Urinary Incontinence (Clinical)

Overview

Definition

Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (UI) is the involuntary leakage of urine.

Epidemiology^[1,3]

• Women > men
• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency ↑ with age
• Both genders are equally affected after 80 years of age.
• In the United States, 20 million women and 6 million men experience urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (UI) during their lifetime.
• Globally, approximately 35% of individuals > 60 years of age suffer from UI.
• Up to 80% of women in nursing homes have UI.
• Only 25% of individuals affected by UI seek treatment owing to social stigma.

Etiology and risk factors^{[2,4,6,7,20,28]}

• Age
• Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity^[4]
• Major risk factors for women:
  • History of multiple pregnancies^[2]
  • Current pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Vaginal delivery
  • Damage due to surgery or trauma near/on the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess or pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause
• Major risk factor for men: prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. surgery
• Conditions affecting the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification or spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy, such as:
  • Stroke 
  • Multiple sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor 
  • Parkinson disease Parkinson disease Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder. Although the cause is unknown, several genetic and environmental risk factors are currently being studied. Individuals present clinically with resting tremor, bradykinesia, rigidity, and postural instability. Parkinson’s Disease
  • Cerebral palsy Palsy paralysis of an area of the body, thus incapable of voluntary movement Cranial Nerve Palsies
• Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus
• Chronic renal disease 
• Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease 
• Medications:^[19]
  • Antipsychotics and antidepressants
  • Alpha antagonists (decrease urethral sphincter tone)
  • Diuretics Diuretics Agents that promote the excretion of urine through their effects on kidney function. Heart Failure and Angina Medication (increase urine production and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess contractility)
  • Sedative hypnotics
  • Angiotensin-converting–enzyme inhibitors
  • Medications for Parkinson disease Parkinson disease Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder. Although the cause is unknown, several genetic and environmental risk factors are currently being studied. Individuals present clinically with resting tremor, bradykinesia, rigidity, and postural instability. Parkinson’s Disease ( anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs)
• Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation^[7]
• ↑ Alcohol or caffeine Caffeine A methylxanthine naturally occurring in some beverages and also used as a pharmacological agent. Caffeine’s most notable pharmacological effect is as a central nervous system stimulant, increasing alertness and producing agitation. Several cellular actions of caffeine have been observed, but it is not entirely clear how each contributes to its pharmacological profile. Among the most important are inhibition of cyclic nucleotide phosphodiesterases, antagonism of adenosine receptors, and modulation of intracellular calcium handling. Stimulants intake
• High impact exercise (jumping and weightlifting)^[6]

Consequences of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence^[23,28,29]

• Increased:
  • Rates of depression and social isolation 
  • Hospitalizations 
  • Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
  • Pressure ulcers 
  • Admission to long-term residential care 
• Decreased:
  • Work productivity 
  • General health
  • Quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life 

Pathophysiology and Classification

Normal bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess function^[11,23]

• The bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess has 2 main functions:
  • Store urine 
  • Expel urine 
• Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess function is controlled by:
  • Detrusor muscle Detrusor muscle Urinary Incontinence → contracts during voiding 
  • Urethral sphincter → contracts during filling
• The bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess is innervated by the parasympathetic, sympathetic, and voluntary nervous systems.
• During filling → sympathetic stimulation, which leads to:
  • Sympathetic stimulation → detrusor muscle Detrusor muscle Urinary Incontinence relaxation
  • Contraction of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Contraction of the external urinary (urethral) sphincter
• During voiding:
  • Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess distention → activation of mechanoreceptors → afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology signals to the pons Pons The front part of the hindbrain (rhombencephalon) that lies between the medulla and the midbrain (mesencephalon) ventral to the cerebellum. It is composed of two parts, the dorsal and the ventral. The pons serves as a relay station for neural pathways between the cerebellum to the cerebrum. Brain Stem: Anatomy
  • Inhibition of sympathetic stimulation and relaxation of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Parasympathetic activation of the detrusor leads to detrusor contraction and the expulsion of urine
• Increased intra-abdominal pressure during the Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse is transmitted to the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy (squeezing it closed) and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess (increasing its pressure) equally, though under normal circumstances, urethral pressure should be enough to maintain continence.
• The urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy is supported by the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscles, which help to close the urethral opening.

Incontinence pathophysiology and classification^[28,29]

Alterations in bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess and/or urethral sphincter pressures lead to UI.

• Stress urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (SUI):
  • Intra-abdominal pressure > bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess sphincter pressure results in urine leakage with effort or exertion (e.g., coughing, running)
  • Cause 1: Weakness of the urinary sphincter, which may be from:
    • Trauma (e.g., during vaginal delivery)
    • Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma therapy
    • Neurologic disease
    • Aging
  • Cause 2: Urethral hypermobility:
    • Occurs because of damage to the tissue supporting the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy
    • With this loss of support, during times of ↑ intra-abdominal pressure, the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy moves (rather than being compressed) → results in SUI 
• Urge urinary incontinence (UUI):
  • Overactivity of the detrusor muscle Detrusor muscle Urinary Incontinence (called overactive bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess [OAB]) causes an urgency to void and involuntary urine leakage.
  • Exact pathophysiology unclear
  • Theories include:
    • An imbalance between stimulatory and inhibitory neural pathways to the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess and urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy
    • Alterations in the sensitivity of detrusor muscle Detrusor muscle Urinary Incontinence receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors
  • In men, detrusor overactivity often coexists with bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia (most commonly due to prostatic enlargement)
• Mixed incontinence: combined detrusor muscle Detrusor muscle Urinary Incontinence and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess sphincter pathology
• Overflow incontinence Overflow incontinence Symptom of underactive detrusor muscle of the urinary bladder that contracts with abnormally reduced strength or duration resulting in an incomplete and/or prolonged bladder emptying. Urinary Incontinence:^[28]
  • Incomplete bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess emptying due to:
    • Bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia
    • Impaired detrusor contractility
  • Inability to void the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess completely → urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium → overdistention of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess → continuous or frequent loss of urine
  • Neurologic causes (termed “neurogenic bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess”):
    • Multiple sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor
    • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury
    • Parkinson disease Parkinson disease Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder. Although the cause is unknown, several genetic and environmental risk factors are currently being studied. Individuals present clinically with resting tremor, bradykinesia, rigidity, and postural instability. Parkinson’s Disease
    • Stroke
    • Pelvic nerve injury Nerve Injury Surgical Complications
  • Myogenic causes:
    • Prolonged overdistention (acute)
    • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus
  • Causes due to outlet obstruction:
    • Scarring Scarring Inflammation after pelvic/abdominal surgery 
    • Enlarged prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid.
    • Pressure on the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy by a tumor Tumor Inflammation (e.g., prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer)
    • Urethral stricture Stricture Primary Sclerosing Cholangitis 
    • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
    • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
• Functional incontinence:
  • Inability to control urine voiding due to a physical or mental impairment impeding the individual from reaching the toilet
• Other types of incontinence classified by the American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS):^[29]
  • Extraurethral urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence, which includes leakage of urine through:
    • Fistulas (typically to the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy): urethral, vesical, ureteral
    • Ectopic ureters Ureters One of a pair of thick-walled tubes that transports urine from the kidney pelvis to the urinary bladder. Urinary Tract: Anatomy
  • Occult stress incontinence Stress incontinence Involuntary discharge of urine as a result of physical activities that increase abdominal pressure on the urinary bladder without detrusor contraction or overdistended bladder. The subtypes are classified by the degree of leakage, descent and opening of the bladder neck and urethra without bladder contraction, and sphincter deficiency. Urinary Incontinence: SUI that occurs only after concurrent pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse (POP) is reduced (POP may actually “kink” the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, hiding SUI)
  • Postural urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence: UI associated with changes in body position
  • Coital urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence: UI with intercourse

Clinical Presentation and Diagnosis

General approach

Focus the history on symptoms consistent with incontinence based on the type of circumstance:

Diagnosing UI includes:^[29,31]

1. Taking a careful history
2. Physical exam (which includes a pelvic exam and assessment of urethral mobility)
3. Attempting to demonstrate SUI
4. Urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children
5. Assessment of post-void residual volume Residual volume The volume of air remaining in the lungs at the end of a maximal expiration. Common abbreviation is rv. Ventilation: Mechanics of Breathing (PVR) and other focused diagnostic testing.

History^{[18,24-26,29,31]}

• Take careful history of urinary symptoms:^[29]
  • Characterization of incontinence:
    • Duration, severity/volume leaked, and effects on daily life
    • SUI symptoms: UI with increases in intra-abdominal pressure (e.g., during exercise, activity, cough/sneeze)
    • UUI symptoms: urge to void, but leakage before reaching the restroom
    • Mixed: symptoms of both
  • Symptoms related to bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess storage:
    • ↑ Frequency of voiding
    • Nocturia Nocturia Frequent urination at night that interrupts sleep. It is often associated with outflow obstruction, diabetes mellitus, or bladder inflammation (cystitis). Diabetes Insipidus or nocturnal enuresis Nocturnal enuresis Involuntary discharge of urine during sleep at night after expected age of completed development of urinary control. Elimination Disorders (leakage of urine when asleep)
  • Symptoms related to bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess emptying:
    • Hesitancy (difficulty initiating voiding)
    • Slow stream
    • Feeling of incomplete emptying
    • Straining to void
    • Dysuria Dysuria Painful urination. It is often associated with infections of the lower urinary tract. Urinary Tract Infections (UTIs)
  • Other symptoms:
    • Leakage of urine after surgery 
    • Hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma
    • Dampness in the undergarments without knowledge of urine leakage
• For individuals who have difficulty recalling or quantifying symptoms:
  • Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess diary:
    • Fluid intake 
    • Frequency of voiding 
    • Urine volume
    • Number of episodes of incontinence
  • Pad test:
    • The individual is asked to wear a pad.
    • The volume of urine leaked is checked by the weight and the number of pads used per day.
• Validated UI questionnaires may aid diagnosis/elucidate UI patterns; examples include:^[29,30]
  • Urogenital Distress Inventory (UDI)
  • Incontinence Impact Questionnaire (IIQ)
  • Questionnaire for Urinary Incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence Diagnosis (QUID)
  • Incontinence Quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of Life Questionnaire (I-QOL)
  • Incontinence Severity Index (ISI)
  • International Consultation on Incontinence Questionnaire (ICIQ)
• Always ask about impact on quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life:^[29]
  • Disruption in daily activities due to urine leakage 
  • May be a mild nuisance or severely limiting
  • Asking about the impact of UI will help guide treatment
• Inquire about risk factors:
  • Obstetric history Obstetric History Prenatal Care
  • Prior pelvic surgery or trauma
  • Comorbid conditions affecting the neurologic system
  • Alcohol and caffeine Caffeine A methylxanthine naturally occurring in some beverages and also used as a pharmacological agent. Caffeine’s most notable pharmacological effect is as a central nervous system stimulant, increasing alertness and producing agitation. Several cellular actions of caffeine have been observed, but it is not entirely clear how each contributes to its pharmacological profile. Among the most important are inhibition of cyclic nucleotide phosphodiesterases, antagonism of adenosine receptors, and modulation of intracellular calcium handling. Stimulants intake
  • Medication use
• Review of systems:
  • Infectious causes may present with:
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever/ chills Chills The sudden sensation of being cold. It may be accompanied by shivering. Fever
    • Pelvic/back/ flank pain Flank pain Pain emanating from below the ribs and above the ilium. Renal Cell Carcinoma
  • Neurologic causes may present with:
    • Bowel incontinence
    • Perineal anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts
    • Focal neurologic findings
    • Changes in gait Gait Manner or style of walking. Neurological Examination
    • Mental status changes

Physical examination^[23,29–31]

• Pelvic exam to check for:
  • Integrity and strength of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscles
  • Urethral hypermobility:^[30]
    • Defined as ≥ 30 degrees of displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms from horizontal during Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse while in a supine lithotomy position
    • Most commonly assessed visually or with the Aa AA Amyloidosis point in the Pelvic Organ Prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse Quantification (POP-Q) System (used for evaluating pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse)
    • The Q-tip test (a traditional test involving insertion of a Q-tip into the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy) is rarely done any more because it is uncomfortable and has questionable reliability Reliability Reliability refers to the reproducibility of a test or research finding. Causality, Validity, and Reliability.
  • Vaginal atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
  • Pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse
  • Pelvic/uterine masses
  • Urethral diverticulum Diverticulum A pouch or sac opening from the colon. Diverticular Disease, which may result in UI episodes or post-void dribbling
  • Fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula
• Attempt to demonstrate SUI: have patient cough or bear down
• Abdominal exam to palpate for pelvic and abdominal masses
• Rectal exam to check for:
  • Size and consistency Consistency Dermatologic Examination of the prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. gland
  • Stool impaction
  • Rectal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast

Laboratory tests^{[18,20,25,29,31]}

• Urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children:
  • Should be obtained during all UI workups
  • WBC or RBC may indicate infection; send urine culture Urine culture Urinary Tract Infections (UTIs) if present
  • Hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma or proteinuria Proteinuria The presence of proteins in the urine, an indicator of kidney diseases. Nephrotic Syndrome in Children may indicate renal pathology
• Consider blood tests for renal function:
  • Creatinine 
  • Blood urea Urea A compound formed in the liver from ammonia produced by the deamination of amino acids. It is the principal end product of protein catabolism and constitutes about one half of the total urinary solids. Urea Cycle nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle 
  • Estimated glomerular filtration rate Glomerular filtration rate The volume of water filtered out of plasma through glomerular capillary walls into Bowman’s capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests

Clinical tests^[26,30,31]

Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess stress test (also called the “cough stress test”):^[30]

• Should be done during all UI workups
• Full bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess (at least 300 mL), in order to maximize sensitivity
• Ask the individual to cough or bear down.
• Observe any urine leakage.
• If no urinary leakage is observed, repeat the test with the patient standing.
• Interpretation:
  • Loss of urine during coughing is diagnostic of SUI.
  • Delayed fluid loss (considered a negative test) suggests detrusor overactivity.

Post-void residual volume Residual volume The volume of air remaining in the lungs at the end of a maximal expiration. Common abbreviation is rv. Ventilation: Mechanics of Breathing (PVR):

• Assess the amount of urine left in the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess after voiding (by ultrasound or straight catheter)
• Abnormal: > 150 mL or ⅓ of pre-void volume

Urodynamic tests:

• Measure the pressure the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess/urinary sphincter muscle can withstand, and the flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure of urine:
  • Cystometry: measures pressure and volume of fluid in the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess during filling, storage, and voiding
  • Uroflowmetry: measures the rate of urine flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
  • Urethral pressure profile: tests urethral function
  • Leak point pressure: determines the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess or abdominal pressure when leakage occurs
• Indications:^[26,30]
  • Those with an unclear diagnosis (including a negative cough stress test)
  • Symptoms that do not correlate with objective findings
  • Known or suspected neurologic dysfunction
  • Abnormal urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children findings (e.g., hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma, pyuria Pyuria The presence of white blood cells (leukocytes) in the urine. It is often associated with bacterial infections of the urinary tract. Pyuria without bacteriuria can be caused by tuberculosis, stones, or cancer. Urinary Tract Infections (UTIs))
  • Elevated PVR
  • POP beyond the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy (POP-Q ≥ stage 3)
  • Significant voiding dysfunction
  • Failed initial treatment
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with prior pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy or incontinence surgery
• Not indicated in cases of uncomplicated SUI, which includes:
  • SUI demonstrated on cough stress test
  • Normal urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children
  • No POP beyond the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Normal PVR

Radiology and procedures^[29,31]

• Not always necessary
• Indicated based on abnormal history or exam findings
• Pelvic ultrasonography:
  • To detect tumors 
  • To detect nephrolithiasis Nephrolithiasis Nephrolithiasis is the formation of a stone, or calculus, anywhere along the urinary tract caused by precipitations of solutes in the urine. The most common type of kidney stone is the calcium oxalate stone, but other types include calcium phosphate, struvite (ammonium magnesium phosphate), uric acid, and cystine stones. Nephrolithiasis 
  • To check urine volume before and after voiding
• Cystoscopy: A thin tube with a camera is passed through the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy and into the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess.
• Abdominal CT: rule out masses/infection (e.g., renal carcinoma, pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess)
• Spinal MRI Spinal MRI Imaging of the Spine and Spinal Cord: rule out cord compression Compression Blunt Chest Trauma, cauda equina Cauda Equina The lower part of the spinal cord consisting of the lumbar, sacral, and coccygeal nerve roots. Spinal Cord Injuries, and spinal abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease

Management

Management of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence is often delayed because many individuals hesitate to seek treatment.^[9] The major indications for treatment are to treat bothersome symptoms and urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium.  

US and UK Guidelines

1. US guideline for OAB: American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guideline^[25]
2. US guideline for SUI: AUA/SUFU guideline^[26]
3. UK guidelines: Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence in women^[18] and men^[24]

Factors affecting management

Management of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence is dependent on several factors:

• Type and severity of incontinence
• Presence of urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
• Patient preferences:
  • How bothersome the symptoms are
  • Desire to try or to avoid certain treatments
• Underlying cause
• Response to treatment
• Age
• General health and mental state 

Goals of therapy

The major goals of UI therapy are to reduce involuntary leakage and improve quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life. Urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium must be addressed, if present.

• SUI:
  • Provide urethral support (through Kegel exercises Kegel Exercises Pelvic Organ Prolapse, medical devices, or surgery)
  • Minimize intra-abdominal pressure (through weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).)
• UUI: reduce detrusor overactivity
• Overflow incontinence Overflow incontinence Symptom of underactive detrusor muscle of the urinary bladder that contracts with abnormally reduced strength or duration resulting in an incomplete and/or prolonged bladder emptying. Urinary Incontinence: address the underlying etiology as much as possible
• Bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia: relieve the obstruction
• Fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula/urethral diverticulum Diverticulum A pouch or sac opening from the colon. Diverticular Disease: surgical correction

Note: Catheterization is generally not recommended as part of the management of routine UI. It may be indicated in individuals with persistent urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium, symptomatic infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease, and/or renal dysfunction.^[31]

Indications for specialist referral^[31] 

Individuals may need urologic, gynecologic, neurologic, and/or nephrology consultation in the following circumstances:

• Recurrent urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infection ( UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections (UTIs)) 3 times in 1 year or twice in 6 months; culture-proven
• Gross or microscopic hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma in the absence of a UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections (UTIs)
• Lifelong incontinence 
• Suspected fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula or urethral diverticulum Diverticulum A pouch or sac opening from the colon. Diverticular Disease on pelvic exam
• Other abnormal exam findings: uterine prolapse Uterine prolapse Downward displacement of the uterus. It is classified in various degrees: in the first degree the uterine cervix is within the vaginal orifice; in the second degree the cervix is outside the orifice; in the third degree the entire uterus is outside the orifice. Pelvic Organ Prolapse, pelvic masses
• New neurologic symptoms in addition to UI
• Associated fecal incontinence Fecal incontinence Failure of voluntary control of the anal sphincters, with involuntary passage of feces and flatus. Pediatric Constipation
• Suspected overflow incontinence Overflow incontinence Symptom of underactive detrusor muscle of the urinary bladder that contracts with abnormally reduced strength or duration resulting in an incomplete and/or prolonged bladder emptying. Urinary Incontinence/ urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
• Previous urethral, vaginal, or continence surgery

Lifestyle/behavioral modifications^{[11-13,18,21,28,29]}

Lifestyle and behavioral modifications, including pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscle exercises, are 1st-line therapy for all types of UI in both men and women.

• Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity^[4,5,13,29]
• Management of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
• Dietary changes:
  • Reduce or eliminate bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess irritants: alcohol, caffeine Caffeine A methylxanthine naturally occurring in some beverages and also used as a pharmacological agent. Caffeine’s most notable pharmacological effect is as a central nervous system stimulant, increasing alertness and producing agitation. Several cellular actions of caffeine have been observed, but it is not entirely clear how each contributes to its pharmacological profile. Among the most important are inhibition of cyclic nucleotide phosphodiesterases, antagonism of adenosine receptors, and modulation of intracellular calcium handling. Stimulants, vitamin C Vitamin C A six carbon compound related to glucose. It is found naturally in citrus fruits and many vegetables. Ascorbic acid is an essential nutrient in human diets, and necessary to maintain connective tissue and bone. Its biologically active form, vitamin C, functions as a reducing agent and coenzyme in several metabolic pathways. Vitamin C is considered an antioxidant. Water-soluble Vitamins and their Deficiencies, and carbonated beverages 
  • Normalize fluid intake if drinking excess amounts of water; limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation fluid to 2 L per day.^[29]
  • Avoid drinking water for several hours before bedtime.
• Smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation
• Timed voiding and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess training: urinate on a schedule; start by voiding every 30‒60 minutes
  • Urinate before physical or strenuous activities.
  • Do not wait for the urge to urinate.
  • The time between trips to the bathroom is progressively delayed.
  • Gradually ↑ time between voids to 2.5–3.5 hours as tolerated.
• Double voiding: Avoid overflow incontinence Overflow incontinence Symptom of underactive detrusor muscle of the urinary bladder that contracts with abnormally reduced strength or duration resulting in an incomplete and/or prolonged bladder emptying. Urinary Incontinence by urinating and then urinating again after a few minutes.
• Avoid ↑ intra-abdominal pressure maneuvers (e.g., heavy lifting)
• Pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscle (Kegel) exercises:^[15,18,29]
  • Effective in stress and urge incontinence Urge incontinence Involuntary discharge of urine that is associated with an abrupt and strong desire to void. It is usually related to the involuntary contractions of the detrusor muscle of the bladder (detrusor hyperreflexia or detrusor instability). Urinary Incontinence
  • Similar in both men and women:
    • Contract the muscles that are used to stop the flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure of urine for 5 seconds. 
    • Relax the muscles for the next 5 seconds.
    • Note: Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should not do Kegels Kegels Urinary Incontinence while actually urinating (except for maybe the 1st time or 2 in order to learn which muscles to contract).
  • Effort should be made to progress gradually to 10 seconds per contraction.
  • 3 sets of repetitions per day 
• Symptom management with pads or moisture-wicking catheters

Management of SUI in women^[17,28,29]

In addition to the behavior/lifestyle interventions mentioned above, nonsurgical (conservative) and surgical options exist for female patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with SUI who desire additional therapy.

Nonsurgical options:^[28,29]

• Vaginal estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy: 
  • For perimenopausal and postmenopausal women with vaginal atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
  • Tones and rejuvenates urethral and vaginal tissues 
  • Preparations:
    • Estradiol Estradiol The 17-beta-isomer of estradiol, an aromatized C18 steroid with hydroxyl group at 3-beta- and 17-beta-position. Estradiol-17-beta is the most potent form of mammalian estrogenic steroids. Noncontraceptive Estrogen and Progestins vaginal cream (100 µg estradiol Estradiol The 17-beta-isomer of estradiol, an aromatized C18 steroid with hydroxyl group at 3-beta- and 17-beta-position. Estradiol-17-beta is the most potent form of mammalian estrogenic steroids. Noncontraceptive Estrogen and Progestins per 1 g of cream): Insert 0.5–1 g of cream intravaginally daily for 2 weeks and then 0.5 mg–1 g twice weekly.
    • Estradiol Estradiol The 17-beta-isomer of estradiol, an aromatized C18 steroid with hydroxyl group at 3-beta- and 17-beta-position. Estradiol-17-beta is the most potent form of mammalian estrogenic steroids. Noncontraceptive Estrogen and Progestins vaginal tablet/inserts (Imvexxy^®, Vagifem^®, Yuvafem^®): Insert 4- or 10-µg tablet intravaginally once daily for 2 weeks and then twice weekly.
    • Estradiol Estradiol The 17-beta-isomer of estradiol, an aromatized C18 steroid with hydroxyl group at 3-beta- and 17-beta-position. Estradiol-17-beta is the most potent form of mammalian estrogenic steroids. Noncontraceptive Estrogen and Progestins ring (Estring^®): 2-mg intravaginal ring (releases 7.5 µg estradiol Estradiol The 17-beta-isomer of estradiol, an aromatized C18 steroid with hydroxyl group at 3-beta- and 17-beta-position. Estradiol-17-beta is the most potent form of mammalian estrogenic steroids. Noncontraceptive Estrogen and Progestins per day); replace every 90 days
  • Note: Systemic estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy does not improve SUI symptoms.^[28]
• Continence pessary:
  • A flexible silicone device that is inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy; provides support for the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy
  • Available in a variety of shapes and sizes
  • Some pessaries Pessaries Devices worn in the vagina to provide support to displaced uterus or rectum. Pessaries are used in conditions such as uterine prolapse; cystocele; or rectocele. Pelvic Organ Prolapse also support the internal pelvic organs and are used to treat POP as well.
  • Must be fitted by a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship in clinic
  • Instructions for use:
    • Inserted and removed by the patient; worn as needed
    • Wash with soap and water when removed
    • For frequent SUI symptoms: typically inserted during the day and removed at night
    • May be inserted by clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship in clinic and left in place for up to 3 months at a time if the patient is unable to remove and replace the device herself
    • Concurrent vaginal estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy may help reduce vaginal atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation and the risk of erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes
• Vaginal inserts (e.g., Poise^® Impressa^®):
  • A tampon-like device inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy that functions like a pessary, supporting the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy
  • Available over the counter without a prescription
• Duloxetine Duloxetine A thiophene derivative and selective neurotransmitter uptake inhibitor for serotonin and noradrenaline (SNRI). It is an antidepressant agent and anxiolytic, and is also used for the treatment of pain in patients with diabetes mellitus and fibromyalgia. Serotonin Reuptake Inhibitors and Similar Antidepressants:^[28]
  • Approved for SUI in Europe (off-label in the US)
  • A serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS– norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS reuptake inhibitor (SNRI)
  • Acts on the pudendal nerve Pudendal nerve A nerve which originates in the sacral spinal cord (s2 to s4) and innervates the perineum, the external genitalia, the external anal sphincter and the external urethral sphincter. It has three major branches: the perineal nerve, inferior anal nerves, and the dorsal nerve of penis or clitoris. Gluteal Region: Anatomy alpha-adrenergic and 5-hydroxytryptamine-2 receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors, which may improve urinary symptoms
  • Dose: 20–40 mg once or twice daily (start with lower dose)

Surgical options:^[17,28,29]

• Urethral bulking agents:
  • Synthetic bulking material is injected into the tissue surrounding the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy.
  • Increased mechanical pressure around the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy prevents leaking.
  • Materials:
    • Solid silicone elastomer (Macroplastique^®)
    • Hydrogel (Bulkamid^®)
    • Glutaraldehyde cross-linked collagen Collagen A polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth). Connective Tissue: Histology (Contigent^®)
    • Porcine dermal implant (Permacol ^{TM Tm Tubular System})
    • Calcium Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes hydroxyapatite (Coaptite^®)
  • Less effective than other surgical options, may require repeat injections
• Mid-urethral slings (MUS):
  • Synthetic mesh creates a sling under the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy at the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess.
  • Highest success rates of all available SUI interventions
  • Most commonly used surgical intervention
  • Procedures (equivalent efficacy):
    • Transvaginal tape (TVT): edges/sides of the sling are retropubic; higher risk of bladder perforation Bladder Perforation Basic Procedures and postoperative voiding dysfunction
    • Transobturator tape (TOT): edges/sides are through the obturator foramen; higher risk of postoperative groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Risk of mesh complications: erosions Erosions Corneal Abrasions, Erosion, and Ulcers
• Other procedures:
  • Autologous fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis pubovaginal sling
    • Fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis is typically from the rectus sheath or fascia lata Fascia lata Femoral Region and Hernias: Anatomy
    • More effective than colposuspension procedure
  • Burch (retropubic) colposuspension: traditional procedure; higher risk of voiding difficulties postoperatively than with MUS

Management of SUI in men^[24]

After lifestyle/behavioral interventions, the most common management techniques include:

• Duloxetine Duloxetine A thiophene derivative and selective neurotransmitter uptake inhibitor for serotonin and noradrenaline (SNRI). It is an antidepressant agent and anxiolytic, and is also used for the treatment of pain in patients with diabetes mellitus and fibromyalgia. Serotonin Reuptake Inhibitors and Similar Antidepressants (approved in Europe, off-label in the US)
• Transurethral bulking agents:
  • Lower success rates than in women; typically < 25%
  • Typically requires repeated injections
• Perineal sling:
  • Use synthetic mesh placed through the obturator foramen.
  • Typically for postprostatectomy SUI, if symptoms do not resolve spontaneously after 6‒12 months of observation
• Artificial urinary sphincter:
  • Most effective long-term treatment for severe SUI
  • A fluid- or air-filled ring is placed around the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, acting as an artificial sphincter when the cuff is inflated.
  • A pump Pump ACES and RUSH: Resuscitation Ultrasound Protocols is implanted under the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions in the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy, which moves the fluid or air in the cuff to a reservoir Reservoir Animate or inanimate sources which normally harbor disease-causing organisms and thus serve as potential sources of disease outbreaks. Reservoirs are distinguished from vectors (disease vectors) and carriers, which are agents of disease transmission rather than continuing sources of potential disease outbreaks. Humans may serve both as disease reservoirs and carriers. Escherichia coli/balloon located in the abdominal cavity when the patient needs to void.

Management of UUI and OAB in women

In UUI/OAB, medical management with antimuscarinic agents or β₃-adrenergic agonists are the mainstay of initial therapy after behavior/lifestyle interventions. If pharmacologic therapy is inadequate, additional treatment options are available.

Antimuscarinic agents for UUI/OAB:^[25,28]

• Oral drugs: start with the lowest dose first
  • Darifenacin Darifenacin Anticholinergic Drugs 7.5–15 mg once daily
  • Trospium (taken on an empty stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy):
    • Extended-release: 60 mg once daily
    • Immediate-release: 20 mg twice daily
  • Oxybutynin Oxybutynin Anticholinergic Drugs:
    • Extended-release (better tolerability than immediate release): 5–10 mg once daily, increase by 5 mg every 1‒2 weeks as needed; maximum dose: 30 mg/day
    • Immediate-release: 5 mg 2 to 4 times daily
    • Transdermal patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes: 3.9 mg/day, changed twice weekly
  • Solifenacin Solifenacin A quinuclidine and tetrahydroisoquinoline derivative and selective m3 muscarinic antagonist. It is used as a urologic agent in the treatment of urinary incontinence. Anticholinergic Drugs 5–10 mg once daily
  • Fesoterodine Fesoterodine Anticholinergic Drugs 4–8 mg once daily
  • Tolterodine Tolterodine An antimuscarinic agent selective for the muscarinic receptors of the bladder that is used in the treatment of urinary incontinence and urinary urge incontinence. Anticholinergic Drugs:
    • Extended-release 2–4 mg once daily
    • Immediate-release 1–2 mg twice daily
• Potential adverse effects: peripheral anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs effects
  • Urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
  • Dry mouth and dry eyes
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
  • GI upset
  • Somnolence
  • Mental status changes/decreased cognitive function, primarily in older adults
• Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to antimuscarinic drugs:
  • Tachyarrhythmias
  • Myasthenia gravis Myasthenia Gravis Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by weakness and fatigability of skeletal muscles caused by dysfunction/destruction of acetylcholine receptors at the neuromuscular junction. MG presents with fatigue, ptosis, diplopia, dysphagia, respiratory difficulties, and progressive weakness in the limbs, leading to difficulty in movement. Myasthenia Gravis
  • Gastric retention
  • Narrow angle-closure glaucoma Angle-Closure Glaucoma Glaucoma

β₃-Adrenergic agonists for UUI/OAB:^[25,28,29]

• Stimulate bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors, triggering smooth muscle relaxation
• Have similar efficacy to and fewer potential adverse effects than antimuscarinic agents
• No impact on cognitive or cardiac function
• Drugs:
  • Mirabegron (extended-release tablets) 25–50 mg daily
    • Avoid in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or “uncontrolled” hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension
    • Monitor blood pressure after starting.
  • Vibegron: 75 mg daily
• Potential adverse effects:
  • Urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension with mirabegron
  • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
  • GI upset
  • Rhinorrhea Rhinorrhea Excess nasal drainage. Respiratory Syncytial Virus

Additional treatment options^[28,29] (for individuals whose symptoms were not adequately controlled by, or who could not tolerate, antimuscarinic and β-adrenergic agents):

• Tibial nerve Tibial Nerve The medial terminal branch of the sciatic nerve. The tibial nerve fibers originate in lumbar and sacral spinal segments (L4 to S2). They supply motor and sensory innervation to parts of the calf and foot. Popliteal Fossa: Anatomy stimulation:^[28]
  • Percutaneous or transcutaneous electrical stimulation of the posterior tibial nerve Tibial Nerve The medial terminal branch of the sciatic nerve. The tibial nerve fibers originate in lumbar and sacral spinal segments (L4 to S2). They supply motor and sensory innervation to parts of the calf and foot. Popliteal Fossa: Anatomy just above the medial ankle
  • Stimulates the sacral micturition center via the S2 S2 Heart Sounds‒ S4 S4 Heart Sounds sacral plexus Sacral plexus Pelvis: Anatomy
  • Typical treatment cycle: 30-minute sessions once a week for 12 weeks
• Injection of botulinum toxin Botulinum toxin Toxic proteins produced from the species Clostridium botulinum. The toxins are synthesized as a single peptide chain which is processed into a mature protein consisting of a heavy chain and light chain joined via a disulfide bond. The botulinum toxin light chain is a zinc-dependent protease which is released from the heavy chain upon endocytosis into presynaptic nerve endings. Once inside the cell the botulinum toxin light chain cleaves specific snare proteins which are essential for secretion of acetylcholine by synaptic vesicles. This inhibition of acetylcholine release results in muscular paralysis. Botulism (neurotoxin inhibiting the presynaptic release of acetylcholine Acetylcholine A neurotransmitter found at neuromuscular junctions, autonomic ganglia, parasympathetic effector junctions, a subset of sympathetic effector junctions, and at many sites in the central nervous system. Receptors and Neurotransmitters of the CNS:^[29]
  • ↓ Detrusor muscle Detrusor muscle Urinary Incontinence contractility
  • Injected directly into the detrusor muscle Detrusor muscle Urinary Incontinence of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess every 6–12 months via cystoscopy
  • May lead to bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess paralysis and higher rates of UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections (UTIs)
• Sacral neuromodulation (InterStim^®):^[29]
  • Beneficial primarily for OAB and neurogenic incontinence
  • Device is inserted subcutaneously in the buttock, with electrodes Electrodes Electric conductors through which electric currents enter or leave a medium, whether it be an electrolytic solution, solid, molten mass, gas, or vacuum. Electrocardiogram (ECG) placed near the sacral nerve 
  • Delivers an electric signal that stimulates the sacral nerve and aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS in bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess control
  • High rate of reintervention within 5 years due to device malfunction

Management of UUI/OAB in men^[24,25]

As in women, primary management of UUI/OAB in men is with pharmacologic agents. Additional options exist for those for whom medical management fails.

Medications:

• Antimuscarinic anticholinergics Anticholinergics Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs:
  • Helpful in OAB/UUI symptoms
  • Best for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with normal PVRs and without bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia
  • Use with caution in benign Benign Fibroadenoma prostatic hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation ( BPH BPH Benign prostatic hyperplasia (bph) is a condition indicating an increase in the number of stromal and epithelial cells within the prostate gland (transition zone). Benign prostatic hyperplasia is common in men > 50 years of age and may greatly affect their quality of life. Benign Prostatic Hyperplasia; especially when PVRs are ≥ 250 mL) in order to avoid worsening urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium.
  • Often given in combination with an α-blocker
  • Same drugs/dosing as for women ( darifenacin Darifenacin Anticholinergic Drugs, trospium, oxybutynin Oxybutynin Anticholinergic Drugs, solifenacin Solifenacin A quinuclidine and tetrahydroisoquinoline derivative and selective m3 muscarinic antagonist. It is used as a urologic agent in the treatment of urinary incontinence. Anticholinergic Drugs, fesoterodine Fesoterodine Anticholinergic Drugs, tolterodine Tolterodine An antimuscarinic agent selective for the muscarinic receptors of the bladder that is used in the treatment of urinary incontinence and urinary urge incontinence. Anticholinergic Drugs)
• β₃-Adrenergic agonists:
  • Typically 2nd-line, behind antimuscarinic anticholinergics Anticholinergics Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs
  • Best for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with normal PVRs and without bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia
  • Less concern about urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium than with anticholinergics Anticholinergics Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs
  • Same drugs/dosing as for women (mirabegron, vibegron)
• α₁-Adrenergic receptor Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors antagonists: 
  • Helpful for UI due to prostatic enlargement in men with BPH BPH Benign prostatic hyperplasia (bph) is a condition indicating an increase in the number of stromal and epithelial cells within the prostate gland (transition zone). Benign prostatic hyperplasia is common in men > 50 years of age and may greatly affect their quality of life. Benign Prostatic Hyperplasia and bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia
  • Function to relax the smooth muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Usually used in combination with other agents
  • Oral drugs (start with the lowest dose):
    • Doxazosin Doxazosin A prazosin-related compound that is a selective alpha-1-adrenergic blocker. Antiadrenergic Drugs 1–8 mg once daily 
    • Tamsulosin Tamsulosin A sulfonamide derivative and adrenergic alpha-1 receptor antagonist that is used to relieve symptoms of urinary obstruction caused by benign prostatic hyperplasia. Antiadrenergic Drugs 0.4 mg once daily
    • Alfuzosin 10 mg once daily
    • Silodosin 8 mg once daily with food
    • Terazosin Terazosin Antiadrenergic Drugs 1–10 mg once daily at bedtime
• 5α-Reductase inhibitors:
  • Helpful for UI due to prostatic enlargement in men with BPH BPH Benign prostatic hyperplasia (bph) is a condition indicating an increase in the number of stromal and epithelial cells within the prostate gland (transition zone). Benign prostatic hyperplasia is common in men > 50 years of age and may greatly affect their quality of life. Benign Prostatic Hyperplasia
  • Often used in combination
  • Oral drugs:
    • Finasteride Finasteride An orally active 3-oxo-5-alpha-steroid 4-dehydrogenase inhibitor. It is used as a surgical alternative for treatment of benign prostatic hyperplasia. Androgens and Antiandrogens 5 mg once daily
    • Dutasteride Dutasteride A 5-alpha-reductase inhibitor that is reported to inhibit both type-1 and type 2 isoforms of the enzyme and is used to treat benign prostatic hyperplasia. Androgens and Antiandrogens 0.5 mg once daily
• Botulinum toxin Botulinum toxin Toxic proteins produced from the species Clostridium botulinum. The toxins are synthesized as a single peptide chain which is processed into a mature protein consisting of a heavy chain and light chain joined via a disulfide bond. The botulinum toxin light chain is a zinc-dependent protease which is released from the heavy chain upon endocytosis into presynaptic nerve endings. Once inside the cell the botulinum toxin light chain cleaves specific snare proteins which are essential for secretion of acetylcholine by synaptic vesicles. This inhibition of acetylcholine release results in muscular paralysis. Botulism: for refractory symptoms
• Tibial nerve Tibial Nerve The medial terminal branch of the sciatic nerve. The tibial nerve fibers originate in lumbar and sacral spinal segments (L4 to S2). They supply motor and sensory innervation to parts of the calf and foot. Popliteal Fossa: Anatomy stimulation: for refractory symptoms

Additional nonsurgical options:

• Penile clamps:
  • Penile compression Compression Blunt Chest Trauma devices 
  • Suitable for light-to-moderate cases to prevent leakage of urine 
  • Short-term use 
• Catheterization:
  • Generally not recommended to manage UI symptoms
  • Indicated in individuals unable to empty their bladders and/or with urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium

Procedural options:

• Typical indications:
  • Bladder outlet obstruction Bladder Outlet Obstruction Benign Prostatic Hyperplasia/enlarged prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. with urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium 
  • Failed medical management
• Treatments for BPH BPH Benign prostatic hyperplasia (bph) is a condition indicating an increase in the number of stromal and epithelial cells within the prostate gland (transition zone). Benign prostatic hyperplasia is common in men > 50 years of age and may greatly affect their quality of life. Benign Prostatic Hyperplasia include:
  • Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. ablation: vaporization, laser, microwave
  • Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. resection
• Sacral neuromodulation:
  • Same procedure as in women (most studies with this technology are in women)
  • Candidates: men with refractory symptoms