UI Basics & Burden - Leaky Business
- ICS Definition: Complaint of any involuntary loss of urine.
- Epidemiology:
- Affects millions; prevalence ↑ with age.
- More common in women (Stress & Urge UI).
- Elderly: ~30% community-dwelling, 50% nursing home residents.
- Impact: Significantly ↓ Quality of Life (QoL) - social, psychological, physical.
⭐ Urinary incontinence is NOT a normal part of ageing, though prevalence increases with age.
UI Types - The Great Divide
📌 Mnemonic: S U M OF UI (Stress, Urge, Mixed, Overflow, Functional)
| Type | Definition/Pathophysiology | Key Symptoms/Triggers | Common Causes |
|---|---|---|---|
| Stress | Urethral hypermobility/ISD | Leak with ↑ abdominal pressure (cough, sneeze) | Childbirth, prostatectomy, obesity |
| Urge (OAB) | Detrusor overactivity | Sudden urge; frequency, nocturia | Idiopathic, neurogenic (stroke, MS), UTI |
| Mixed | Stress + Urge UI features | Symptoms of both stress & urge | Common in older women; combined causes |
| Overflow | Detrusor underactivity or Bladder Outlet Obstruction (BOO) | Dribbling, incomplete emptying, weak stream | BPH, stricture, neurogenic bladder (diabetes), drugs (anticholinergics) |
| Functional | Physical/cognitive impairment | Can't reach toilet despite normal Lower Urinary Tract | Dementia, immobility, environmental barriers |
UI Diagnosis - The Leak Detective
- History: Detailed voiding diary (24-72h: frequency, volume, leakage episodes, triggers, fluid intake), symptom questionnaires (e.g., ICIQ-SF, 3IQ).
- Physical Exam: Direct observation of leakage (cough stress test), Digital Rectal Exam (DRE), focused neurological exam (perineal sensation, anal reflex for S2-S4), pelvic exam (POP-Q for prolapse, atrophy).
- Initial Investigations:
- Urinalysis: Mandatory to exclude UTI, hematuria.
- Post-Void Residual (PVR) volume: Catheterization/ultrasound. Normal <50ml; significant >200ml.
- Urodynamic Studies (UDS) - When to Consider: Failed conservative management, before surgical intervention, diagnostic uncertainty, or suspected neurogenic bladder.
⭐ > A positive cough stress test is highly suggestive of Stress Urinary Incontinence.
UI Management - Plugging the Leaks
-
Conservative (All Types):
- Pelvic Floor Muscle Training (PFMT/Kegel's): 📌 3 sets of 8-12 contractions, held for 8-10s, 3x/day.
- Bladder training (timed voiding).
- Fluid/diet modification (↓caffeine, alcohol).
- Weight loss.
-
Stress UI (SUI):
- 1st Line: PFMT.
- Pharmacological: Duloxetine (SNRI; ↑sphincter tone; SE: nausea).
- Surgical: Mid-Urethral Slings (TVT/TOT), Burch colposuspension, bulking agents.
⭐ Mid-urethral slings (TVT/TOT) are the gold standard surgical treatment for Stress Urinary Incontinence in women.
-
Urge UI (UUI/OAB):
- 1st Line: Bladder training.
- Pharmacological:
- Antimuscarinics (Oxybutynin, Tolterodine; MOA: block M3 detrusor receptors; SE: dry mouth, constipation).
- Beta-3 agonists (Mirabegron; MOA: relaxes detrusor; fewer anticholinergic SEs).
- Refractory: Botox injections, Neuromodulation (PTNS, Sacral).
-
Overflow UI:
- Treat cause: Relieve obstruction (e.g., TURP for BPH); catheterization for atonic bladder.
High‑Yield Points - ⚡ Biggest Takeaways
- Stress Incontinence (SUI): Leakage on effort; Kegels first-line; mid-urethral slings (TVT/TOT) for surgery.
- Urge Incontinence (OAB): Detrusor overactivity; Rx: bladder training, anticholinergics (oxybutynin), mirabegron.
- Overflow Incontinence: From BOO or detrusor underactivity; high PVR is characteristic.
- Mixed Incontinence: Combines stress and urge features; treat dominant symptom.
- Urodynamic studies (UDS): For diagnostic uncertainty or pre-surgery.
- Q-tip test: >30° angle indicates urethral hypermobility in SUI.
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