Bladder outlet obstruction (e.g., BPH ).Neuropathy and polyuria in diabetes mellitus.Neurogenic bladd er in multiple sclerosis.Impaired (weak) detrusor contractility due to:. Overflow incontinence ( overflow bladder ) Long-term management: usually surgical (e.g., fistula repair), in consultation with urology and/or urogynecology.Short-term management: pads and external catheters.Urinary leakage occurs at all times, with no associated preceding symptoms or specific trigger activity.Complete loss of sphincter function (due to previous surgery, nerve damage, metastasis) or abnormal anatomy ( fistula between urinary tract and skin).Treat the most bothersome symptom first, e.g., anticholinergics for urge incontinence.May have any of the clinical features above.Combination of mechanisms of stress incontinence and urge incontinence.See “ Treatment of urge incontinence” for additional information.Second line: interventional procedures (e.g., sacral nerve stimulation, injection of botulinum toxin into the bladder wall).Strong, sudden sense of urgency, followed by involuntary leakage.Inflammatory conditions (e.g., UTI ) or neurogenic disorders → sphincter dysfunction, detrusor overactivity, or overactive bladder → autonomous contractions of the detrusor muscle and premature initiation of a normal micturition reflex.See “ Treatment of stress incontinence” for additional information.Surgical procedures (e.g., urethral slings or suspensions, artificial urinary sphincter).Injection of periurethral bulking agents.Minimally-invasive solutions, e.g., vaginal pessaries or urethral inserts.In refractory or severe incontinence, refer to urology for:.Trial of conservative management of UI for 6–8 weeks.Positive bladder stress test : urinary leakage during activities that increase intraabdominal pressure (e.g., coughing, Valsalva maneuver).Increase in intraabdominal pressure (e.g., from laughing, sneezing, coughing, exercising) → ↑ pressure within the bladder → bladder pressure > urethral sphincter resistance to urinary flow.Intrinsic sphincter deficiency, caused by:.Childbirth (i.e., damage of the pelvic floor muscle levator ani and/or the S2 – S4 nerve roots ).Poor pelvic support caused by pelvic postmenopausal estrogen loss.Urethral hypermobility in women ( bladder outlet incompetence ) secondary to:.To remember the reversible causes of acute urinary incontinence, think DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/ vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output ( hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.
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