Urinary Incontinence and Lower Urinary Tract Dysfunction
What you must know
Classify incontinence: stress (urethral hypermobility/intrinsic sphincter deficiency), urgency (detrusor overactivity or sensory urgency), mixed, overflow (retention), and functional. Understand the continence mechanism - urethral closure pressure plus supportive hammock - and how each fails.
Behavioral therapy (bladder training, timed voiding, fluid/caffeine modification, pelvic floor muscle training with biofeedback) is first line for both stress and urgency. Pharmacotherapy: antimuscarinics (dry mouth, constipation, cognitive concerns) and beta-3 agonists (hypertension caution). Refractory urgency: onabotulinumtoxinA, sacral neuromodulation, posterior tibial nerve stimulation. Stress: midurethral sling (retropubic or transobturator), Burch colposuspension, bulking agents for intrinsic sphincter deficiency.
Understand retention and overflow, urethral obstruction after sling, and catheter management. Know de novo urgency after sling and the workup of voiding dysfunction (PVR, urodynamics, sling loosening/division).
Traps
Equating urgency incontinence with "overactive bladder" without excluding infection, stones, or malignancy. Another trap: choosing surgery first for urgency. Remember antimuscarinics can worsen cognition and constipation; beta-3 agonists can raise blood pressure. Don't forget that overflow incontinence requires relieving obstruction, not antimuscarinics.
Rule of thumb
"Leaks with cough = stress; leaks with urge = urgency; leaks without warning or with incomplete emptying = overflow." Treat overflow by restoring emptying.
Worked example: A woman with diabetes, a PVR of 400 mL, and continuous leakage. This is overflow from an underactive bladder or obstruction; the next step is catheter drainage and evaluation, not anticholinergic therapy.