A "Brief" Synopsis of AFP's "Diagnosis of Urinary Incontinence"

A brief synopsis of; 
Diagnosis of Urinary Incontinence
CHRISTINE KHANDELWAL, DO, and CHRISTINE KISTLER, MD, MASc, University of North Carolina, Chapel Hill, North Carolina
Am Fam Physician. 2013 Apr 15;87(8):543-550.
http://www.aafp.org/afp/2013/0415/p543.pdf

     Urinary incontinence can be a embarrassing situation for patients of all ages. It is not something that comes with age. It is pathologic. The 5 types of urinary incontinence are stress, urge, mixed, overflow, and functional. Stress incontinence is due to sphincter weakness. The patient will lose small amounts of urine during physical activity or with increased intra abdominal pressure. Leakage will coincide with coughing. It is common in obese women and men after prostatectomy.
     Urge incontinence is due to detrusor overactivity due to bladder irritation (from cystitis, prostatitis, atrophic vaginitis, or bladder diverticuli), or loss of neurological bladder control (from dementia, stroke, spinal cord injury, or parkinson disease). Patients will report a sudden and severe desire to urinate and will "not make it to the toilet . Changes in body position or minor sensory stimulation may trigger bladder contraction. They will have a history of variable volume loss, frequency, nocturia, and urgency.
     Mixed incontinence is a mix of stress and urge. Patients report involuntary leakage with exertion, sneezing, coughing or urgency.
     Overflow incontinence is due to impaired detrusor contractility causing overdistention of the bladder. This causes dribbling, hesitancy  and inability to feel when the bladder is full.  This is commonly due to medication side effects or effects from other illnesses (diabetes, MS, BPH, or spinal cord illnesses).
     Functional incontinence will present with variable amounts of leakage caused by cognitive or physical impairment such as dementia, immobility, or mental health disorder
     When diagnosing incontinence, the physician should first rule out reversible (transient) causes  The mnemonic to remember the causes is "DIAPPERS", which stands for
delirium,
infection (UTI),
atrophic vaginitis,
pharmaceuticals ,
psychological disorders such as depression,
excessive urine output,
reduced mobility, and
stool impaction.
     Common pharmaceuticals that may cause this are antihypertensives, pain relievers  antidepressants, antihistamines, and anticholinergics. Once these causes are ruled out, then one of the chronic types of urinary incontinence should be considered. Along with a proper history, a quick questionnaire can be given which ask three questions. It asks if the patient has leaked urine in the last three months and if so, was physical activity, coughing, sneezing, a feeling of urgency, or inability to reach a restroom a contributing factor. It also asks which situations cause the most amount of leakage. A focused physical exam including looking for signs of volume overload, bladder distention, neurological or psychological impairment, will help with the diagnosis. post void residual volume can help determine they type of incontinence  Less than 50 ml is often seen with stress, urge or mixed incontinence. Volumes greater than 200 ml is often seen with overflow incontinence.  Laboratory tests and a "cough stress test (positive in stress incontinence)" may be considered. A voiding diary (of at least three days) documenting frequency of incontinent episodes, leakage, dribbling, fluid intake and nighttime activity is also helpful.