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Case 3

Female Urinary Incontinence
A 46-year-old woman, gravida 4, para 4, presents to her physician’s office with complaints of
urinary incontinence.

QUESTION
What are the causes of urinary incontinence in women?
DISCUSSION
There are three general categories of female urinary incontinence. Genuine stress urinary incontinence
(GSUI) is the most common and is generally caused by an anatomic defect of the posterior urethrovesical
angle. GSUI usually is a result of pelvic floor muscle damage from childbearing.
Urge incontinence associated with detrusor instability (DI) is another common cause of female
urinary incontinence. DI is defined by the onset of spontaneous detrusor contractions with bladder filling;
it may also be caused by neurologic disease.
Mixed incontinence includes both stress and urge components in the cause of urine loss.

QUESTION
What questions might the physician ask this patient to further evaluate her urinary
incontinence?
DISCUSSION
In evaluating a patient with urinary incontinence, it is essential to obtain a voiding diary. In the diary the
patient should document the times and amounts that she voids, the times that she is incontinent, and the
precipitating events.

The patient should also complete a thorough urologic questionnaire, which should inquire about
how often she voids during the day and night, the amounts of urine voided or leaked, the presence of an
urgency to void, whether she has a history of urinary infections or stones, and when her incontinence
began. It should also include questions regarding what medications she takes and what precipitates her
urine loss.

The patient tells the physician that she typically loses urine with coughing or sneezing and that she
sometimes doesn’t make it to the bathroom in time. She noticed that these symptoms began after
the birth of her second child, improved for a time, and have since worsened. She has to wear a
diaper, which becomes soaked from leaking urine. Her diary shows that she drinks a cup of coffee
and a glass of orange juice in the morning and a glass of iced tea at lunch. She doesn’t drink any
liquids after dinner for fear that she may have to get up during the night. She usually gets up to
void once during the night. Her voiding diary demonstrates more episodes of leakage in the
mornings than at any other time of day. She presently takes hydrochlorothiazide and verapamil for
her hypertension.

QUESTIONS
What kind of incontinence might this patient have?
What part of her history could be exacerbating her incontinence?
What might be done to improve her symptoms?
DISCUSSION
Because she first reported symptoms after childbirth, and because her urine loss typically occurs with an
increase in abdominal pressure (i.e., with coughing or sneezing), the patient most likely has stress
incontinence. However, a patient’s history does not always correlate with the type of urinary

incontinence. This diagnosis should be confirmed with the demonstration of urine loss with the Valsalva
maneuver, accompanied by a descent of the posterior urethrovesical angle. Detrusor instability should
also be excluded cystometrically.
Coffee and tea can irritate the bladder mucosa and can exacerbate incontinence. The patient
should be advised to avoid caffeine and tea intake. Her use of hydrochlorothiazide, a diuretic, and
verapamil, a calcium channel blocker, also may be exacerbating her incontinence; she might be switched
to an alternative medication with fewer effects on the bladder. The patient should also be instructed on
how to perform Kegel exercises, which strengthen the pubococcygeus muscles and can improve
incontinence symptoms in up to 75% of individuals.

QUESTION
What elements of the physical examination are important to obtain?
DISCUSSION
The physical examination is necessary to exclude a neoplasia, diverticulum or fistula, and pelvic mass.
The examination should assess the patient’s hormonal status; check for the presence of a cystocele,
rectocele, and uterine prolapse; and evaluate for pelvic floor muscle tone. A neurologic examination of
the perineum and lower extremities should also be performed to exclude neuromuscular disorders such as
multiple sclerosis.

The patient’s physical examination demonstrates a moderate uterine prolapse and a moderate
cystocele and rectocele. The result of her neurologic examination is normal.

QUESTION
What other evaluation can be performed to confirm the diagnosis?

DISCUSSION
Once a presumptive diagnosis of stress incontinence has been established, office cystometrics can be
performed to confirm the diagnosis and to exclude detrusor instability or mixed incontinence as the cause
of urine loss. The office evaluation should include a postvoid residual test, which should be less than 100
mL; this catheterized sample should be sent for culture and sensitivities to exclude urinary tract infection.
Simple cystometrics can be performed by filling the bladder through a catheter, noting the patient’s first
sensation to void and when she senses a maximally full bladder. If the patient develops spontaneous
bladder contractions with bladder filling, this is indicative of detrusor instability, not stress incontinence. If
leakage of urine can be demonstrated with a full bladder with straining, this is indicative of stress
incontinence. In the presence of both, further studies must be performed to evaluate for mixed
incontinence or other causes.