Weak pelvic floor muscles causing stress incontinence, urge incontinence, and overactive bladder (OAB)
UTI and constipation commonly contribute, especially in older adults
Types:
- Stress: Weak sphincters leading to leakage with increased intra-abdominal pressure (e.g., coughing, laughing)
- Urge: Overactive bladder (OAB) with involuntary detrusor contractions ± weak sphincters
- Overflow: Poor bladder emptying due to detrusor underactivity or bladder outlet obstruction

Differential Diagnosis: DIAPPEERSSS

Delirium/dementiaInfection

Infection - UTI / interstitial cystitis

Atrophic vaginitis

Psychl (neuro) - MS, stroke, parkinsons, spinal cord inj, depression

Pharmaceuticals (anticholinergic inc TCA, diuretics, sedatives, opioids)

Excess fluids/weight - Alcohol, caffeine, ↑ intra-abdominal pressure

Endocrine - Diabetes (polyuria), hyperCa (polyuria, weak bladder)

Restricted mobility

Stool impaction

Sphincter weakness (childbirth, pelvic organ prolapse)

Sphincter blockage (bladder stone/tumour, BPH, prostate cancer, urethral stricture, ovarian tumour)

History

Type
- Stress: Worse with coughing, sneezing
- Urge: Sudden, strong need to void ± leakage
- Overflow: Incomplete emptying, dribbling
Storage symptoms: Frequency, urgency, nocturia
Voiding symptoms: Hesitancy, dribbling, incomplete emptying
Severity: Frequency, pad use, impact on QoL

Key History Questions to Differentiate Causes

Dysuria
Haematuria
Vaginal dryness / postmenopausal
Medication use
Etoh/caffeine intake
Restricted mobility
Constipation
Previous childbirths, prolapse
Weight loss
Previous prostatic surgery
Family history prostate ca
Bone pain
Incomplete emptying

Additional Considerations

Anticholinergics: Increase muscle relaxation → may worsen overflow incontinence, especially in neurological patients (e.g., Parkinson’s, dementia)
Urge incontinence → Often from bladder irritation (e.g., stones, infection, malignancy, atrophic vaginitis)

Examination

General Exam:

BMI: Obesity → Stress incontinence risk
Abdomen: Palpable bladder → Chronic retention, mass if suprapubic fullness
Neurological (Lower Limbs & Perineum): Assess for spinal cord pathology, MS, stroke

Women:

Pelvic exam: Atrophic vaginitis, pelvic organ prolapse
Pelvic floor strength: Ask patient to contract muscles
Cough test: Observe for stress incontinence

Men:

Genital exam: Phimosis, narrow meatus
DRE: Prostate size, consistency (BPH, malignancy)

Investigations:

US for KUB and PVR (>100mL abnorm)
Urine MCS
Bladder diary
Fasting BSL
eGFR (assess kid inj, more in men if susp retention)
STI screen
PSA

Key Notes:

Pelvic organ prolapse & atrophic vaginitis → Assess in women
PVR is crucial for differentiating overflow incontinence
Neurological causes → Consider in abnormal lower limb reflexes/perineal sensory loss
Bladder diary helps distinguish urge, stress, mixed, and overflow incontinence

Management

Non-Pharmacological

Bladder diary to identify patterns and triggers
Bladder training / timed voiding to increase bladder capacity and reduce urgency
Avoid excessive fluid intake, especially after midday
Avoid bladder diuretics (e.g., caffeine, alcohol) that increase urine production
Avoid bladder irritants (e.g., spicy foods, artificial sweeteners, carbonated drinks)
Pelvic floor exercises (e.g., Kegel exercises) to strengthen muscles and improve control
Maintain regular soft bowel motions with a high-fibre diet to prevent constipation, which worsens incontinence
Weight loss in overweight/obese patients to reduce intra-abdominal pressure and symptom severity
Smoking cessation as smoking worsens incontinence via chronic cough and bladder irritation

Pharmacological

Anticholinergics: Oxybutynin (patch formulation reduces dry mouth), solifenacin
Beta-adrenergic agonists: Mirabegron (useful in overactive bladder, fewer cognitive side effects than anticholinergics)
Vaginal oestrogens: Estradiol pessaries (limited evidence, but may improve urogenital atrophy in postmenopausal women)
Note: Laser ablation/resection of the prostate is as effective as TURP and may have fewer complications in selected patients

Benign Prostatic Hyperplasia (BPH) and Incontinence

All the above non-pharmacological strategies can be used for BPH-related incontinence
Mild BPH (IPSS <7): Non-pharmacological management alone may be sufficient
Alpha-blockers:
- Tamsulosin, prazosin (risk of postural hypotension, dizziness, erectile dysfunction)
5-alpha reductase inhibitors:
- Dutasteride (can cause erectile dysfunction, reduced libido)
- Combination therapy (tamsulosin + dutasteride = Duodart) for moderate to severe symptoms
Anticholinergics (e.g., oxybutynin, solifenacin) may be used in select cases with overactive bladder symptoms
Note: Consider using the International Prostate Symptom Score (IPSS) to guide management

Incontinence

Most Common Factor

Weak pelvic floor muscles: Contributes to stress incontinence, urge incontinence, and overactive bladder (OAB).
Common co-factors: UTI and constipation, especially in older adults, can exacerbate or unmask incontinence.

Types of Urinary Incontinence

Stress Incontinence
- Leakage with increased intra-abdominal pressure (coughing, laughing, sneezing, lifting).
- Typically due to weak sphincters or poor pelvic floor support (e.g. after childbirth).
Urge Incontinence / Overactive Bladder (OAB)
- Sudden, intense urge to void, ± involuntary detrusor contractions.
- May be triggered by bladder irritation (stones, infection, atrophic vaginitis).
Overflow Incontinence
- Incomplete bladder emptying leading to constant dribbling or leaking.
- Common in outflow obstruction (BPH, strictures) or detrusor underactivity (e.g. diabetes, neurological disorders).

Differential Diagnosis: DIAPPEERSSS

Delirium/Dementia: Cognitive impairment can lead to functional incontinence
Infection (UTI/interstitial cystitis)
Atrophic vaginitis (in women, post-menopausal changes)
Psychological/neurological conditions (MS, stroke, Parkinson’s, depression)
Pharmaceuticals: Anticholinergics (including TCAs), diuretics, sedatives, opioids
Excess fluids/weight (alcohol, caffeine, obesity → increased intra-abdominal pressure)
Endocrine disorders (diabetes → polyuria, hypercalcaemia → polyuria)
Restricted mobility (arthritis, frailty)
Stool impaction (faecal loading can impede bladder emptying)
Sphincter weakness (childbirth, pelvic organ prolapse) or Sphincter blockage (bladder stone/tumour, BPH, prostate cancer, urethral stricture)

History

Type of Incontinence:
- Stress: Leakage with coughing/sneezing/laughing.
- Urge: Sudden strong need to void ± leakage.
- Overflow: Chronic dribbling, incomplete emptying.
Storage Symptoms: Frequency, urgency, nocturia.
Voiding Symptoms: Hesitancy, dribbling, feeling of incomplete emptying.
Severity: Frequency of episodes, pad use, impact on quality of life.
Key Questions: Dysuria, haematuria, vaginal dryness (atrophy), medication use, caffeine/alcohol, mobility, constipation, obstetric history (childbirth/prolapse), weight loss, prior prostatic surgery or family history of prostate cancer, bone pain.

Additional Considerations

Anticholinergics can worsen overflow incontinence, especially in neurological patients (Parkinson’s, dementia).
Urge Incontinence may come from bladder irritation (stones, infection, malignancy, atrophic vaginitis).

Examination

General: Check BMI (obesity → increased risk of stress incontinence).
Abdomen: Look for a palpable bladder (chronic retention) or masses.
Neurological: Assess lower limb and perineal sensation/reflexes for possible neurological causes.
Women:
- Pelvic Exam: Evaluate for atrophic vaginitis, pelvic organ prolapse.
- Assess pelvic floor muscle strength (e.g. Kegel test).
- Cough Test: Observe for stress incontinence.
Men:
- Genital Exam: Look for phimosis, urethral abnormalities.
- DRE: Assess prostate size and consistency (suspect BPH, cancer if abnormal).

Investigations

Ultrasound (KUB) and Post-Void Residual (PVR): A PVR >100 mL suggests incomplete emptying/overflow.
Urine MCS: Exclude UTI or haematuria.
Bladder Diary: Track fluid intake, voiding times, volumes, and incontinence episodes.
Fasting BSL: Rule out diabetes if polyuria.
Renal Function (eGFR), especially in men with suspected retention.
STI Screen if urethritis or high-risk sexual history.
PSA if suspect prostatic pathology (men >50).
If red flags or suspicious for complex pathology: Cystoscopy, referral to urology.

Management

Non-Pharmacological

Bladder Diary: Identify patterns/triggers (fluid intake, certain foods).
Bladder Training / Timed Voiding: Gradually extend interval between voids, reduce urgency episodes.
Fluid Management: Avoid excessive fluid intake late in the day; limit bladder irritants (caffeine, alcohol).
Pelvic Floor Exercises (Kegel): Strengthen pelvic support, especially for stress incontinence.
Healthy Bowels: High-fibre diet to prevent constipation.
Weight Reduction if overweight; reduces intra-abdominal pressure.
Smoking Cessation: Chronic cough can worsen stress incontinence; nicotine can irritate the bladder.

Pharmacological

Anticholinergics for Overactive Bladder: e.g. oxybutynin (patch form reduces side effects), solifenacin
Beta-3 Agonist (Mirabegron): Fewer cognitive side effects; used for OAB
Vaginal Oestrogens (e.g. estradiol pessaries) for postmenopausal atrophic changes (limited evidence but can help dryness/irritation)

Prostate-Related Incontinence

For men with BPH:
- Alpha-blockers (tamsulosin, prazosin) to relax smooth muscle
- 5-alpha reductase inhibitors (dutasteride, finasteride) in moderate-severe BPH with enlarged prostate
- Consider anticholinergics only if overactive bladder symptoms are predominant (caution with large PVR)

Notes

Medication Overuse: Anticholinergics can worsen overflow in patients with neurological disease.
Laser ablation/resection of the prostate can be effective (alternative to TURP) if obstructive BPH is the main cause.
International Prostate Symptom Score (IPSS) can guide BPH severity and treatment.
Consider referral to urology if complicated or if initial measures fail.
Follow up to re-assess symptom control, compliance with pelvic floor exercises, and medication side effects.

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