Female Urology, Neurourology, and Voiding Dysfunction
Incontinence categories
Stress urinary incontinence is leakage with increased abdominal pressure; urgency incontinence is leakage preceded by urgency; mixed incontinence combines both. Diagnosis rests on history, examination, cough stress test, post-void residual, and urodynamics in complex, neurogenic, or previously failed cases. Intrinsic sphincter deficiency versus urethral hypermobility influences surgical choice; midurethral sling and colposuspension are the mainstays, with pelvic floor training and pessaries as conservative options.
Overactive bladder
Management is stepwise: behavioural therapy, then antimuscarinic or beta-3 agonist, then intradetrusor onabotulinumtoxinA with counselling about retention, then sacral neuromodulation or augmentation. Refractory symptoms require cystoscopy and cytology to exclude malignancy or stones.
Neurogenic bladder
Upper motor neuron lesions cause detrusor overactivity with detrusor-sphincter dyssynergia and risk of high-pressure renal injury; lower motor neuron lesions cause an acontractile bladder managed with clean intermittent catheterisation. Surveillance includes video-urodynamics and upper-tract imaging.
Traps
Prescribing antimuscarinics to a patient with a high post-void residual; diagnosing stress incontinence without objective demonstration; forgetting that sacral neuromodulation requires a trial period; attributing new incontinence after sling surgery to persistence rather than obstruction or erosion.
Worked example
A 65-year-old woman leaking with coughs, a positive cough stress test at 300 mL, and a low residual has stress incontinence; she should start pelvic floor training and be offered a midurethral sling, not antimuscarinics.