Urinary incontinence

Probability diagnosis

Stress incontinence

Cystitis

Overactive bladder (detrusor instability)

Outflow obstruction e.g. prostatism

Post pelvic surgery

Enuresis

Serious disorders not to be missed

Infection:

• Prostatitis

• Chronic UTI

Cancer/tumour:

• Bladder

Other:

• Dementia

• Fistula

• Ectopic urethra

Pitfalls (often missed)

Neurogenic: multiple sclerosis, neuropathy, others

Interstitial cystitis (women)

Rarities:

• Bladder calculus

• Post pelvic fracture

Masquerades checklist

Diabetes: polyuria

Drugs (see list in history)

Endocrine: diabetes insipidus

Spinal dysfunction incl. cauda equina lesion

Urinary tract infection

Is the patient trying to tell me something?

Functional (?psychogenic)

Key history

Focus on the duration and patterns of voiding, bowel function, drug use, obstetric and pelvic surgery history. A voiding diary is helpful to pinpoint the cause. Use of a severity index questionnaire is very helpful. Obstructive symptoms in men with detrusor overactivity. Consider a sleep related problem. Check drug history: diuretics, alcohol, sedatives, antidepressants, α-adrenergic blockers e.g. prazosin, caffeine, psychoactive agents, anticholinergics, calcium channel blockers e.g. nifedipine.

Key examination

Based on neurological, pelvic and rectal examinations

Key investigations

First line:

• urinalysis

• MSU

• KFTs

Consider (based on specialist referral):

• cystoscopy

• cystometry

• urodynamic studies

• selective imaging e.g. ultrasound, micturating cystourethrogram, IVU

Diagnostic tips

Classify incontinence into the main categories: stress, urge and continuous (overflow).