Continuous Dribbling of Small Amounts of Urine Uworld

Summary

Urinary incontinence (UI) is a common condition characterized by involuntary leakage of urine. Causes and presentations are variable. Stress incontinence, urge incontinence, and mixed incontinence are the most common types. UI is more common in older individuals, and approximately twice as common in women than in men. The diagnosis can often be made based on a detailed medical history, a voiding diary, physical examination, and basic testing including urinalysis and measurement of postvoid residual volume (PVR). Advanced diagnostic studies may be required for patients with red flags in urinary incontinence or incontinence refractory to treatment. Initial management involves conservative measures (e.g., management of comorbidities, pelvic floor exercises, bladder training) and provision of continence products; further treatment is based on the underlying mechanism and may involve pharmacotherapy or surgery. If left untreated, UI can have a severely detrimental effect on patients' psychosocial well-being, mobility, and independence, and can increase the risk of infection.

For the management of stress incontinence and urge incontinence, see also the respective articles.

Epidemiology

• Prevalence ^[1]
  • Increases with age
  • Up to 50% of women and up to 25% of men older than 65 years are affected.
• Sex: ♀ > ♂ (2:1) ^[2]
  • Stress incontinence and mixed incontinence are the most common types of incontinence in female patients.
  • Urge incontinence is the most common type in male patients.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

• Idiopathic
• Neurological causes
  • Multiple sclerosis
  • Spinal injury
  • Normal-pressure hydrocephalus
  • Dementia
  • Delirium
• Genitourinary causes
  • Trauma to the pelvic floor
  • Intrinsic sphincter deficiency
  • Urethral hypermobility in women
  • Impaired detrusor contractility
  • Bladder outlet obstruction
  • Pelvic floor weakness
  • Urogenital fistula
• Transient causes of urinary incontinence
  • Drugs (e.g., diuretics )
  • Urinary tract infections
  • Postmenopausal atrophic urethritis
  • Psychiatric causes (especially depression, delirium/confused state)
  • Excessive urinary output (in conditions like hyperglycemia, hypercalcemia, CHF)
  • Stool impaction
  • Impaired mobility
• General risk factors
  • Recurrent urinary tract infections
  • Obesity
  • Caffeine
  • Alcohol

DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.

Overview

Types of urinary incontinence

Overview of urinary incontinence [3] [4] [5]
	Underlying mechanism	Clinical features	Treatment
Stress incontinence	Urethral hypermobility in women ( bladder outlet incompetence ) secondary to: Poor pelvic support caused by pelvic postmenopausal estrogen loss Connective tissue disorders Childbirth (i.e., damage of the pelvic floor muscle levator ani and/or the S2 – S4 nerve roots ) Intrinsic sphincter deficiency, caused by: Aging Obesity Pelvic trauma Prostate surgery (in men) Increase in intraabdominal pressure (e.g., from laughing, sneezing, coughing , exercising) → ↑ pressure within the bladder → bladder pressure > urethral sphincter resistance to urinary flow	Positive bladder stress test : urinary leakage during activities that increase intraabdominal pressure (e.g., coughing, Valsalva maneuver)	Trial of conservative management of UI for 6–8 weeks [5] In refractory or severe incontinence, refer to urology for: [4] Minimally-invasive solutions, e.g., vaginal pessaries or urethral inserts Injection of periurethral bulking agents Surgical procedures (e.g., urethral slings or suspensions, artificial urinary sphincter) See "Treatment of stress incontinence" for additional information.
Urge incontinence [6]	Inflammatory conditions (e.g., UTI ) or neurogenic disorders → sphincter dysfunction, detrusor overactivity, or overactive bladder → autonomous contractions of the detrusor muscle and premature initiation of a normal micturition reflex	Strong, sudden sense of urgency , followed by involuntary leakage	Conservative management of UI First line: pharmacotherapy Anticholinergics (e.g., oxybutynin ) Sympathomimetic (e.g., mirabegron) Second line: interventional procedures (e.g., sacral nerve stimulation, injection of botulinum toxin into the bladder wall) See "Treatment of urge incontinence" for additional information.
Mixed incontinence	Combination of mechanisms of stress incontinence and urge incontinence	May have any of the clinical features above	Conservative management of UI Treat the most bothersome symptom first, e.g., anticholinergics for urge incontinence. [3] [7] [8]
Total incontinence	Complete loss of sphincter function (due to previous surgery, nerve damage, metastasis) or abnormal anatomy (fistula between urinary tract and skin)	Urinary leakage occurs at all times, with no associated preceding symptoms or specific trigger activity.	Short-term management: pads and external catheters [9] Long-term management: usually surgical (e.g., fistula repair), in consultation with urology and/or urogynecology [3]
Overflow incontinence ( overflow bladder ) [10]	Impaired (weak) detrusor contractility due to: [11] Neurogenic bladder in multiple sclerosis Neuropathy and polyuria in diabetes mellitus Spinal cord injury Medication adverse effects Bladder outlet obstruction (e.g., BPH ) Both mechanisms can lead to incomplete bladder emptying → bladder overfilling → chronically distended bladder with ↑ bladder pressure → dribbling of urine (leak) when intravesical pressure > outlet resistance	Frequent, involuntary intermittent/continuous dribbling of urine in the absence of an urge to urinate Occurs only when the bladder is full Often occurs with changes in position Postvoid residual urine volume (seen on ultrasound or with catherization)	Short-term management includes: Intermittent catheterization : for scheduled bladder emptying Alpha-1 antagonists: for outlet obstruction in men Muscarinic agonists: for detrusor underactivity [12] Long-term management includes treatment of the urinary obstruction, e.g.: Correction of pelvic organ prolapse Transurethral resection of the prostate Urethral dilation or urethroplasty See also " Treatment of urinary retention ."
Neurogenic bladder dysfunction [3] [13]	Depending on the location of the lesion, can cause: Detrusor overactivity (spastic neurogenic bladder), e.g.: detrusor sphincter dyssynergia Simultaneous contractions of the detrusor muscle and involuntary activation of the urethral sphincter → blockage of bladder outlet → small amounts of urine are pressed through the contracted sphincter muscle → high intravesical pressure along with inappropriate contraction of the urethral sphincter Commonly seen in multiple sclerosis and spinal cord injury [14] Detrusor areflexia (flaccid neurogenic bladder)	Voiding and/or storage dysfunction, intermittent voiding, urinary retention Irregular, small volume incontinence without an associated urge to void (sometimes referred to as reflex incontinence )	Initial management: usually conservative Patients with high PVR : intermittent catheterization with or without muscarinic antagonists Management of detrusor overactivity with minimal PVR Good cognitive function and/or mobility: Trial conservative management of UI and muscarinic antagonists. Poor cognitive function and/or mobility: Manage with continence products or an indwelling catheter. Further management depends on the subtype and includes: Minimally invasive interventions Surgical management [15]
Enuresis risoria [16]	Unknown; not related to stress or detrusor weakness	Affects children Involuntary complete voiding triggered by laughing Voiding behavior is otherwise normal (not a feature of enuresis).	Conservative management of UI Reassurance Oxybutynin (second line)

Neural control of micturition: parasympathetic nervous system → S2–S4 ventral root → inferior hypogastric plexus → contraction of the detrusor muscle → voluntary relaxation of the external urethral sphincter muscle via the pudendal nerve → micturition

Stress incontinence is caused by urethral dysfunction, while urge incontinence is caused by bladder dysfunction. Mixed incontinence is a combination of both. ^[17]

The use of muscarinic agonists may lead to urinary urgency, while the use of sympathomimetics or muscarinic antagonists may lead to urinary retention, especially if there is an untreated outlet obstruction. ^[3]

No pharmacological therapies are FDA-approved for stress incontinence; treatment is primarily conservative with surgery. ^[4]

Diagnostics

The following outlines a general approach for the workup of incontinence of unknown mechanism; if the mechanism is known, see "Diagnostics" in "Stress incontinence" and "Urge incontinence."

Refer to urology or urogynecology for specialist workup if any of the following features are present:

Focused history

Physical examination ^{[3] [17]}

Perform a urinary stress test in all patients to distinguish between stress and urge incontinence.

Initial diagnostics

Differentiation between types of incontinence

Only perform upper urinary tract studies if the initial assessment indicates a possible renal pathology and/or renal impairment due to urinary retention and vesicoureteral reflux. ^{[5] [21]}

Advanced studies are performed under specialist guidance for patients with red flags in urinary incontinence or incontinence refractory to initial management.

Management

Assess the impact of incontinence symptoms on the patient's daily activities and discuss their treatment goals; use shared decision-making to individualize treatment plans.

Management of comorbidities

Lifestyle recommendations

• Management of obesity ^[4]
• Smoking cessation
• Limiting consumption of alcohol and caffeine (including carbonated drinks)
• Appropriate fluid intake and timing throughout the day ^[5]

Pelvic floor physical therapy ^[24]

• Exercises that target the pelvic floor to strengthen the muscles that control urinary flow and bowel movements
• To increase efficacy, exercises may be supplemented with:
  • Weighted vaginal cones
  • Biofeedback

Bladder training

Special patient groups

Urinary incontinence in older adults ^[3]

Overview

• Management of older patients is similar to that of other populations, but with some modifications.
• Functional incontinence due to cognitive or mobility impairment is more common than in younger patients.
• Comorbid conditions and polypharmacy can make pharmacological management challenging.

Modification to urinary incontinence diagnostics

• Screen for transient causes of urinary incontinence.
• Consider cognitive testing and functional testing in all patients.
• Limit PVR measurement to patients with any of the following:
  • Diabetes mellitus
  • Recurrent UTIs
  • History of prior urinary retention, high PVR, bladder outlet obstruction, or detrusor underactivity
  • No improvement following pharmacological treatment of urge incontinence
  • Medication use that delays bladder emptying
  • Severe constipation

Modifications to the management of urinary incontinence

• Consider life expectancy, goals of care, and the patient's and/or caregiver's ability to manage therapy when planning treatment.
• Prompted voiding may be helpful for older patients with cognitive impairment. ^[3]
• Start any medications at the lowest dose possible and follow-up frequently to assess for adverse effects.
• Consider specialist referral if conservative therapies fail or other chronic conditions need to be addressed (e.g., dementia, functional impairment).

Urinary incontinence in pregnancy ^[10]

• Stress incontinence is common during pregnancy; the incidence rises as gestation progresses. ^{[10] [25]}
• Conservative management of urinary incontinence is recommended during pregnancy and the early postpartum period. ^[25]

Complications

• Mental health: depression, psychosocial distress
• Dermatologic: dermatitis, skin infections, sores ^[26]
• Environmental: decreased independence
• Urinary tract : : increased risk of UTIs

We list the most important complications. The selection is not exhaustive.

References

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2. Abrams P, Cardozo L, Wagg A, Wein A. Incontinence 6th Edition. International Continence Society ; 2017
3. Sangsawang B, Sangsawang N. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. Int Urogynecol J. 2013; 24 (6): p.901-12. doi: 10.1007/s00192-013-2061-7 . | Open in Read by QxMD
4. Nitti VW. The prevalence of urinary incontinence. Rev Urol. 2001; 3 (Suppl 1): p.S2-6.
5. Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of Incontinence Among Older Americans. Vital Health Stat. 2014; 3 (36).
6. Khandelwal C, Kistler C. Diagnosis of urinary incontinence. Am Fam Physician. 2013; 87 (8): p.543-50.
7. Hu JS, Pierre EF. Urinary Incontinence in Women: Evaluation and Management. Am Fam Physician. 2019; 100 (6): p.339-348.
8. Rizvi RM, Ather MH. Assessment of Urinary Incontinence (UI) in Adult Patients. InTech ; 2017
9. ACOG. Practice Bulletin No. 155: Urinary Incontinence in Women. Obstetrics & Gynecology. 2015; 126 (5): p.e66-e81. doi: 10.1097/aog.0000000000001148 . | Open in Read by QxMD
10. Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020; 204 (4): p.778-786. doi: 10.1097/ju.0000000000001297 . | Open in Read by QxMD
11. Danforth KN, Townsend MK, Curhan GC, Resnick NM, Grodstein F. Type 2 Diabetes Mellitus and Risk of Stress, Urge and Mixed Urinary Incontinence. J Urol. 2009; 181 (1): p.193-197. doi: 10.1016/j.juro.2008.09.007 . | Open in Read by QxMD
12. Stoffel, John, et al. Non-Neurogenic Chronic Urinary Retention: Consensus Definition, Management Strategies, and Future Opportunities. AUA White Paper. Linthicum, MD: American Urological Association. 2016 .
13. Khatri G, Bhosale PR, Robbins JB, et al. ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females. J Am Coll Radiol. 2022; 19 (5): p.S137-S155. doi: 10.1016/j.jacr.2022.02.016 . | Open in Read by QxMD
14. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary incontinence in women. JAMA. 2017; 318 (16): p.1592. doi: 10.1001/jama.2017.12137 . | Open in Read by QxMD
15. Welk B, Baverstock RJ. The management of mixed urinary incontinence in women. Canadian Urological Association Journal. 2017; 11 (6S2): p.121. doi: 10.5489/cuaj.4584 . | Open in Read by QxMD
16. Moore KN, Saltmarche B, Query A. Urinary incontinence. Non-surgical management by family physicians. Can Fam Physician. 2003; 49 : p.602-10.
17. Choosing wisely: Don't place an indwelling urinary catheter to manage urinary incontinence. https://web.archive.org/web/20220728141915/http://www.choosingwisely.org:80/clinician-lists/amda-indwelling-urinary-catheter/. . Accessed: July 28, 2022.
18. Lobo RA. Treatment of the Postmenopausal Woman. Academic Press ; 2007
19. Gaitonde S, Malik RD, Christie AL, Zimmern PE. Bethanechol: Is it still being prescribed for bladder dysfunction in women?. Int J Clin Pract. 2018; 73 (8): p.e13248. doi: 10.1111/ijcp.13248 . | Open in Read by QxMD
20. Ginsberg D. The epidemiology and pathophysiology of neurogenic bladder. Am J Manag Care. 2013; 19 (10 Suppl): p.s191-6.
21. Kalsi V, Fowler CJ. Therapy insight: bladder dysfunction associated with multiple sclerosis. Nat Clin Pract Urol. 2005; 2 (10): p.492-501. doi: 10.1038/ncpuro0323 . | Open in Read by QxMD
22. Stoffel JT. Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies. Transl Androl Urol. 2016; 5 (1): p.127-35. doi: 10.3978/j.issn.2223-4683.2016.01.08 . | Open in Read by QxMD
23. Fernandes L, Martin D, Hum S. A case of the giggles: Diagnosis and management of giggle incontinence. Can Fam Physician. 2018; 64 (6): p.445-447.
24. Farage MA, Miller KW, Berardesca E, Maibach HI. Incontinence in the aged: contact dermatitis and other cutaneous consequences. Contact Dermatitis. 2007; 57 (4): p.211-217. doi: 10.1111/j.1600-0536.2007.01199.x . | Open in Read by QxMD
25. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev. 2012 . doi: 10.1002/14651858.cd001405.pub3 . | Open in Read by QxMD
26. John Schorge, Joseph Schaffer, Lisa Halvorson, Barbara Hoffman, Karen Bradshaw, and F. Cunningham. Williams Gynecology. Wiley ; 2010

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