A 46-year-old P3003 presents to your office with a chief complaint of leakage of urine. She reports that she leaks when she coughs or sneezes. She is otherwise healthy, does not smoke, and takes no medications. Her history is significant for three vaginal deliveries.
Which of the following is the most common cause of urinary incontinence in women of this age?
SUI is the involuntary loss of urine when intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. It is often brought on by laughing, coughing, or sneezing. This incidence is highest in women between the ages of 45 and 50. SUI may be caused by urethral hypermobility or intrinsic sphincter deficiency (ISD). The other major cause of incontinence is urge incontinence. With urge incontinence, the bladder leaks urine due to involuntary, uninhibited detrusor contractions. The incidence of urge incontinence increases with age. Other causes of urinary incontinence are less common and include overflow incontinence secondary to urinary retention, congenital abnormalities, infections, fistulas, and urethral diverticula. Urethral diverticula classically present with dribbling incontinence after voiding. Functional incontinence occurs when a patient cannot reach the toilet in time due to physical, cognitive, or psychological limitations.
In the elderly population there are also many transient causes of incontinence that the physician should consider. These include dementia, medications (especially α-adrenergic blockers), decreased patient mobility, endocrine abnormalities (hypercalcemia, hypothyroidism), stool impaction, and UTIs.
If this woman were 78-year-old, what would be the most likely cause of urinary incontinence?
A healthy 59-year-old woman with no history of urinary incontinence undergoes vaginal hysterectomy with anterior and posterior (A&P) repair for uterine prolapse, a large cystocele, and a rectocele. Two weeks postoperatively, she presents to your office with a new complaint of intermittent leakage of urine.
What is the most likely cause of this complaint following her surgery?
Many patients who have uterine prolapse or a large protuberant cystocele will be continent because of urethral obstruction caused by the cystocele or prolapse. In fact, at times these patients may need to reduce the prolapse in order to void. Following surgical repair, if the urethrovesical junction is not properly elevated, SUI may result. This incontinence may present within the first few days to weeks following surgery. Typically, patients undergoing hysterectomy for prolapse will be evaluated with urodynamic or other studies to help determine if they are likely to leak once normal anatomy is restored following surgery. If they are shown to leak when the cystocele is reduced, the physician may recommend a concomitant procedure to support the mid urethra, such as a mid-urethral sling, to avoid the development of SUI postoperatively. Rectovaginal fistula would present with passage of stool from vagina. Vesicovaginal fistula would present with continuous leakage of urine from the vagina. Detrusor instability would have been present prior to her surgery.
A 53-year-old postmenopausal woman, G3P3, presents for evaluation of new onset urinary leakage for the past 6 weeks.
Which of the following is the most appropriate first step in this patient’s evaluation?
When patients present with urinary incontinence, a urinalysis and culture tests should be performed to evaluate for acute cystitis. In patients diagnosed with a UTI, treatment should be initiated, and then the patient should be reevaluated. It is not uncommon for symptoms of urinary leakage to resolve after appropriate therapy. After obtaining the history and physical examination and evaluating a urinalysis and urine culture, only a few clinical tests are necessary in the initial evaluation of the incontinent patient. Most women with incontinence can begin conservative treatment based on history and examination alone. However, further conservative evaluation may include a PVR urine volume, cough stress test, and urinary diary. A PVR is determined by bladder catheterization after the patient has voided; when a large amount of urine remains after voiding, infection and incontinence may result. A cough stress test is performed by filling the bladder with fluid, asking the patient to cough or Valsalva, and directly visualizing the urethra to see if there is leakage.
A 38-year-old woman G4P4 is undergoing evaluation for fecal incontinence. She has no known medical problems.
Which of the following is the most likely cause of this patient’s condition?
The most common cause of fecal incontinence is obstetric trauma that causes direct damage to the anal sphincter or to the pudendal nerve. The rectal sphincter can be completely lacerated, but as long as the patient retains a functional puborectalis sling, a high degree of continence will be maintained. Anal sphincter weakness may also be caused by other nontraumatic etiologies, such as spinal cord injury. Other causes of fecal incontinence include conditions that decrease rectal sensation, such as dementia, central nervous system (CNS) disease, diabetes, or multiple sclerosis. Therapy for fecal incontinence includes bulk-forming and antispasmodic agents, especially in those patients presenting with diarrhea. All caffeinated beverages should be stopped. Biofeedback and electrical stimulation of the rectal sphincter are other possible conservative treatments. Surgical repair of a defect is indicated when conservative measures fail, when the defect is large, or when symptoms warrant a more aggressive treatment approach.
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