Pressure is not always SUI (see later in this section).

SUI patients have normal bladder capacities

and normal postvoid residuals (PVR).
 Hypermobile urethra incontinence (aka HUI, HMI, HMU) : The urethra sits on top of and is
invested within the fibromuscular layer of the anterior vaginal wall (aka pubocervical fascia
or endopelvic fascia), which also forms a hammock underneath the urethra. Additionally, the
urethra is supported at its mid portion by the pubourethral ligament. Normally, the urethra is
compressed against this backboard during stress (e.g., cough) and becomes occluded. If the
hammock is deficient, the urethra becomes hypermobile and is not compressed. This results in
urine leakage during stress. HUI is demonstrated by the Q-tip test (hypermobility), perineal
ultrasonography or fluoroscopy (closed urethrovesical junction (UVJ) at rest).
 Intrinsic sphincteric deficiency (aka ISD, type III urethra, low-pressure urethra, “lead-pipe”
urethra) : Although the urethral support hammock is intact (i.e., no urethral hypermobility), the
urethra itself fails to function as a competent sphincter (i.e., open at rest) because of lack of
one or more of the following essential urethral components : smooth muscle (tonic contraction
at rest), striated muscle (voluntary contraction), autonomic and somatic innervation,
connective tissue elasticity, mucosal coaptation, and submucosal venous plexus. ISD is
suggested by leakage in the supine position and a positive empty bladder stress test (EBST+).
It is best demonstrated by valsava leak point pressure (VLPP <60 cm H2O) and maximum
urethral closure pressude (MUCP <20 cm H20) testing (i.e., complex cystometry with urethral
pressure profile). ISD may result from congenital weakness as a consequence of defects in
muscle, tissue structure, or innervation (e.g., smooth or striated muscle disorder, epispadias or
myelomeningocele) or can result from any of the following :
o Previous anti-incontinence surgery
o Radical pelvic surgery
o Trauma
o Radiation (pelvic x-ray, x-ray therapy [XRT], and the like)
o Spinal cord lesion (sacral spinal cord [sc])
o Childbirth
o Chronic catheter drainage
o Aging
o Hypoestrogenism

 Urinary urgency incontinence (UUI) or OAB-wet—the complaint of involuntary leakage

accompanied by or immediately preceded by urgency. These patients typically have large
volume leaks with complete bladder emptying that is difficult to stop or occasionally have
frequent small losses between voids. Occasionally, increases in intra-abdominal pressure may
provoke detrusor contraction(s) which may cause incontinence. Therefore rises in the intra-
abdominal pressure cause a delayed (5-10 s rather than immediately after cough) continous
leakage of urine. These patients have small bladder capacities but normal PVR.
 Overactive bladder-dry (OAB-dry)—urgency + frequency without incontinence.
 Mixed urinary incontinence (MUI)—the complaint of involuntary leakage associated with
urgency and also with exertion, effort, sneezing, or coughing. Although both stress and urge
incontinence exist, one factor often predominates. The severity of incontinence is also greater in
these patients (i.e., episodes and volumes). PVR is normal.
 Continuous urinary incontinence—the complaint of continuous leakage.
 Bypass urinary incontinence—uncommon cause of incontinence; continuous urine loss due to an
anatomic problem which disrupts the integrity of the urinary tract. Examples include fistulas
(vesicovaginal, vesicouterine, urethrovaginal, ureterovaginal), urethral diverticula (postvoid
dribbling symptoms), ectopic ureter (which empties distal to internal urethral sphincter
mechanism), and epispadias (an opening by the separation of the labia minora and a fissure of
the clitoris).
 Functional urinary incontinence—urine loss due to inability to reach the bathroom in time,
inability to remove clothing (either because many layers or lack of manual dexterity), mentally
recognice the need to go to the bathroom, or inability to access bathroom.
 Transient incontinence—when UI is a presenting symptom of another medical condition (e.g.,
diabetes mellitus [DM], congestive heart failure [CHF], Interstitial Cystitis (IC) and may remit
when the medical condition is treated. Other conditions, most of which are reversible, are
summarized by the acronym DIAPPERS. The following can make the elderly susceptible to UI :
 Delirium—differentiate from dementia
 Infection—elderly may be asymptomatic; bacterial endotoxins inhibit alpha-adrenergic
receptors
 Atrophy—effect of estrogen on incontinence is unclear
 Pharmaceutical—do not forget over the counter medications in addition to prescription
medications
 Psychiatric—factitious disorder, hypochondria, to gain attention
 Excess urine output and endocrine—e.g., CHF/edema and DM or hypercalcemia, respectively
 Restricted mobility—arthritis, gait difficulty
 Stool impaction—fecal impaction cause UI

 Overflow urinary incontinence—urine loss due to bladder hypersensation or loss of detrusor

contraction which result in overdistension of the bladder, urinary retention, incontinence, and
other urinary symptoms (dribbling, SUI). These patients have high bladder capacity, high PVR,
and prone to recurrent urinary tract infections (UTIs). They may be treated by clean, intermittent
self-catheterization, aplha-adrenergic blockers, bethanecol, or even surgical therapy. There are
numerous causes of overflow incontinence :
 Medications (anticholinergic, calcium channel blocker, alpha-adrenergic agonists, beta-
adrenergic agonists)
 Neuropathy (vitamin B12 deficiency, tabes dorsalis, herniated disk, peripheral neuropathy)
 Endocrine (hypothyroid, DM)
 Decreased compliance states (radiation, interstitial cystitis, recurrent UTIs)
 Outflow obstruction (pelvic organ prolapse [POP], pelvic neoplasm [large fibroid, large
adnexal mass], previous incontinence surgery, involuntary contraction of pelvic floor muscle
[from pain, infection, and the like])

 Supine incontinence—leakage of urine while lying on the back.

 Supine empty bladder stress test (EBST +)—observation of urine leakage from the urethra during
positional changes or spontaneous increases in intraabdominal pressure during pelvic
examination in lithotomy position. This suggests ISD.
 Nocturia—the complaint that the individual has to wake at night ≥2 time(s) to void. Beside
OAB, nocturia may be due to shifting of interstitial fluids, diuretic or other medication taken
before bedtime, and reduction of antidiuretic hormone (ADH).
 Nocturnal enuresis—bed-wetting or complaint of loss of urine occuring during sleep. This must
be differentiated from SUI caused by coughing or turning in bed while asleep.
 Polyuria—urine output ≥2800 mL in a day for adults.
 Urgency—the complaint of a sudden compelling desire to pass urine, which is difficult to defer.
Two good examples : (1) strong urge or need to void but may not reach the bathroom on time,
(2) strong need to void when nervous, in hurry, or under stress.
 Frequency—voiding more than 7-8 times per day or voiding more often than every 2 hours.
 Hesitancy—when an individual describes difficulty in initiating micturition resulting in delay in
the onset of voiding after the individual is ready to pass urine. This may occur with urethral
obstruction from advanced POP.
 Dysuria—the feeling of pain or discomfort when passing urine. Besides UTI, suprapubic pain
and chronic pelvic pain with urgency may be due to interstitial cystitis.
 Urodynamic stress incontinence (USUI)—involuntary leakage, observed during bladder filling
cystometry and occurring with increased intra-abdominal pressure in absence of detrusor
contraction. The term “genuine” stress incontinence or GSUI is no longer used.
 Urodynamic detrusor overactivity incontinence (UDOI)—a urodynamic observation
characterized by incontinence due to involuntary detrusor contractions during the filling phase
which may be spontaneous or provoked. The following terms are no longer used, uninhibited
bladder, motor urge incontinence, reflex incontinence, detrusor instability, and detrusor
hyperreflexia.
 Nonneurogenic detrusor overactivity—formerly detrusor instability
 Neurogenic detrusor overactivity—formerly detrusor hyperreflexia
 Overactive bladder(OAB)—term coined by industry for purpose of coding and medication
prescription; it includes any or all of the following: urgency, frequency, nocturia, and urge
incontinence. The more types of OAB symptoms a patient has, the greater the chance that she
has detrusor overactivity on complex cystometry.

HISTORY TAKING
 As with any medical problem, evaluation of UI should begin with a thorough history followed by
a directed physical examination.
 History for evaluation of incontinence serves three main purposes : (1) to find and treat
reversible causes of incontinence, (2) to determine its effect on quality of life, (3) to determine its
severity (i.e., conservative management is chosen for mild symptoms while surgical options may
be explored for severe symptoms).
 Any previous evaluation and/or treatment is important.
 Patient history alone is only 50-70% specific and sensitive in the diagnosis of UI and is poor at
differentiating one type of incontinence from another.
 All patients should be screened for PFD, including UI, especially in the postpartum period.
 It is very important to use language the patient will understand.
 For example, some patients may confuse stress incontinence with emotional stress leading to
incontinence rather than increased intra-abdominal pressure as its cause.
 A large number of women will develop new onset UI, therefore, is important to rescreen all
returning patients.
 Screening questionnaires, like the pelvic floor distress inventory (PFDI), urogenital distress
inventory (UDI), incontinence impact questionnaire (HQ), pelvic floor impact questionnaire
(PFIQ), or pelvic organ prolapse/urinary incontinence sexual function questionnaire (PIS-Q),
 medical, epidemological, and social aspects of aging questionnaire (MESA) questionnaire
may be used to help screen patients for pelvic floor dysfunction and incontinence.
 In patients with symptoms of UI, the following information must be obtained :
 What is the patient’s main complaint?
 What is the duration of the symptoms?
o Abrupt onset -> e.g., allergic or infectious
o Gradual onset -> e.g., if after oophorectomy may be related to estrogen deficiency
 When and how often does it occur?
 Does she wear a pad?
 Does she leak during sexual intercourse?
 What is its effect on the patient’s quality of life (QoL)?
o For example, a patient may leak urine only once a week during exercise and yet be willing
to do almost anything to get this resolved as it has a great impact on her QoL (i.e., decrease
in physical and social functioning, vitality, and an increase in psychological
consequences).
o On the other hand, a woman may soak eight pads per day but is not bothered by it.
o The goal of the IIQ and PFIQ is assessment of life impact of UI and POP.
 Does the patient desire treatment for the condition?
If so, does she have a strong preference for one management over another (conservative vs
surgical)
 Focus on any condition that may be contributing to and/or causing the patient’s UI (e.g.,
constipation).
 Social history: smoking (associated with both stress and urge incontinence), occupational stress
(heavy lifting), recreational or athletic stress (chronic, repetitive straining).
 Family history: prevalence of UI is higher in family members of incontinent women.
 Medical history: DM (e.g., poorly controlled causes polyuria and nocturia), diabetes insipidus,
thyroid disease, lung disease (chronic cough, chronic obstuctive pulmonary disease [COPS],
asthma), chronic constipation, restricted mobility (e.g., severe arthritis, quadriplegia), CHF
(edema mobilization of third-space fluid at night), UTI, radiation (which may have rendered
urethra rigid and fibrotic).
 Neurologic history: Does she have a history of any of the following? Multiple sclerosis (e.g.,
may cause urinary retention and overflow incontinence), history of cerebrovascular accident
(CVA), tumor, dementia, Parkinson’s lumbar disc disease, neuropathy, upper motor neuron
lesion.
 Urologic history: urgency, frequency, dysuria, UTI, hematuria, voiding dysfunction (i.e., urinary
retention, hesitancy, slow urinary stream, straining to void, interrupted urinary stream, feeling of
bladder still being full).
 Urinary diary(aka urolog, 24 hours, 3 days, or 7 days) is an inexpensive and helpful adjunct
because histories may be unreliable or misleading.
 Information such as fluid intake (type, amount, and time; e.g., weight reduction programs
require large fluid intake; also belief that drinking water to “flush the system”), vouds day
versus night, leakage and associated or precipitating factors, sense of urgency, maximum
voided amount, and pad usage. Texas hat may be placed in commode to help with urine
measurement.
 24-hour diary is good for evaluation of frequency and nocturia.
 3-day diaries are most commonly used and have a high degree of correlation to a 7-day diary.
  Diaries require tremendous patient motivation.
 Patients with detrusor overactivity incontinence may have more difficulty keeping track of
voids and leakage episodes.
 Urinary diaries have an observed therapeutic effect that is greater that placebo during
pharmaceutical drug trials. The act of keeping track of the above may have behavioral
modification benefits.
 A few examples are as follows:
o 75-150 mL (small) frequent voids with urge sensation -> rule out OAB
o 350-550 mL (large) infrequent voids and stress symptoms -> rule out SUI
o Patient takes > 4L of fluid per day -> rule out diabetes insipidus.
o Voiding small volumes almost every hour during day only -> rule out psychologic
condition.
 Obstetric history: gravida and para, number and type of deliveries (cesarean, spontaneous
vaginal, forceps), lacerations (third of fourth degree), episiotomies, and desire or lack of desire
for future childbearing is important, as many experts will not perform surgery on those who have
not completed childbearing.
 Gynecologic history: prolapse, menopause/hormone therapy, pain, neoplasm (fibroids or large
ovarian masses may push on the bladder, reduce bladder capacity, and may cause urgency and
frequency symptoms).
 Surgical history: especially gynecologic (hysterectomy or prolapse surgery), previous anti-
incontinence surgeries, or radical surgery.
 Important to obtain records and operative reports if available.
 Prior surgeries may have resulted in trauma to the lower urinary tract which may have caused
uninhibited urethral relaxation.
 Notice surgical scars.