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Diagnosis of Urinary Incontinence

CHRISTINE KHANDELWAL, DO, and CHRISTINE KISTLER, MD, MASc
University of North Carolina, Chapel Hill, North Carolina

Urinary incontinence is common, increases in prevalence with age, and affects quality of life for men and women.
The initial evaluation occurs in the family physician’s office and generally does not require urologic or gynecologic
evaluation. The basic workup is aimed at identifying possible reversible causes. If no reversible cause is identified, then
the incontinence is considered chronic. The next step is to determine the type of incontinence (urge, stress, overflow,
mixed, or functional) and the urgency with which it should be treated. These determinations are made using a patient
questionnaire, such as the 3 Incontinence Questions, an assessment of other medical problems that may contribute to
incontinence, a discussion of the effect of symptoms on the patient’s quality of life, a review of the patient’s completed
voiding diary, a physical examination, and, if stress incontinence is suspected, a cough stress test. Other components
of the evaluation include laboratory tests and measurement of postvoid residual urine volume. If the type of urinary
incontinence is still not clear, or if red flags such as hematuria, obstructive symptoms, or recurrent urinary tract infections are present, referral to a urologist or urogynecologist should be considered. (Am Fam Physician. 2013;87(8):543550. Copyright © 2013 American Academy of Family Physicians.)
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rinary incontinence affects millions of persons, and the prevalence increases with age. Roughly
20 million American women and
6 million American men experience urinary
incontinence at some time in their lives.1
Although women report incontinence
more often than men,2,3 after 80 years of
age, both sexes are affected equally.3 Women
commonly experience stress or urge incontinence (i.e., overactive bladder), or a combination of the two, with approximately
equal frequency.4 In men, prostate problems,
which lead to overflow incontinence, and
their treatments, which lead to stress incontinence, are the most common causes.5
Despite what many patients believe, urinary incontinence is not a normal result of
aging. It is a pathologic condition that affects
quality of life. Patients who have incontinence
are more likely to have depression, limited
social and sexual function, and dependence
on caregivers.3,6,7 Guidelines for diagnosis
and treatment of urinary incontinence were
published in 2012 by the American Urological
Association.8 This article reviews the diagnosis; a separate article in an upcoming issue of
AFP reviews management options in women.
Classification
Incontinence can be classified as transient or chronic.5,9 Transient incontinence

is urinary leaking that spontaneously
reverses after the underlying cause is
resolved.10 Chronic urinary incontinence
does not typically resolve spontaneously,
and is classified into five types: stress, urge,
mixed, overflow, or functional.2,11 Characteristics of each type are shown in Table 1.9,12-14
Stress incontinence is caused by sphincter
weakness, which leads to ineffective function. It is the most common cause of urinary
incontinence in younger women and the second most common cause in older women.15
It also occurs in men after prostate surgery.
Urge incontinence is a result of detrusor
overactivity, and can be further divided into
two subtypes: sensory (a result of local irritation, inflammation, or infection within the
bladder) or neurologic (most often caused by
loss of cerebral inhibition of detrusor contractions).12 Aging increases the prevalence
of urge and stress incontinence, and the two
often coexist, leading to mixed incontinence.
This occurs in about one-third of adults who
have incontinence.9,15
Overflow incontinence is caused by
impaired detrusor contractility, bladder outlet obstruction, or both, resulting in overdistension of the bladder.2,5 Chronic overflow
incontinence is common in men because
of prostatic hyperplasia, but it is uncommon in women.15 Functional incontinence is
caused by cognitive, functional, or mobility

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and how often they experience urine leakage.19 Physicians should take note of patients’ medications. C 27 Systematic review of lowerquality studies A positive cough stress test result is the most reliable clinical assessment for confirming the diagnosis of stress incontinence.2.org/afp Volume 87. especially those started recently. B = inconsistent or limited-quality patient-oriented evidence.17 An algorithm for the diagnosis of urinary incontinence is shown in Figure 1.6. difficulties that impair patients’ ability to use the toilet. a standardized type of chronic urinary incontinence is present.2 The approach is recommended for guiding the initial evalua. C 5. expert opinion.9.11 Transient Urinary Incontinence The first step in the evaluation is to identify transient or reversible causes of urinary incontinence.Urinary Incontinence: Diagnosis SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence rating References Comments The 3 Incontinence Questions tool. correcting the transient causes may resolve the symptoms. if symptoms persist. which asks patients if. Types of Chronic Urinary Incontinence The patient history is often the most important factor in identifying the type. should be used to help categorize the type of urinary incontinence.13 Certain drugs (e. and burden of incontinence for 6 patients.aafp. no highquality evidence is available to support the recommendation Clinical recommendation A = consistent. For information about the SORT evidence rating system. Evaluation Chronic Urinary Incontinence Patients can be evaluated for urinary incontinence in a PATIENT QUESTIONNAIRES family physician’s office.11 544  American Family Physician Urge 9 percent in women 40 to 44 years of age 31 percent in women older than 75 years 42 percent in men older than 75 years Detrusor overactivity (uninhibited bladder contractions) caused by irritation within the bladder or loss of inhibitory neurologic control of bladder contractions Mixed 20 to 30 percent of patients with chronic incontinence Combination of stress and urge incontinence Overflow (urinary retention) 5 percent of patients with chronic incontinence Overdistention of the bladder caused by impaired detrusor contractility or bladder outlet obstruction. Type Prevalence Pathophysiology severity. further evaluation is needed. Table 3 lists the most important medications to consider. but may contribute to incontinence by increasing urine production or impairing nervous system function.10. Table 1. but without a failure of bladder function or neurologic control of urination.16 This type of incontinence is also referred to as toileting difficulty. www.10. Number 8 ◆ April 15. 32 Systematic review of good-quality cohort studies Postvoid residual urine measurement should be performed in select high-risk patients (e.13 However.g. Medication-induced incontinence often can be reversed by stopping the medication. C 2. good-quality patient-oriented evidence. those with overflow incontinence). alcohol) have no pharmacologic action on the lower urinary tract. C 20 Good-quality prospective cohort study with follow-up A three-day voiding diary can be used as part of the initial assessment for urinary incontinence symptoms.g.16 If the incontinence is determined to be related to an acute condition.11. C = consensus.aafp. when. or case series. 15 Consensus opinion. Generally. usual practice. and 12 through 14.18 The mnemonic DIAPPERS is useful for recalling the common reversible causes of urinary incontinence (Table 2). leads to urine leakage by overflow Functional Uncertain Variable leakage of urine.13 Reversible incontinence usually has a sudden onset and has been present for less than six weeks at the time of evaluation. diuretics. go to http://www. more than one office Stress 24 to 45 percent in Sphincter weakness (urethral sphincter women older than and/or pelvic floor weakness) visit is required to perform the physical 30 years examination and necessary tests... disease-oriented evidence. Although most incontinence Several questionnaires are available to determine which research excludes men and children. usually caused by environmental or physical barriers to toileting Information from references 9. 2013 .xml.3 Incontinence Questions is a reliable questionnaire tion.org/afpsort.

loss of urine with exertion. which is known as overactive bladder Loss of neurologic control caused by stroke. Parkinson disease Involuntary leakage associated with symptoms of urgency.15 For example. Treating these conditions may not eliminate incontinence. leading to incontinence.g.15 ASSESSMENT OF QUALITY OF LIFE The severity of symptoms and their effect on quality of life determines the aggressiveness of treatment. sleep. from supine to upright) or with sensory stimulation (e. may occur after prostatectomy in men Loss of urine preceded by a sudden and severe desire to pass urine. and how often patients experience urine leakage. or lead to denervation of the detrusor muscle with resultant retention and overflow incontinence). Number 8 Possible lower urinary tract deficits www. benign prostatic hyperplasia. lifting. 2013 ◆ Volume 87.15 Gynecologic history can assess estrogen status. respectively.. patient typically loses urine on the way to the toilet Volume of urine loss is variable. This questionnaire has been validated in studies that show it to be reasonably accurate in categorizing urinary incontinence in middle-aged to older women.6. social interactions. sneezing. sexual activity. exercise).e. diabetes mellitus.. effort. hand washing. back. whereas another patient may be most concerned about incontinence that occurs during exercise (typically caused by stress incontinence). a history of bowel. inability to empty bladder.Urinary Incontinence: Diagnosis available free of charge (Figure 2).86 and 0.75.60 and 0. cardiovascular disease (volume status or diuretic therapy can increase urine flow and cause incontinence in patients with an overactive bladder). multiple sclerosis. or bladder surgery could affect the anatomy and innervation of the lower urinary tract. estrogen deficiency may result in atrophic vaginitis or atrophic urethritis. sneezing jumping. such as chronic obstructive pulmonary disease (chronic cough can result in stress incontinence).g. mental health disorder (e. cold weather. and general perception of health and quality of life. pelvic organ prolapse. and musculoskeletal conditions (impaired mobility can cause functional incontinence).6.aafp. such as walking or rising from a chair Patient usually can predict which activities will cause leakage Childbirth and obesity in women.77. and a specificity of 0.20 It asks three multiple choice questions about if. spinal cord injury. with their temporal relationship to urinary incontinence. ranging from minimal to flooding (if entire bladder volume is emptied) Bladder contractions may also be stimulated by a change in body position (i. neurologic conditions (central nervous system dysfunction can impair inhibition of detrusor contractions. urine loss without a recognizable urge or sensation of fullness/pressure in lower abdomen Does not usually occur unless bladder emptying is poor (postvoid residual volumes > 200 to 300 mL) Anticholinergic medications.9. a potentially reversible cause of urinary incontinence.20 It has a sensitivity of 0. prostatitis. running water.15 Identifying the most bothersome symptom will help direct management. for classifying stress and urge incontinence. such as cognitive or physical impairments that result in the patient’s inability to void independently Impaired physical function (immobility) and/or impaired cognition Severe dementia. urinary hesitancy. For example. spinal cord injuries Caused by nongenitourinary factors. when. bladder diverticuli. physical frailty or inability to ambulate.20 ASSESSMENT OF MEDICAL PROBLEMS The patient history should include an assessment of other medical conditions and symptoms. one patient may be most concerned about managing nocturia (often caused by urge incontinence). atrophic vaginitis. gynecologic..6 Physicians should also inquire about other comorbidities. interpersonal relationships. arriving at the front door) Frequency and nocturia are common Bladder irritation caused by cystitis. but it may lessen the severity.2.org/afp American Family Physician 545 . Symptoms History Etiology Loss of small amount of urine during physical activity or intra-abdominal pressure (coughing. activities of daily living. prior pelvic radiation therapy Symptoms of urgency may also occur without urinary loss. depression) April 15. or coughing Patient should determine which symptom is predominant and most bothersome Combination of the etiologies for stress and urge incontinence Dribbling of urine.15 Patients should be asked about the effects of incontinence on work.6. dementia. can occur with minimal activity.

physical examination. and laboratory evaluation (may require return visit or referral if diagnosis is inconclusive or red flags are found) Stress (only or predominantly) Symptoms with coughing..g. functional incontinence) or reversible (e.21. For example. Algorithm for the diagnosis of urinary incontinence. no nocturia Voiding diary: small volume leakage (5 to 10 mL) with activity Cough stress test: leakage coincides with coughing Urge (only or predominantly) Symptoms of urgency Voiding diary: variable volume loss. 1985. N Engl J Med. Yalla SV. (PVR = postvoid residual. drug-induced) urinary retention Stool impaction Adapted with permission from Resnick NM.. suggestive of stress incontinence. Differential Diagnosis of Transient Causes of Urinary Incontinence (DIAPPERS Mnemonic) Delirium Infection (acute urinary tract infection) Atrophic vaginitis Pharmaceuticals (Table 3) Psychological disorder.313(13):801. the diary may reveal leakage during times of increased abdominal pressure.e.g. include cough stress test if stress incontinence is suspected Measure PVR urine Yes No further intervention Obtain laboratory evaluation Presumed type of incontinence after history. sneezing. hyperglycemia) Reduced mobility (i.24 Table 2. patients with urge incontinence usually wake more than twice and as often as every hour. or exercise. Management of urinary incontinence in the elderly. The simplest voiding diaries ask patients to record the frequency of incontinence episodes. thereby assessing the effectiveness of management. a voiding diary can be helpful (eFigure A). which can help clarify the type of incontinence. but diaries also can be used to assess the situations in which incontinence occurs. especially depression Excessive urine output (e.) Functional Symptoms may include cognitive impairment and degree of immobility Voiding diary: may show pattern in circumstances of incontinence Cough stress test: no leakage PVR urine: varies .Urinary Incontinence: Diagnosis VOIDING DIARY Because many patients provide an unclear voiding history. or dribbling that is indicative of overflow incontinence.22 A voiding diary can also serve as a baseline for comparing the severity of incontinence after treatment. Diagnosis of Urinary Incontinence Patient presents with urinary incontinence Assess for transient incontinence: Treat reversible causes Apply DIAPPERS mnemonic (Table 2) Review medications (Table 3) Assess for chronic incontinence: Obtain history and give 3 Incontinence Questions questionnaire (Table 1 and Figure 2) No Review voiding diary (eFigure A) Incontinence resolved? Perform physical examination (Table 4).21 Patients with stress incontinence usually wake once or not at all at night to void. frequency and nocturia noted Cough stress test: may show delayed leakage after cough PVR urine < 50 mL Mixed Symptoms equally as often with physical activity as with a sense of urgency Voiding diary: varies Cough stress test: may show leakage with coughing PVR urine < 50 mL Overflow No symptoms with physical activity or urgency Voiding diary: varies Cough stress test: no leakage PVR urine > 200 mL PVR urine < 50 mL Figure 1.23..

which can exert pressure sible than longer diaries in routine clinical settings. and can cause or exaggerate sensory urge incontinence. primarily older adults. retention.the diagnosis.35 April 15. urgency.3.aafp.g. which Opioids Relax the bladder. causing functional or overflow incontinence edema that might indicate volume overload. causing fecal impaction. causing sedation.11.24 A frequency-volume voiding diary functional assessment should be included to evaluate for requires recording the amount of fluid intake. but it often accompanies atroA three-day diary is as informative as a longer-term phic vaginitis. retention. diabetes mellitus).6. an external gynecoAntihistamines.14. Inhibit bladder contractions. should be palpated for masses and tenderness.If stress incontinence is suspected.2. sedation. the volume functional incontinence.to assess for fecal impaction. Common Medications and Substances That Can Cause Urinary Incontinence Class Mechanism of effect Antihypertensives Alpha-adrenergic antagonists Decrease sphincter tone.31 A rectal examination is important assessment. COUGH STRESS TEST and an estimation of the volume of each incontinent epi. a cognitive and can also be used..31 Information from references 6 and 13. causing stress incontinence Calcium channel blockers Relax the bladder.29. impair bladder emptying.10. causing stress incontinence Angiotensin-converting enzyme inhibitors May increase coughing. which are typically inconclusive. causing sedation. Number 8 www.25-27 on the urethra. a prostate examination should be Alcohol Leads to diuretic effect and depressed central included to identify prostate enlargement. select patients.32-34 although it requires further voiding diary can reveal whether the patient is experi.g. causing urge incontinence.16 In particular. The abdomen Skeletal muscle relaxants Inhibit bladder contractions.6. causing urge incontinence associated with incontinence are listed in Pain relievers Table 4. or rectocele) may not lead to incontinence. whereas stress ticated multichannel urodynamic studies.32 When compared with more sophiscally involves a large volume of urine loss. and overflow incontinence vaginitis or other vulvar signs of irritation Medications for urinary Inhibit bladder contractions.Urinary Incontinence: Diagnosis Table 3. excess fluid intake. the cough incontinence is often a smaller volume and is associated stress test demonstrates good sensitivity and specificity with increased abdominal pressure. and overflow incontinence aggravates urge incontinence. Findings contractions. or both.6. and may be more fea. overflow which may contribute to an outlet obstrucincontinence. 2013 ◆ Volume 87. causing sedation. inhibition.. rales. and overflow incontinence and the bladder percussed for distention that Psychotherapeutics would indicate overflow.17 The extremities Antidepressants. the cough stress test sode. such as a frequency.14.28. urethral polyps.confirmatory urodynamic evaluation if the results are encing frequent large volume voids.16 of urine voided (in mL) of each continent episode (using a measuring cup or plastic hat placed below the toilet seat). and peripheral Sedatives and hypnotics Lead to sedation and impaired cognition.14. and overflow incontinence caused by incontinence. has good reliability.15 In women.28 This approach can reliably discriminate between is the most reliable clinical assessment for confirming urge and stress incontinence.17.31 Estrogen defiThiazolidinediones Increase fluid retention. causing nocturnal ciency may predispose women to urinary diuresis and functional incontinence frequency. and overflow incontinence function (impairment of which might indiantipsychotics cate functional incontinence). Pelvic organ prolapse (with cystocele.30 A frequency. Inhibit bladder contractions.11 In volume voiding diary for assessing bladder activity. Urge incontinence typi. causing retention and overflow incontinence associated with conditions causing polyuria (e.org/afp American Family Physician 547 . urgency retention.tate overflow incontinence caused by retention. and precipiMore sophisticated diaries. Others In men. pedal edema) that anti-inflammatory drugs might result in increased urine flow. logic examination can assess for atrophic anticholinergics retention.11. the cardiovascular Cyclooxygenase-2 Increase fluid retention.10. causing nocturnal examination should look for evidence of volselective nonsteroidal diuresis and functional incontinence ume overload (e.11. or both tion.for stress incontinence. causing retention should be examined for joint mobility and antiparkinsonian agents. PHYSICAL EXAMINATION The physical examination can identify anatomic abnormalities or transient causes that may not have been considered after applyDiuretics High urine flow that leads to bladder ing the DIAPPERS mnemonic.

The 3 Incontinence Questions 1. The patient stands while wear. have you leaked urine (even a small amount)? ❏ Yes ❏ No (questionnaire completed) LABORATORY TESTS 2. and not a Referral for Further Evaluation weakness of the sphincter. The alternative is in-and-out urein the standing position. When you were performing some physical activity. During the past three months.35 The bladder. If not already performed to exclude acute urinary tract infection as a cause of reversible incontinence. lifting. the test should be repeated method if available.11 If PVR urine cannot be minates with its cessation. Without physical activity and without a sense of urgency? ❏ D. and glycosuria.13.. or if severe prolapse masks flow as a main contributing factor of incontinence.35 nence is strongly suspected. This indicates possible urge If the cause of urinary incontinence is unclear after the incontinence. Overflow is more common activity and sense of urgency in older persons. may have overflow incontinence.urethral trauma. urine always be measured in patients who 2006. et al. or exercising? ❏ B. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence.13 assessment.org/afp Volume 87. the patient should be in the lithotomy To measure PVR urine. a urinalysis should be obtained to rule out hematuria. (and the measurement should be repeated on another if the pelvic floor muscles contract to override urethral occasion). the patient empties the position.10. referral to a urologist or urogynecologist is Definitions of type of urinary incontinence are based on responses to question 3: 548  American Family Physician www. any of which require a diagnostic workup.nificant prostate enlargement.thral catheterization. Without physical activity and without a sense of urgency? 3.12 to 15 seconds. Subak LL. About equally as often with physical activity as with a sense of urgency? Laboratory tests should include a serum creatinine level. and rules out most cases of stress inconA PVR urine measurement less than 50 mL is negative tinence. the test is positive for stress measured in the office setting and if overflow incontiincontinence.6 POSTVOID RESIDUAL URINE A measurement of postvoid residual (PVR) urine is recommended to diagnose overflow Response to question 3 Type of incontinence incontinence. proteinuria. When you were performing some physical activity. or exercising? ❏B . Ann Intern Med. but you could not get to the toilet fast enough? ❏C . further urodynamic evaluA negative test shows no leak or a delayed leak by five ation is warranted. Most often with physical activity Stress only or stress predominant patients with incontinence.36 False-negative results may occur if a patient’s for overflow. A  bout equally with physical Mixed renal function. did you leak urine most often: (check only one) ❏ A . 2013 . 100 to 200 mL is considered indeterminate bladder is empty. Number 8 ◆ April 15. which is the preferred and no leakage is observed. and some experts recommend measuring PVR urine With a full bladder (although not to the point of when another cause is not obvious.aafp. a delayed leak may suggest a bladder spasm triggered by the cough.13 If the test is initially performed supine a handheld ultrasound unit. Women should separate the labia. which is important in men with sigage. Expert opinion recommends that PVR of Incontinence Study (DAISy) Research Group. When you had the urge or feeling that you needed to empty your bladder.5. but you could not get to the toilet fast enough? ❏ C. and then the amount of urine remaining in patient should relax the pelvic muscles and forcibly the bladder is measured. Diagnostic Aspects sis. it is important B. which may be elevated if there is urinary retention (overflow bladder) caused by bladder outlet obstruction or denervation of the detrusor. such as coughing. If urine leaks with the onset of the cough and ter.144(10):716. When you had the urge or the feeling that you needed to empty your bladder. sneezing. Bradley CS. During the past three months. lifting.15 abrupt urination). if the cough is not forceful enough. Most often with the urge to Urge only or urge predominant to exclude this diagnosis because chronic empty the bladder C. W  ithout physical activity or Other cause only or other cause failure of bladder emptying can lead to sense of urgency predominant hydronephrosis and irreversibly impaired D. such as coughing.36 Furthermore.28 In-and-out catheterization ing a pad or with his or her legs shoulder-width apart requires training to decrease the risk of infection and over a cloth or paper sheet on the floor to see the leak. Questionnaire for the evaluation of urinary incontinence. but it can also occur in young adults as a manifestation of neuFigure 2. During the past three months. and greater than 200 mL is suggestive of oversphincter incompetence. did you leak urine: (check all that apply) ❏A .6 the leakage. sneezing. This can be performed with cough once.35. such as multiple scleroAdapted with permission from Brown JS. rologic disorders.10 Although overflow incontinence is present in only a minority of A.

further evaluation is recommended. Studies show that routine preoperative urodynamic testing in patients who have uncomplicated stress incontinence does not result in better surgical outcomes. damage to detrusor upper motor neurons (cervical stenosis) or areflexia (lumbar stenosis) Overflow Enlarged prostate. Number 8 recommended (Table 518. pelvic mass Chronic outflow obstruction from detrusor overactivity Overflow Following prostatectomy Sphincter and/or nerve damage Stress Vulvar or vaginal atrophy Diminished estrogen effects on periurethral tissues can contribute to inflammation-induced detrusor overactivity Stress. alcoholism Detrusor underactivity Overflow Cardiac Pelvic Information from references 6. 2013 ◆ Volume 87.org/afp American Family Physician 549 . or recurrent urinary tract infections. environmental barriers Urge. University of North Carolina at Chapel Hill. muscle weakness. for his assistance with this article. assistant professor in the Department of Family Medicine. peripheral neuropathy caused by diabetes mellitus. functional. Indications for Urologic Referral Incontinence associated with relapse or recurrent symptomatic urinary tract infections Incontinence with new-onset neurologic symptoms. and 16. functional. April 15. MD. or both Neurologic Cerebral vascular accident.37 The authors thank Anthony Viera. arthritis Postponement of voiding and/or detrusor overactivity Urge. pain. environmental barriers Urge. normal pressure hydrocephalus Detrusor overactivity from central cause. or both Marked prostate enlargement Pelvic organ prolapsed past the introitus Pelvic pain associated with incontinence Persistent hematuria Persistent proteinuria Postvoid residual volume > 200 mL Previous pelvic surgery or radiation Uncertain diagnosis Information from references 18 and 36.aafp. functional. Patients with typical stress or urge incontinence usually do not have any of the red flags of hematuria. dementia Failure to recognize need to void or to use toilet. MPH. urge.Urinary Incontinence: Diagnosis Table 4. failure to recognize need to void or to use toilet. Table 5. obstructive symptoms (straining to void or sensation of incomplete bladder emptying). 11.36 ). or both Impaired mental status (delirium). Physical Examination Findings Associated with Urinary Incontinence Organ system Finding or comorbidity Mechanism of effect Type of incontinence Abdominal Masses Chronic outflow obstruction from detrusor overactivity Overflow Palpable bladder Detrusor overactivity from a neurologic or obstructive cause Overflow Arteriovascular disease Detrusor underactivity or areflexia from ischemic myopathy or neuropathy Urge Volume overload (congestive heart failure) Fluid excretion shift toward increased volume of urine Urge Musculoskeletal Mobility restriction. Data Sources: A literature search for scientific evidence supporting evaluation of urinary incontinence was performed in PubMed Clinical www. or mixed Weak pelvic floor muscles Denervation of pelvic floor and/or striated sphincter trauma Stress Pulmonary Chronic cough from chronic obstructive pulmonary disease or bronchitis Increase in intra-abdominal pressure overcomes sphincter closure mechanisms in the absence of a bladder contraction Stress Rectal Fissures may indicate chronic constipation from fecal impaction Intravesical pressure exceeds maximum urethral pressure. detrusor underactivity Overflow Reduced or absent anal sphincter tone. or both Spinal stenosis Detrusor underactivity.36 Routine referral for urodynamic testing is not recommended. If any of these are present. even if a patient is a candidate for surgical treatment of stress incontinence.

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