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Urinary Incontinence
- Involuntary loss of urine due to dysfunction of bladder storage, outlet control, or both. Classified as stress, urge (overactive bladder), overflow, functional, or mixed types.
- Very common in women after menopause or childbirth. Overflow type occurs more often in men with benign prostatic hyperplasia or neurologic disease.
Clinical Presentation
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Stress Incontinence: Leakage with increased intra-abdominal pressure (cough, sneeze, laugh); common postpartum or post-menopause.
The question stem would likely describe a postmenopausal woman who reports urine leakage when she exercises, laughs, or coughs. -
Urge Incontinence: Sudden, strong urge to void with inability to reach the toilet in time; caused by overactive detrusor muscle; nocturia is common.
The question stem would likely describe a patient who feels an abrupt urge to urinate and cannot make it to the bathroom in time, often awakening several times at night. -
Overflow Incontinence: Dribbling and incomplete emptying due to bladder outlet obstruction or detrusor underactivity; seen with benign prostatic hyperplasia, neurogenic bladder, or diabetes.
The question stem would likely describe an older man with benign prostatic hyperplasia who reports dribbling urine and a sensation of incomplete emptying. -
Functional Incontinence: Normal bladder function but impaired mobility or cognition (dementia, post-stroke).
The question stem would likely describe an elderly nursing home resident with dementia who is unable to reach the bathroom before urinating. -
Mixed Incontinence: Combination of stress and urge symptoms; common in older women.
The question stem would likely describe an older woman with both leakage when coughing and episodes of urgency.
Diagnostics
- Urinalysis and urine culture: First step to rule out urinary tract infection.
- Serum BUN and creatinine: Assess renal function in chronic or severe cases.
- Post-void residual measurement:
- Less than 50 mL is normal.
- Greater than 200 mL suggests overflow incontinence.
- In older adults, a residual up to about 100 mL can be normal.
- Bladder stress (cough) test: With a full bladder, immediate leakage after a single cough confirms stress incontinence.
- Voiding diary (48–72 hours) and medication review: Identify transient or medication-related causes (e.g., diuretics, anticholinergics, calcium-channel blockers, opioids, alpha-blockers).
- Urodynamic studies: A small catheter measures bladder pressure and urine flow during filling and emptying; used to identify detrusor overactivity, impaired contractility, or outlet obstruction when the diagnosis is uncertain or before surgery.
- Neurologic evaluation: Consider if diabetic neuropathy or spinal cord involvement is suspected.
Treatment
Step 1: Behavioral and Lifestyle Measures
- Bladder training: Scheduled voiding at gradually longer intervals to increase bladder capacity and reduce urgency episodes.
- Timed voiding and fluid management; limit caffeine, alcohol, and bladder irritants.
- Kegel (pelvic floor) exercises for stress incontinence.
- Weight loss and smoking cessation.
- Topical vaginal estrogen for postmenopausal atrophic urethritis or vaginitis contributing to symptoms.
Step 2: Pharmacologic Management (Type-Specific)
- Urge / Overactive bladder:
- Antimuscarinic agents (oxybutynin, tolterodine) reduce detrusor contractions. Avoid in gastric retention or untreated narrow-angle glaucoma and in patients with high post-void residuals.
- Beta-3 adrenergic agonist (mirabegron) relaxes bladder muscle; use if antimuscarinics are not tolerated. Avoid in uncontrolled hypertension.
- Overflow incontinence:
- Alpha-adrenergic blockers (tamsulosin, terazosin) relieve obstruction in benign prostatic hyperplasia.
- Intermittent self-catheterization as needed.
- Bethanechol may help stimulate detrusor contraction in neurogenic bladder (limited use).
- Stress incontinence:
- Pelvic floor therapy first-line.
- Pseudoephedrine (alpha-agonist) may increase urethral tone but is rarely used.
- Pessary can be used when pelvic organ prolapse contributes or surgery is undesired.
- Functional incontinence:
- Environmental modifications, scheduled toileting, and mobility support.
Step 3: Surgical and Procedural Options
- Stress incontinence: Mid-urethral sling or urethropexy for refractory cases.
- Overflow incontinence: Surgical relief of outlet obstruction (e.g., transurethral resection of the prostate).
- Refractory urge/overactive bladder: Posterior tibial nerve stimulation, sacral neuromodulation, or intradetrusor botulinum toxin after failure of conservative or medication therapy.
Exam Keys
- Leakage with coughing or sneezing → Stress incontinence → Pelvic floor therapy → Sling procedure if refractory. Add topical estrogen for atrophic changes or use a pessary if prolapse contributes.
- Sudden urge and nocturia → Urge incontinence → Oxybutynin or bladder training. If refractory, consider posterior tibial nerve stimulation, sacral neuromodulation, or intradetrusor botulinum toxin. Exclude urinary retention before treatment.
- Dribbling, weak stream, high post-void residual, benign prostatic hyperplasia history → Overflow incontinence → Tamsulosin or intermittent catheterization → TURP if obstruction persists.
- Incontinence in dementia or immobility → Functional incontinence → Scheduled toileting and assistance.
- Medication associations: diuretics can precipitate urgency; anticholinergics, calcium-channel blockers, and opioids can cause retention or overflow; alpha-blockers can worsen stress incontinence in women.
- Avoid antimuscarinic drugs in overflow incontinence—they can worsen urinary retention.
Overactive Bladder (OAB)
- Urgency, frequency, and nocturia with or without urge incontinence, in the absence of infection or another identifiable cause.
- Caused by detrusor muscle overactivity, leading to involuntary bladder contractions and reduced control.
- Common in older adults; chronic but not life-threatening.
Clinical Presentation
- Urinary urgency, frequent small-volume voids (more than 7–8 times per day), and nocturia.
- May have urge incontinence if unable to reach the toilet in time.
- No dysuria, hematuria, or fever—these findings suggest infection or another etiology.
- The question stem would likely describe an older adult who reports a sudden, strong urge to urinate, frequent small voids during the day and night, and no signs of infection.
Diagnostics
- Urinalysis and culture: Rule out urinary tract infection.
- Post-void residual: Normal (less than 50 mL).
- Voiding diary: Tracks voiding frequency, timing, and fluid intake.
- Medication review: Identify contributing agents (diuretics, caffeine, alcohol).
- Urodynamic studies: May show uninhibited detrusor contractions; reserved for unclear or refractory cases.
- Cystoscopy: Consider only if hematuria or pelvic pain is present.
Treatment
Step 1: Behavioral and Lifestyle Measures
- Bladder training: Timed voiding with gradually increasing intervals to improve bladder capacity and control.
- Pelvic floor (Kegel) exercises: Strengthen muscles controlling detrusor activity.
- Limit caffeine, alcohol, and bladder irritants.
- Weight reduction and constipation management.
Step 2: Pharmacologic Management
- Antimuscarinics: Oxybutynin, tolterodine, solifenacin—reduce detrusor contractions. Avoid in glaucoma, gastric retention, or elevated post-void residuals.
- Beta-3 agonist: Mirabegron or vibegron—relax bladder muscle; alternative when antimuscarinics are not tolerated. Avoid in uncontrolled hypertension.
Step 3: Procedural and Surgical Options
- Posterior tibial nerve stimulation (noninvasive) or sacral neuromodulation (implant) for refractory cases.
- Intradetrusor botulinum toxin injections reduce detrusor contractions; effects last about 6–9 months.
- Augmentation cystoplasty: Rare; reserved for severe, refractory cases.
Exam Keys
- Urgency, frequency, nocturia without infection → Overactive bladder → Bladder training and Kegel exercises first-line.
- Behavioral therapy fails → Add oxybutynin or tolterodine.
- Antimuscarinics not tolerated → Use mirabegron.
- Persistent symptoms → Posterior tibial nerve stimulation or botulinum toxin.
- Normal post-void residual distinguishes OAB from overflow incontinence.
- Absence of dysuria or hematuria differentiates from urinary tract infection or bladder cancer.
Bladder Prolapse (Cystocele)
- Descent of the bladder into the anterior vaginal wall due to weakened pelvic floor or loss of connective tissue support.
- Common in postmenopausal women, those with multiple vaginal deliveries, or chronic increased intra-abdominal pressure (obesity, cough, constipation).
Clinical Presentation
- Vaginal “bulge,” pelvic pressure, or heaviness, worse with standing or straining.
- May have urinary frequency, incomplete emptying, or stress incontinence.
- Exam shows anterior vaginal wall protrusion, accentuated by Valsalva.
- The question stem would likely describe a postmenopausal woman with a vaginal bulge and urine leakage when coughing or standing, relieved when lying down.
Diagnostics
- Pelvic exam: Confirms diagnosis; bladder descends into the anterior vaginal wall during Valsalva.
- Post-void residual: May be increased if incomplete emptying.
- Urinalysis: Rule out UTI.
- Imaging rarely needed—clinical diagnosis.
Treatment
Mild: Pelvic floor (Kegel) exercises, topical vaginal estrogen, pessary support.
Moderate/Severe: Surgical repair with anterior colporrhaphy (bladder suspension).
Avoid heavy lifting, manage chronic cough or constipation.
Exam Keys
- Vaginal bulge or pelvic pressure → Cystocele.
- Urinary symptoms plus anterior vaginal wall protrusion → Bladder prolapse.
- First-line: Kegel exercises or pessary.
- Definitive: Anterior colporrhaphy.
- Distinguish from rectocele (posterior wall bulge, constipation) and uterine prolapse (uterine descent).
Cryptorchidism
- One or both testes absent from the scrotum due to failure of descent.
- Most common congenital GU abnormality; usually unilateral.
- Increases risk of infertility, testicular torsion, and malignancy (seminoma).
Risk Factors
- Premature birth
- Low birth weight
- Family history of undescended testes
Clinical Presentation
- Found on routine pediatric exam as an empty or underdeveloped hemiscrotum.
- Testis may be nonpalpable or located in the inguinal canal or abdomen.
- The question stem would likely describe an infant boy with one side of the scrotum empty on physical exam.
Diagnostics
- Physical exam: Provider unable to palpate one or both testicles.
- Ultrasound: Used if the testis is nonpalpable.
- MRI: Considered if ultrasound is inconclusive.
- Differentiate from retractile testis, which can be manipulated into the scrotum.
Treatment
- Initially watchful waiting: Most testes descend by 6–12 months of age.
- If persistent after 6 months (definitely by 1 year): → Orchiopexy.
- hCG injections may stimulate testosterone and descent but are less reliable.
- Early surgery (<12–24 months) reduces risk of infertility and malignancy.
Exam Keys
- Infant with empty scrotum on one side → Observe until 6 months → Orchiopexy if persistent.
- Increased risk of testicular torsion and cancer even after correction.
- Bilateral nonpalpable testes → Evaluate for endocrine or chromosomal disorder.
- Retractile testis is normal variant—no treatment needed.
Peyronie Disease
- Fibrous scar tissue formation within the tunica albuginea of the penis causes curvature or deformity during erection.
- May lead to painful erections and difficulty with intercourse.
- Thought to result from microvascular trauma and abnormal wound healing.
Clinical Presentation
- Curved or bent penis during erection.
- Penile pain or discomfort with erection.
- Erectile dysfunction in some cases.
- The question stem would likely describe a middle-aged man with progressive penile curvature and painful erections that interfere with sexual activity.
Diagnostics
- Clinical diagnosis based on exam and history.
- Ultrasound may be used to confirm presence and extent of fibrous plaque.
Treatment
- Observation: Mild cases may resolve spontaneously.
- Intralesional injections: Verapamil, collagenase (Xiaflex), or corticosteroids may reduce plaque size and curvature.
- Surgery: Indicated for severe deformity or when conservative measures fail (e.g., plaque excision, grafting, or plication).
Exam Keys
- Penile curvature with pain during erection → Peyronie disease.
- Caused by fibrous plaque in tunica albuginea.
- Mild: Observation.
- Moderate to severe: Intralesional therapy or surgical correction.
- Distinguish from congenital curvature (present since adolescence, no pain).
Genitourinary Trauma
- Injury to the kidneys, ureters, bladder, or urethra from blunt or penetrating trauma.
- Common mechanisms: motor vehicle accidents, pelvic fractures, or straddle injuries.
- May cause hematuria, urinary retention, or flank/perineal bruising.
Clinical Presentation
- Renal trauma: Flank pain, ecchymosis, gross or microscopic hematuria after blunt injury.
- Bladder injury: Suprapubic pain, inability to void, distended abdomen, hematuria—often with pelvic fracture.
- Urethral injury: Blood at urethral meatus, perineal bruising, high-riding or nonpalpable prostate.
- Penile trauma: Rapid swelling or deformity after sexual activity → suspect penile fracture (tunica albuginea rupture).
- The question stem would depend on the type of trauma.
Diagnostics
- Urinalysis: Check for hematuria.
- CT abdomen/pelvis with contrast: For suspected renal or bladder trauma.
- Retrograde urethrogram (RUG): Always perform before catheterization if urethral injury is suspected (blood at meatus, pelvic fracture).
- Cystography (retrograde cystogram): To confirm bladder rupture.
Treatment
- Renal trauma: Conservative if stable; surgery for vascular injury or severe laceration.
- Bladder rupture:
- Extraperitoneal → Foley catheter drainage.
- Intraperitoneal → Surgical repair.
- Urethral injury: Surgical repair after suprapubic catheter placement.
- Penile fracture: Surgical repair of tunica albuginea.
Exam Keys
- Blood at urethral meatus → Do NOT insert Foley catheter → Perform retrograde urethrogram first.
- Gross hematuria after trauma → CT abdomen/pelvis with contrast.
- Pelvic fracture + urinary retention → Suspect urethral injury.
- Suprapubic pain + distension + pelvic fracture → Bladder rupture.
- Sudden penile pain + “snapping” during intercourse → Penile fracture → Surgical repair.
Vesicoureteral Reflux (VUR)
- Retrograde flow of urine from the bladder into the ureters and kidneys due to an incompetent vesicoureteral junction (UVJ).
- Primary VUR: Congenital defect (short intramural ureter, familial tendency).
- Secondary VUR: Results from increased bladder pressure due to obstruction or dysfunction (posterior urethral valves, neurogenic bladder, recurrent infection).
- Goal of management: Prevent infection and renal scarring, not just correct reflux.
Clinical Presentation
- Recurrent febrile urinary tract infections or pyelonephritis in infants and children.
- May present with poor growth, flank pain, or hypertension if chronic.
- Often discovered incidentally after evaluation for prenatal hydronephrosis or sibling screening.
- The question stem would likely describe a young child with recurrent febrile UTIs and renal ultrasound showing hydronephrosis or cortical scarring.
Diagnostics
- Urinalysis and culture: Confirm infection.
- Renal ultrasound: Initial study for hydronephrosis or renal scarring.
- Voiding cystourethrogram (VCUG): Diagnostic test of choice; shows retrograde urine flow during voiding.
- DMSA renal scan: Evaluates renal cortical scarring.
- Grading (I–V):
- I–II: Reflux into ureter ± renal pelvis without dilation
- III: Mild/moderate dilation
- IV–V: Severe dilation and tortuosity
Treatment
- Grades I–II (mild): Observation ± low-dose antibiotic prophylaxis; most resolve spontaneously.
- Grades III–V or recurrent febrile UTIs: Continuous antibiotic prophylaxis (TMP-SMX, nitrofurantoin, or cephalexin).
- Endoscopic Deflux injection (dextranomer/hyaluronic acid): Minimally invasive treatment for moderate/severe reflux refractory to medical therapy.
- Surgical ureteral reimplantation: For persistent high-grade or complicated cases (renal scarring, recurrent pyelonephritis).
- Supportive measures: hydration, timed/double voiding, constipation prevention, and perineal hygiene.
Exam Keys
- Recurrent febrile UTI in a child → Order VCUG.
- Low-grade: Observation ± prophylactic antibiotics.
- High-grade or recurrent infection: Endoscopic Deflux injection or surgical correction.
- Major risk → renal scarring → hypertension → CKD.
- ~25% of siblings may also have VUR (familial tendency).
- Focus on preventing infection and renal damage rather than eliminating reflux itself.
