Dx: Fluid overuse. The patient is drinking an excessive quantity of fluid, as evidenced by urine volume >2100 cc. (The International Continence Society defines polyuria as >40 mL/kg per day.14 )
Advise the patient to decrease her overall fluid intake, particularly within several hours of bedtime. Studies of tea and coffee consumption and incontinence have had conflicting results,15,16 and data on caffeinated soda consumption and incontinence are lacking. Nonetheless, patients should be advised that there is a possible association between caffeinated beverages and urinary incontinence. (In one small study, caffeine was found to cause a significant increase in detrusor pressure.17 ) Giving women one-time general instructions on fluid intake modification has been shown to significantly decrease incontinence episodes.18
Dx: Badly timed medication intake. This patient is taking one or more drugs that may contribute to incontinence, such as alpha-blockers or diuretics, either shortly before going to bed or before activities that make a bathroom visit inconvenient or impossible.
Adjust her medication regimen to minimize nocturia or urinary urgency during times of peak activity—eg, taking a diuretic early in the day instead of in the afternoon or evening, if possible. Keep in mind, however, that this strategy is based primarily on expert opinion, as very little evidence exists to show that medication of any type has a significant effect on urinary continence.19
Dx: Lower extremity edema with postural diuresis. The patient has nocturia, with larger total urine output at night than during the day. She may or may not have some leakage.
Women with lower extremity edema due to a variety of medical causes often experience postural diuresis overnight. If the patient is already on a diuretic, the problem can often be ameliorated by taking it early in the day instead of in the afternoon or evening; if she’s not, prescribe a small dose of a diuretic, to be taken in the morning. This therapeutic intervention has not been rigorously studied, but is relatively easy to implement and worth a try for patients with heart failure or other causes of pedal edema.
Dx: Constipation associated with autonomic dysfunction. Because the rectum and bladder are controlled by the same sacral segments of the spinal cord and share many autonomic ganglia, problems in one compartment often affect another. In a patient for whom incontinence is a minor, or occasional, problem while constipation is a major complaint, the optimal approach is to treat the constipation first and see if the urinary incontinence also resolves.
A trial of polyethylene glycol is a good place to start, particularly if there is no evidence of another correctable cause of the incontinence. Studies have shown that successful treatment of constipation often results in significant improvement of urinary urgency and frequency.20
TABLE
Anticholinergic medications for urge incontinence11,12
| Medication | Dosing | Comments |
|---|---|---|
| Oxybutynin | 2.5-5 mg bid to tid (≤5 mg qid) | Significant adverse effects, including constipation, dry mouth, blurred vision, urinary retention; confusion and sedation, particularly in elderly |
| Oxybutynin ER | 5-10 mg/d; increase weekly by 5-mg/d increments to ≤30 mg/d | |
| Oxybutynin transdermal patch (Oxytrol) | 1 patch 2x/wk on abdomen, hips, or buttocks (dose=3.9 mg/d) | Adverse effects may be less frequent than with oral medication due to the avoidance of metabolites |
| Oxybutynin transdermal gel (Gelnique) | 1 gel pack/d on abdomen, thighs, or shoulders (dose=100 mg in 1-g gel pack) | |
| Tolterodine (Detrol) | 1-2 mg bid (immediate release) or 2-4 mg/d (ER) | Similar effects and efficacy as oxybutynin, but adverse effects are decreased due to greater uroselectivity on muscarinic receptors |
| Darifenacin hydrobromide (Enablex) | 7.5 mg/d; increase to 15 mg/d after 2 wk if necessary | |
| Solifenacin (VESIcare) | 5-10 mg/d | |
| Fesoteridine (Toviaz) | 4-8 mg/d | |
| Trospium (Sanctura) | 20 mg bid (immediate release) or 60 mg/d (ER) | |
| ER, extended release. | ||
These conditions typically warrant a referral
Dx: Hematuria. Urinalysis with hematuria but no evidence of a urinary tract infection should raise a red flag, regardless of other findings. The patient should be referred for further urologic evaluation, including cystoscopy, although you may want to repeat the urinalysis with another clean-catch specimen first. Straight catheterization is not recommended in such a case, as a traumatized urethra can be a source of hematuria.
Dx: Stress incontinence with an anatomic abnormality. There are 2 options for a patient who has stress incontinence with an obvious cystocele on exam: Fit her with a pessary (or refer her to a physician who has this capability), or provide a referral to a urogynecologist for corrective surgery. Which option to choose should be a collaborative decision between patient and physician. For most women, it makes sense to try the pessary first.