Urinary Incontinence
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Direct answer
Female urinary incontinence divides into stress incontinence — leakage with coughing, sneezing or exertion from sphincter weakness, the commonest type in parous women — urgency or urge incontinence from detrusor overactivity, mixed incontinence combining both, and overflow incontinence from chronic retention, plus continuous leakage from fistulae or ectopic ureters. Stress incontinence is treated first with pelvic floor muscle training and weight loss, then a mid-urethral sling (retropubic TVT or transobturator TOT) when conservative care fails; urge incontinence responds to bladder training with antimuscarinics or the beta-3 agonist mirabegron, and refractory cases to intravesical botulinum toxin. In India, obstetric vesicovaginal fistula remains an important cause of continuous leakage demanding surgical repair.
What you must remember
- Stress urinary incontinence: leakage on exertion from urethral hypermobility or intrinsic sphincter deficiency, commoner after vaginal births and at menopause.
- Urge incontinence: involuntary detrusor contractions producing urgency with frequency and nocturia, with or without leakage; mixed incontinence shows both patterns — treat the dominant symptom first.
- Overflow incontinence: chronic retention with dribbling and a palpable bladder from an atonic bladder (diabetes, post-surgical) or obstruction; continuous leakage in a girl suggests an ectopic ureter, and after surgery or radiotherapy a genitourinary fistula.
- Evaluation: bladder diary, urinalysis and culture, cough stress test, post-void residual by ultrasound; urodynamics (cystometry) before surgery and in confusing or neurogenic cases.
- Stress incontinence: supervised pelvic floor training for at least three months and weight loss first; peri-urethral bulking agents suit selected unfit women.
- Surgery for stress incontinence: mid-urethral slings — retropubic tension-free vaginal tape or transobturator tape — are standard, with Burch colposuspension and fascial slings as alternatives; prolapse-mesh restrictions do not ban these tapes.
- Urge incontinence: bladder training and fluid advice first, then antimuscarinics (oxybutynin, tolterodine, solifenacin — dry mouth, constipation, caution in glaucoma and cognitive impairment), mirabegron as a beta-3 alternative, posterior tibial nerve stimulation, and intravesical botulinum toxin for refractory disease.
Common confusion
The examinable split is the trigger: leak with cough equals stress, leak with a sudden irresistible urge equals urge, both equal mixed — operating on an undiagnosed mixed case worsens the urge component. Continuous all-day leakage is not stress incontinence but a fistula or ectopic ureter until proved otherwise. Overflow presents as "incontinence" but is retention — the residual volume, not the pad, makes the diagnosis.
Exam-focused takeaway
FMGE pairs symptom pattern with treatment class: stress — pelvic floor training then mid-urethral tape; urge — bladder training then antimuscarinics; refractory urge — botulinum toxin; continuous leak — fistula repair. Know the antimuscarinic side-effects, mirabegron's beta-3 mechanism, and urodynamics as the pre-surgical test.
Frequently asked questions
How do stress and urge incontinence differ?
Stress incontinence leaks with exertion, coughing or sneezing from sphincter weakness; urge incontinence leaks with a sudden compelling need to void from detrusor overactivity, usually with frequency and nocturia.
What is the first treatment for stress urinary incontinence?
Supervised pelvic floor muscle training for at least three months with weight loss and control of cough and constipation; surgery follows when conservative therapy fails.
Which surgery is standard for stress incontinence?
Mid-urethral sling procedures — retropubic tension-free vaginal tape or transobturator tape — with Burch colposuspension and autologous fascial slings as alternatives.
Which drugs treat urge incontinence?
Bladder training with antimuscarinics such as oxybutynin, tolterodine or solifenacin (beware dry mouth, constipation, glaucoma and cognitive caution), or the beta-3 agonist mirabegron.
What does continuous urinary leakage suggest?
A genitourinary fistula (vesicovaginal or ureterovaginal, after obstetric trauma, surgery or radiotherapy) or an ectopic ureter in a girl — both need surgical repair, not drug trials.