Urinary Incontinence: Evaluation and Medical/Surgical Management
Classification and evaluation
Stress urinary incontinence (SUI) is leakage with effort/sneezing/coughing; urge incontinence is associated with urgency; mixed has both. Initial evaluation: history, bladder diary, urinalysis, postvoid residual, pelvic exam, cough stress test. Urodynamics is indicated for complex cases, prior surgery, neurogenic bladder, or discrepancy between symptoms and findings.
Management ladder
Behavioral therapy (pelvic floor muscle training, weight loss, fluid/caffeine modification) is first-line for SUI and mixed. For SUI, midurethral sling (retropubic or transobturator) and Burch colposuspension are effective surgical options; bulking agents for selected patients. For urgency incontinence: bladder training, pelvic floor training, then antimuscarinics or beta-3 agonists (mirabegron); refractory cases may need botulinum toxin, sacral neuromodulation, or PTNS.
Traps
- Offering surgery for SUI without confirming the diagnosis (cough stress test, consider urodynamics).
- Missing urinary retention or overflow incontinence (elevated PVR) before starting anticholinergics.
- Assuming antimuscarinics are safe in elderly without anticholinergic burden consideration.
- Confusing urgency incontinence with SUI; mixed incontinence needs stepwise therapy.
Rule of thumb
Treat the most bothersome component first and reassess. In mixed incontinence, treat urgency symptoms before SUI surgery if urgency is predominant, because SUI surgery may not resolve urgency.