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Topic updated on 06/21/17 12:07pm

  • cystoceleA 68-year-old women who is 10 years post-menopausal has a ten year history of involuntary loss of urine with coughing, sneezing, and laughing. It does not occur at night. She has no dysuria. On exam, you find a protrusion of the bladder from the anterior vagina. (Urinary Stress Incontinence with cystocele) 
  • Increased incidence with
    • chronic cough
    • age
    • birth trauma
    • obesity
  • There are 4 types of incontinence
    • stress incontinence
    • urge incontinence
    • functional incontinence
    • outflow incontinence
Stress incontinence
  • Caused by laxiety of pelvic floor muscles
    • allows proximal urethra to drop below the pelvic floor
    • ↓ urethral/vessicle angle allows bladder pressure to exceed urethral pressure briefly at times of strain
  • Associated with
    • cystocele
      • bulging of bladder wall into the upper anterior vaginal wall
    • estrogen
  • Presentation
    • symptoms
      • leak with cough or laughing
  • Treatment 
    • topical vaginal estrogen
    • Kegel excersizes to strengthen pelvic floor muscles
    • α-adrenergic agonists to ↑ muscle tone of bladder neck
    • if conservative management fails
      • surgery (mid-urethral sling)
Urge incontinence
  • Caused by involunatary bladder contraction
    • result of ↑ detrusor muscle activity
  • most common type
  • Presentation
    • symptoms
      • urinary frequency
      • small volume voids
      • nocturia
  • Treatment
    • anticholinergics to ↓ parasympathetic tone of detrusor muscle
Functional incontinence
  • Caused by urinary volume
    • secondary to large volume intake or diuresis
    • patients are continent without the increased urinary volume
Outflow incontinence
  • Caused by urinary rentention
    • secondary to obstruction (e.g. BPH) or bladder atony (e.g. diabetes autonomic neuropathy)
  • Presentation
    • symptoms
      • small volume voids
      • urinary frequency
  • Treatment
    • cholinergic agonists to ↑ detrusor muscle tone (for bladder atony)
    • α-adrenergic antagonists to ↓ tone of bladder neck



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