems Abdo : Exclude masses, urinary retentionPelvic: Inspection, pt in left lateral position ask to cough, or on standing, use sim’sspeculum to look for prolapse of bladder neck, feel for any pelvic masses

Ix1. MSU & dipstix rule out infection

2. Urinary diary3. Consider IVP to rule out fistula & U/s or post micturation catherterization 

retention & urinary overflow4. If no overflow/fistula/infection urodynamics

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Notes by Sarah Mehrtens

www.askdoctorclarke.com

Diagnosis very diff icult on history alone: need to confirm with u rodynamics

GSI Genuine Stress= involuntary loss of urine when intravesical pressure exceeds the

maximal urethral closure pressure (in absence of detrusor overactivity). Very common,10% women, 50% of incontinence: due to bladder neck weakness so bladder neckdescends. Common with pregnancy, multiparity, vaginal delivery (partic prolongeddelivery & forceps), obesity, chronic cough, age & oestrogen deficiency: oftencoexisting prolapse. Small, frequent passage of urine when raised intra-abdominalpressure: coughing, sneezing, laughing.

Mx  Advise: lose weight, address cough, give up smoking  Conservative: Vaginal cones & sponges, physiotherapy pelvic floor exercises to

strengthen pelvic floor  Determine GSI: urodynamic studies

  Surgery: must exclude overactive bladder. Tension-free vaginal tape/ Burchcolposuspension. Peri-urethral collagen injections in elderly

Overactive bladder : involuntary loss of urine due to uninhibited detrusor contractions:35% of incontinence. Often Hx childhood enuresis & faecal urgency. Causes:idiopathic, follow ing surgery for GSI, neurogenic bladder.

Causes urgency: detrusor instability, irritation (infection, stones, tumour), prolapse,pregnancy, psychosomatic, neurological, diabetes 

Mx

  Advise: reduction fluid intake, avoid caffeine & alcohol  Urinary diary  Urodynamics: cystometry shows detrusor contractions on filling/ provocation  Bladder drill retraining: voiding by clock, not desire, using progressively longer

time intervals  Drugs: Tolterodine/ oxybutynin, synthetic ADH desmopressin for nocturia  Very severe: clam augmentation ileocystoplasty

Mixed= 10%. Tx overactive bladder first.

Chronic urinary retention & overflow = 1%

Sensory urgency= no detrusor overactivity, although frequency + urgency + nocturia stones, infections, tumours, interstitial cystitis, psychogenic e.g. anxiety.

NoteThese notes were written by Sarah Mehrtens as a medical student and submitted in 2009. They arepresented in good faith and every effort has been taken to ensure their accuracy. Nevertheless,medical practice changes over time and it is always important to check the information with yourclinical teachers and with other reliable sources. Disclaimer: no responsibility can be taken by eitherthe author or publisher for any loss, damage or injury occasioned to any person acting or refrainingfrom action as a result of this information. Please inform us of any ambiguities, inaccuracies orerrors by emailing bob@askdoctorclarke.com