Urinary incontinence differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Differential diagnosis

Urinary incontinence may have different etiologies depending upon the underlying dysfunction. The various types of urinary incontinence should be differentiated from each other for optimal management. The following table differentiates the various types of urinary incontinence:

Diseases		Type of incontinence				Clinical manifestations										Para-clinical findings						Gold standard	Additional findings
						Symptoms							Physical examination
																Lab Findings			Imaging
						Loss of consciousness	Fever	Abdominal pain	Urinary symptoms				Hypertension	Pitting edema	Neurological deficit	Urine residue	Urinalysis	Other	Ultrasonography	CT scan	Other
		Urge	Stress	Functional	Overflow				Dysuria	Frequency	Dribbling	Nocturia
Neurological diseases	Stroke	+	+	-	-
	Alzheimer's disease	+	+	-	-
	Parkinson's disease	+	+	-	-
	Altered mental status	-	-	+	-
	Traumatic spinal cord injury	-	+	-	-
	Multiple sclerosis	+	-	-	+
Urogenital disorders	Benign prostatic hyperplasia	+	-	-	+
	Genitourinary surgical procedures	+	+	-	-
	Multiple childbirths	+	+	-	-
	Uterine fibroids	-	-	-	+
	Uterine prolapse	-	+	-	-
Gastrointestinal diseases	Fecal impaction	-	-	-	+
	Rectal prolapse	-	-	-	+

Type Of Incontinence	Causes	Prevalence	Pathophysiology	History Findings	Signs and symptoms							Management
					Urgency	Frequency (> 8 times/day)	Dribbling of urine	Amount of dribbling with each episode of incontinence	Ability hold urge	Nocturia	Post-void residual volume
Urge incontinence (detrusor instability)	Stroke Alzheimer's disease Parkinson's disease Benign prostatic hyperplasia (BPH)	9% in women age 40-44 years 31% in women older than 75 years 42% in men older than 75 years	Detrusor overactivity Increased parasympathetic drive to the bladder (S2-S4)	Variable amount of urine loss; ranging from small volumes to complete emptying of the bladder	+	+	-	Small to large volume	-	++	< 50 ml	Pelvic floor excercises Oxybutynin Tolterodine
Stress incontinence	Genitourinary surgical procedures Multiple childbirths	25-45% in women > 30 years	Weakness of the uretheral sphincter Weakness of the pelvic floor muscles	Patient recognizes which activities promote incontinence Incontinence with cough, sneezing, straining	-	-	+	Small volume	+	+/-	< 50 ml	Pelvic floor excercises Alpha agonists Topical estrogen cream
Overflow incontinence	Benign prostatic hyperplasia Fecal impaction	5% of patients with chronic incontinence More common in males	Overdistension of the bladder Impaired bladder contractility Bladder outlet obstruction (BOO)	Poor bladder emptying Post-void urine volume > 200-300 ml	-	-	+	Small volume	+	+	> 200 ml	Alpha-adrenergic blockers: Tamsulosin Terazosin Catheterization Diversion
Mixed incontinence (urge and stress)	Stroke Alzheimer's disease Parkinson's disease Benign prostatic hyperplasia (BPH) Genitourinary surgical procedures Multiple childbirths	-	Combined urge and stress incontinence	Patient able to determine the pre-dominant symptoms	+	+/-	+	Variable volume	+/-	+/-	Variable	Symptomatic management
Functional incontinence	Altered mental status	-	Inability to reach the toilet to urinate Environmental barriers Physical barriers	Immobility Lower urinary tract deficits	-	-	+	Variable volume	+	+	< 50 ml	Cause-dependent