Notes by Sarah Mehrtens

Incontinence- History Taking

Important points in Hx
HPC
Stress? accidents when coughing/sneezing/laughing- do you ever leak when
you dont intend to?
Urge? Do you every not make it to the toilet in time?
Daytime Frequency? >8times a day
Urgency?
Nocturia (>1 a night)/ Enuresis?
Haematuria?
Dysuria?
Fluid intake
Prioritize symptoms & disruption on life
Faecal urgency/ incontinence?
Prolapse symptoms: dragging sensation/ sensation of lump/ worse at end of
day/standing up? Frequency? Difficulty bowels, e.g. put a finger in? Disrupting
sex/ bleeding/ discharge?
O&G Hx
Any other menstrual probs/ pelvic pain/ abnormal discharge?
Obs: details
PMH

Childhood enuresis
Diabetes/ neuro conditions
Recent weight change/ coughing conditions?
Post menopausal? HRT?

Examination
General: weight, chest problems
Abdo: Exclude masses, urinary retention
Pelvic: Inspection, pt in left lateral position ask to cough, or on standing, use sims
speculum to look for prolapse of bladder neck, feel for any pelvic masses
Ix
1. MSU & dipstix rule out infection
2. Urinary diary
3. Consider IVP to rule out fistula & U/s or post micturation catherterization
retention & urinary overflow
4. If no overflow/fistula/infection urodynamics

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Notes by Sarah Mehrtens

Diagnosis very difficult on history alone: need to confirm with urodynamics
GSI Genuine Stress= involuntary loss of urine when intravesical pressure exceeds the
maximal urethral closure pressure (in absence of detrusor overactivity). Very common,
10% women, 50% of incontinence: due to bladder neck weakness so bladder neck
descends. Common with pregnancy, multiparity, vaginal delivery (partic prolonged
delivery & forceps), obesity, chronic cough, age & oestrogen deficiency: often
coexisting prolapse. Small, frequent passage of urine when raised intra-abdominal
pressure: coughing, sneezing, laughing.
Mx
Advise: lose weight, address cough, give up smoking
Conservative: Vaginal cones & sponges, physiotherapy pelvic floor exercises to
strengthen pelvic floor
Determine GSI: urodynamic studies
Surgery: must exclude overactive bladder. Tension-free vaginal tape/ Burch
colposuspension. Peri-urethral collagen injections in elderly

Overactive bladder: involuntary loss of urine due to uninhibited detrusor contractions:

35% of incontinence. Often Hx childhood enuresis & faecal urgency. Causes:
idiopathic, following surgery for GSI, neurogenic bladder.
Causes urgency: detrusor instability, irritation (infection, stones, tumour), prolapse,
pregnancy, psychosomatic, neurological, diabetes
Mx

Advise: reduction fluid intake, avoid caffeine & alcohol

Urinary diary
Urodynamics: cystometry shows detrusor contractions on filling/ provocation
Bladder drill retraining: voiding by clock, not desire, using progressively longer
time intervals
Drugs: Tolterodine/ oxybutynin, synthetic ADH desmopressin for nocturia
Very severe: clam augmentation ileocystoplasty

Mixed= 10%. Tx overactive bladder first.

Chronic urinary retention & overflow = 1%
Sensory urgency= no detrusor overactivity, although frequency + urgency + nocturia
stones, infections, tumours, interstitial cystitis, psychogenic e.g. anxiety.
Note
These notes were written by Sarah Mehrtens as a medical student and submitted in 2009. They are
presented in good faith and every effort has been taken to ensure their accuracy. Nevertheless,
medical practice changes over time and it is always important to check the information with your
clinical teachers and with other reliable sources. Disclaimer: no responsibility can be taken by either
the author or publisher for any loss, damage or injury occasioned to any person acting or refraining
from action as a result of this information. Please inform us of any ambiguities, inaccuracies or
errors by emailing bob@askdoctorclarke.com

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