Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2749_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter 34 • Urinary Incontinence
https://t.me/med1917
399
Box 34-1
Reversible Factors That Can Cause
Urinary Incontinence in Adults
D Delirium, dementia, depression
I Infection
A
Atrophic vaginitis/urethritis
P Pharmaceuticals
E
Endocrine/excess urine production
R Restricted mobility, retention
S Stool impaction
Modified from Resnick NM: Initial evaluation of the incontinent patient,
J Am Geriatr Soc 38:311, 1990.
l
Do you have vaginal dryness or itching?
l
Do you have pain/discomfort with sexual activity?
l
Have you had changes in bowel function?
l
When was your last bowel movement?
l
Are you feeling depressed or “blue”?
l
Are you aware of any urinary incontinence?
l
How active are you?
l
Are you able to get to the toilet easily?
l
Do you have any chronic health problems?
Medications
Hypnotic-sedatives, diuretics, anticholinergic agents,
adrenergic agents, and calcium channel blockers
can cause incontinence. a-Adrenergic agonists and
b-adrenergic agonists increase sphincter tone and
may cause retention. Anticholinergics, prostaglandin
inhibitors, calcium channel blockers, and narcotic
analgesics decrease detrusor tone. Diuretics can cause
incontinence because of increased production of
urine. Central nervous system (CNS) depressants,
such as hypnotic-sedatives, can interfere with func-
tional ability.
Table 34-1 lists categories of medications and their
mechanism of action in urinary incontinence.
Urinary Tract Infection, Vaginal Dryness,
and Dyspareunia
Urinary tract infection (UTI) and atrophic vaginitis can
cause incontinence through local irritation and loss of
muscle tone. Pain with sexual intercourse and vaginal
dryness can be a sign of atrophic vaginitis.
Bowel Function
Fecal impaction can cause incontinence through
mechanical obstruction of the urethra.
Mental Status, Mobility, and Chronic Health
Problems
Excessive urine production may be a problem if mobil-
ity is restricted, health is poor, or orientation is variable.
Chronic health problems, psychological factors, and
restricted mobility can result in incontinence because of
loss of functional ability and/or mentation.
What do the presenting symptoms tell me?
Key Questions
l
What is the primary symptom (e.g., urgency; dribbling;
lack of sensation; nocturia; abdominal discomfort;
Table 34-1
Medications That Can Cause or Contribute to Urinary Incontinence
MEDICATION CATEGORY TYPE OF INCONTINENCE MECHANISM OF ACTION
Anticholinergics Overflow Decreased bladder contractions with retention
Antidepressants Overflow Decreased bladder contractions with retention
Antipsychotics Overflow Decreased bladder contractions with retention
Sedative-hypnotics Overflow Decreased bladder contractions with retention
Antihistamines Overflow Decreased bladder contractions with retention
Narcotics Overflow Decreased bladder contractions with retention
Alcohol Overflow Decreased bladder contractions with retention
Calcium channel blockers Overflow Decreased bladder contractions with retention
b-Adrenergic agonists
a-Adrenergic agonists
a-Adrenergic antagonists
Diuretics Urge Contractions stimulated by high urine flow
Caffeine Urge Diuretic effect
Sedative-hypnotics Urge Depressed CNS inhibition of micturition
Alcohol Urge Diuretic effect and depressed CNS inhibition
Adapted from Weiss BD: Diagnostic evaluation of urinary incontinence in geriatric patients, Am Fam Physician 57:2675, 1998.
Overflow Decreased bladder contractions with retention
Overflow Sphincter contraction with outflow obstruction
Stress Sphincter relaxation with urinary leakage
400
https://t.me/med1917
Chapter 34 • Urinary Incontinence
burning; leakage with laughing, coughing, or
sneezing)?
l
How frequently do you urinate?
l
How much urine is voided each time?
l
Do you have difculty starting to urinate?
l
Does your urine stream start and stop while you are
urinating?
l
Do you urinate involuntarily when you cough,
sneeze, or exercise?
Primary Symptom
Urgency incontinence is the primary symptom of detrusor overactivity. Symptoms of urgency incontinence
are involuntary leakage with the sense of urgency to
urinate.
The symptoms of stress incontinence are leakage
of urine associated with increased intra-abdominal
pressure commonly caused by sneezing, laughing,
coughing, or working out. Stress incontinence is
caused by sphincter dysfunction. The severity of
provoked symptoms varies based on the level of
sphincter dysfunction.
Overow incontinence is often described by
urinary dribbling, urinary leakage, and the feeling
of incomplete bladder emptying. Overow incontinence is caused by dysfunctional detrusor contractility or bladder outlet obstruction. Men often report
nocturia and dribbling with overow incontinence.
Abdominal discomfort often occurs with overow
incontinence because of bladder distention. A decrease in urine frequency can be caused by overow
incontinence. This can lead to a buildup of urine
in the bladder that may result in a secondary stress
incontinence.
Frequency of Voiding
Increase in frequency of voiding occurs with detrusor
instability or hyperactivity and may occur with some
transient causes such as use of diuretics or largevolume uid intake. Decreased frequency is common
in overow incontinence.
Amount of Urine Lost With Each Episode
Involuntary loss of small amounts of urine occurs with
stress incontinence and overow incontinence.
Are there any other symptoms that will point me in the
right direction?
Key Questions
l
How much uid do you drink in a day?
l
How much caffeine and alcohol do you drink in a day?
l
What time of day do you drink uids?
l
How thirsty are you?
l
Have you lost or gained weight recently?
Fluid Intake
A signicant increase in the amount of uid intake
or an unusually large volume may indicate diabetes
mellitus (DM). Caffeine and alcohol can act as diuretics and may be a cause of reversible incontinence.
Caffeine can also be a bladder irritant and either
produce or exacerbate urge incontinence. A large
volume of uid intake may produce enuresis secondary
to a large urine volume, particularly if uids are
consumed in the evening before bedtime.
Thirst
Unusual thirst accompanied by an unusually large
intake of uid may indicate DM.
Weight Loss or Gain
Weight loss may indicate a chronic health problem,
tumor, or dementia. Weight gain may indicate congestive heart failure, DM, or loss of mobility.
CHILDREN
Is this primary or secondary enuresis?
Key Question
l
Has the child ever had consistent dryness for at least
6 months?
Primary enuresis occurs when a child has never
achieved consistent dryness. Secondary enuresis is
involuntary voiding of urine in a child who has had a
period of dryness of more than 6 months. Secondary
enuresis is often indicative of some other form of voiding dysfunction or signicant underlying pathology.
In children, daytime urinary incontinence beyond the
age of 4 years may indicate congenital abnormalities in
the urinary tract or nervous system.
Character of Stream
Voiding a small-caliber or intermittent stream or
difculty in starting the stream indicates obstructive
uropathy. In males, this may be secondary to an
enlarged prostate.
Is this organic enuresis?
Key Questions
l
Does the child have pain on urination?
l
Does the child have intermittent daytime wetness?
Chapter 34 • Urinary Incontinence
https://t.me/med1917
401
l
Does the child seem thirsty and urinate a lot?
l
Has the child had nervous system trauma?
l
Does the child have constipation or encopresis?
l
Does the child have constant wetness or dribbling
throughout the day?
l
Does the child have an abnormal stream such as
dribbling or hesitancy?
l
Has the child had a change in gait?
l
Has the child had a recent lumbar puncture?
l
Does the child snore or have apnea at night?
l
Does the child report rectal itching at night?
Organic explanations of enuresis focus primarily on
the genitourinary and nervous systems.
Genitourinary System
Fifteen percent of children with a UTI present with
enuresis. It is unclear whether UTI causes the enuresis
or vice versa. A wet perineum predisposes to ascending
infection, and prompt treatment of the infection cures
the enuresis in about one third of the cases. Asymptomatic bacteremia in school children is associated with
enuresis.
Fecal retention that is chronic or intermittent is
responsible for the production of functional bladder
neck obstruction. Displacement of the bladder and
posterior urethra by the full rectum in the xed
and limited space of the bony pelvis causes detrusor
perineal dyssynergia, which is thought to be the
mechanism responsible for urinary stasis and interference with micturition produced by constipation.
Abnormal daytime voiding suggests urological
abnormality. Dribbling suggests the presence of an
ectopic ureter, labial fusion, a deep positioned meatus
or a hymen covering the meatus. Chronic leakage
of urine in females may indicate an ectopic ureter
that terminates in the vagina. Partial distal urethral
obstruction can cause straining to urinate. Polyuria
from glucose-induced osmotic diuresis can be seen in
patients with DM. Renal tubules lose their ability to
concentrate urine, resulting in the production of large
volumes of very dilute urine.
Interference with the nerve supply to the bladder
causes a neurogenic bladder and obstruction. This can
be functional, resulting from an imbalance between
detrusor muscle contraction and urethral sphincter relaxation. It can also be congenital or acquired such as
with meningomyelocele or spinal cord injury.
Sleep apnea interferes with the child’s ability to
wake appropriately in response to stimuli to void.
Other
Pinworms (Enterobius vermicularis) primarily inhabit
the cecum and lower bowel and are the most common
cause of rectal itching in children. Pinworms have been
implicated in incontinence in children, although the
reason is not clear.
What risk factors does this child have for nonorganic
enuresis?
Key Questions
l
Is the child a boy or a girl?
l
Is there a history of bedwetting in the family?
l
Is the child a twin?
l
What is the child’s birth order?
l
Has the child been institutionalized?
l
Does the child have sickle cell disease?
l
What is the child’s daily uid intake?
Gender
Boys are more likely to have nocturnal enuresis.
Girls are more likely to have diurnal enuresis related
to UTI.
Family History
Children with nonorganic enuresis often have a very
strong family history of fathers who had nocturnal
enuresis as a child.
Twin/Birth Order
Nocturnal enuresis is most common in the rstborn
and in twins.
Nervous System
Lumbosacral disorders affect bladder innervation and
may cause enuresis. Head injury or brain tumor can
cause polyuria and polydipsia. If the kidneys are
unable to concentrate urine because of deciency in
the hypothalamic production of antidiuretic hormone
(ADH), central diabetes insipidus (DI) develops,
whereas renal unresponsiveness to ADH causes
nephrogenic DI.
Institutionalization
Institutionalized children have a greater tendency for
enuresis because of developmental delay.
Sickle Cell Disease
Children with sickle cell anemia may have a concentrating defect and excrete low specific gravity
urine in large volumes, which may make the child
wet the bed.
402
https://t.me/med1917
Chapter 34 • Urinary Incontinence
Fluid Intake
A large volume of uid intake may produce enuresis
secondary to a large urine volume, particularly if the
uids are consumed in the evening before bedtime.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Perform Mental Status Examination
Assess orientation and cognitive function. In adults,
incontinence can occur as the result of disorientation,
delirium, or dementia.
In children, secondary enuresis can be caused by the
presence of stress factors during the developmental
period from 2 to 4 years of age. Separation from family, death of a parent, birth of a sibling, a move, marital
conict, and other stress-related causes may produce
transient and intermittent enuresis.
Observe Gait
The urinary bladder receives extensive autonomic as
well as somatic innervation. Gait abnormalities can be
a marker for lesions along the neuraxis from the cortex
to peripheral nerves that produce abnormalities of
micturition.
Take Vital Signs
Blood pressure readings in children are important to
rule out nephrotic causes of enuresis. When chronic
renal failure is the result of an inadequate amount of
normally functioning renal tissue, the clinical presentation may be enuresis. Fever in infants without any
other signs is likely caused by UTI.
Examine the Abdomen
Palpate for masses, suprapubic tenderness, or fullness.
Palpate the bladder. Abdominal distention or palpable
bladder is suggestive of urinary retention and overow
incontinence.
Examine Genitalia in Males
Look for abnormalities of the foreskin, glans, meatus,
penis, and perineal skin that might contribute to or
produce incontinence.
Perform Pelvic Examination in Females
Note signs of pelvic prolapse (cystocele, rectocele).
Palpate for a pelvic mass and perivaginal muscle tone.
Note the condition of the vaginal mucosa and look for
atrophic vaginitis, which will produce incontinence in
adults.
Examine Vaginal Area in Children
Place the child on the caretakers lap in a frog leg
position. Examine the labia and vagina. Reddened
labia and vagina may signal vaginitis, which can cause
urinary incontinence in children.
Observe for evidence of sexual abuse such as abrasions, tears, or bruising. Urethral irritation, especially if
discharge is present, may indicate sexual abuse in children.
Perform Provocative Stress Testing
During the pelvic examination, ask the patient to relax
and then cough vigorously (or perform a Valsalva
maneuver). Watch for urine loss from the urethra,
which indicates stress incontinence.
Perform Digital Rectal Examination
Assess for perineal sensation, resting and active sphincter tone, rectal mass, fecal impaction, and ssures. A lax
sphincter suggests spinal cord involvement. Use the
fth digit for rectal examination in children, feeling for
stool in the rectal vault.
In men, assess the consistency and contour of the
prostate. Prostate enlargement or masses suggest the
possibility of overow incontinence from obstruction.
Conduct a Neurological Examination
Assess the intactness of the neurological system. Note
focal decits, test deep tendon reexes, and test for
sensation in the perineal and perirectal areas. Assess
spinal nerve roots S2 to S4 by testing anal reex and
sphincter tone. To test the anal reex, lightly stroke the
circumanal skin and watch for contraction of the external anal sphincter (anal wink). Test for muscle tone and
strength. Decits may point to a neurological cause for
the incontinence.
Examine and Palpate the Spine in Children
Look for an undetected birth defect that may be causing a neurological disturbance. A spinal dimple or hair
tuft may alert you to a potential problem.
Perform Musculoskeletal Examination
Assess mobility, strength, and functional ability. In
many older adults, the inability to get to a toilet causes
incontinence.
An easy assessment of mobility is the timed getup-and-go test. Time the patient getting up from
a chair, walking 10 feet, and sitting back down.
Although the time required to perform this test will
vary, an older adult who is mobile and independent can
perform this activity in about 10 seconds.
Chapter 34 • Urinary Incontinence
https://t.me/med1917
403
Additional Procedures
Postvoid Residual
Have the patient void without straining and then
catheterize. A residual volume greater than 100 mL
suggests either bladder weakness (stress incontinence)
or outlet obstruction (overow incontinence).
Observe Voiding
Note hesitancy, dribbling, interrupted stream, and decreased force or caliber of stream. These symptoms
suggest outlet obstruction and overow incontinence.
LABORATORY AND DIAGNOSTIC STUDIES
Urinalysis
Dipstick urinalysis (U/A) can rule out or point to infection or systemic disease as a cause of the incontinence.
Note hematuria, pyuria, bacteriuria, or the presence
of leukocyte esterase or nitrites as indicators of UTI.
Glycosuria or proteinuria may indicate DM or renal
disease.
Specific Gravity
A specic gravity greater than 1.015 rules out diabetes
insipidus as the cause of incontinence.
Urine Culture
A culture can be used to determine the organism(s)
producing a UTI and can conrm the diagnosis.
Urine Cytology
Urine for cytology is indicated if microscopic or gross
painless hematuria is present in the absence of infection.
Bladder Diary
A 24-hour bladder diary (3-day voiding diary for children) can provide an accurate record of urine output,
average voided volume, frequency of voiding, frequency and nature of incontinent episodes, as well as
the type and volume of uid intake. Patients or parents
can use a measuring cup to catch and measure urine
output.
Blood Urea Nitrogen and Creatinine
Use these indicators of renal function if you suspect
obstruction or urinary retention.
Vaginal Specimen Microscopy, DNA Testing, or
Culture
These tests can conrm vaginal infection. See Chapter
37 for the procedures for these tests.
Office Cystometrography
Have the patient void and empty the bladder. Have
men lie supine and place women in the dorsal lithot-
omy position. Insert a sterile 12 to 14 French (nonbal-
looned) catheter and empty the bladder. (Measure the
postvoid residual and collect urine for U/A at that
time.) Insert a 50-mL syringe with the plunger re-
moved into the end of the catheter and position it about
15 cm above the urethra. Fill the syringe by pouring
sterile water into it in 25- to 50-mL increments. Record
cumulative total uid instillation in the bladder and
note the volume at which the patient rst reports the
urge to void. Continue adding uid slowly until the
uid level in the syringe rises, indicating an increase in
intrabladder pressure and contraction of the detrusor
muscle. The rise may be gradual or sudden. Detrusor
contraction at less than 300 to 350 mL of bladder vol-
ume indicates detrusor instability (urge incontinence).
Have the patient void at the end of the procedure. The
amount instilled minus the amount voided will also
provide a measure of postvoid residual.
Urodynamic Testing
Complete urodynamic testing includes uroowmetry,
cystometrography, perineal electromyelography, and
voiding cystourethrography (VCUG). It is indicated
when patient symptoms do not correlate with objective
physical ndings, when results may change manage-
ment, after treatment failure, or if more information is
needed to plan further therapy (see the Evidence-Based
Practice box, Urodynamic Testing).
Cystoscopy and Contrast Radiography
These procedures are indicated for detection of neo-
plasms or stones.
Ultrasound
Ultrasonography may be useful in determining the
presence of an obstruction.
DIFFERENTIAL DIAGNOSIS
Incontinence From Anatomical Causes
Stress Incontinence
Stress incontinence is associated with activities that
increase intra-abdominal pressure, such as coughing,
sneezing, running, or laughing. The underlying abnor-
mality is typically urethral hypermotility as a result of
inadequate pelvic support of the bladder neck (urethro-
vesical junction). Normally, increased intra-abdominal
pressure is transmitted evenly across the bladder neck
404
https://t.me/med1917
Chapter 34 • Urinary Incontinence
EVIDENCE-BASED PRACTICE
A Cochrane systematic review compared outcomes in women
with urinary incontinence based on urodynamic testing. The
authors concluded that women assessed using urodynamic
testing in addition to clinical methods were more likely to
receive medication or surgical treatment. However, there was
insufficient evidence to show whether they were less likely to
Data from Clement KD, Lapitan MCM, Omar MI, Glazener CMA: Urodynamic studies for management of urinary incontinence in children and adults.
Cochrane Database Syst Rev 2013, Issue 10. Art. No.: CD003195.
and body. When adequate support is lacking, an increase in intra-abdominal pressure displaces the bladder neck outside the abdominal cavity. The subsequent
disproportionate increase in bladder pressure as compared to urethral pressure results in urine loss. Poor
urethral sphincter function also contributes to stress
incontinence. The amount of urine lost with each
episode is small. The patient usually has a history of
childbirth. On examination, pelvic oor relaxation
may be evident with the presence of a cystocele and/or
Urodynamic Testing
be incontinent after treatment than women who did not have
urodynamic tests. The authors concluded that larger definitive trials are needed to determine if performance of urodynamics results in higher continence rates after treatment. No
data were available to evaluate the use of urodynamics in
other patient groups.
Postvoid residual is normal. Diagnostic testing includes U/A and culture to rule out infection and determination of blood urea nitrogen and creatinine levels
to rule out nephropathy. On ofce cystometrography,
the urine volume is less than 300 to 350 mL before
the urge to void occurs. Complete urodynamic testing
can conrm the diagnosis.
For more information, see the Evidence-Based
Practice box: Determining the Type of Urinary Incon-
tinence.
rectocele. The urethral sphincter may appear lax, and
there is loss of urine with provocative testing. Atrophic
vaginitis is a common nding in postmenopausal
women. U/A and culture may be performed to rule out
infections or urinary tract problems. Postvoid residual
is normal.
Mixed Incontinence
Patients who experience symptoms of both stress
and urge incontinence are considered to have mixed
incontinence. It is important to determine which symptom is predominant and most bothersome to the patient
and treat it rst.
Urge Incontinence
Urge incontinence is characterized by an uncontrolled
urge to void, secondary to detrusor muscle irritability
or hyperactivity or to a hypersensitive bladder. Most
cases result from an idiopathic inability to suppress
detrusor contraction. The urine volume lost is large.
Physical examination results are usually normal.
Overflow Incontinence
Overow incontinence occurs in the presence of
obstruction or interruption in the nervous system. It is
a result of overdistention of the bladder from an
underactive or acontractile detrusor muscle, from
sphincter-detrusor dyssynergia (loss of the synergistic
EVIDENCE-BASED PRACTICE
The authors of this systematic review report o n the most
accurate way to determine the type of urinary incontinence
during office assessment. The authors concluded that a
systematic approach that includes a history, physical examination, and urinary stress test improves the ability to
Reference: Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE: What type of urinary incontinence does this woman have? JAMA 299:1446,
2008.
Determining the Type of Urinary Incontinence
correctly determine the type of incontinence. The symptom
of urine loss associated with urinary urgency helps predict
urge incontinence. A urinary stress te st, particul arly a filledbladder stress test, may be helpful in diagnosing stress
incontinence.
Chapter 34 • Urinary Incontinence
https://t.me/med1917
405
urinary sphincter relaxation that normally occurs with
bladder detrusor muscle contraction), or from bladder
outlet or urethral obstruction. Sphincter weakness can
occur from damage to the urethra, errors in its innervation, or from pelvic oor muscle relaxation. Interference with the nerve supply to the bladder can result in
neurogenic bladder obstruction, and consequent overow incontinence caused by an imbalance between
detrusor muscle contraction and urethral sphincter relaxation. Overow incontinence can also be congenital
or acquired, such as with meningomyelocele or spinal
cord injury, or can be a surgical complication from
radical prostatectomy. On examination, the anal sphincter may be lax. Neurological testing may reveal decits.
Overow incontinence is small-volume incontinence, with symptoms of dribbling and hesitancy. In
men, symptoms of an enlarged prostate may be present
(i.e., nocturia, dribbling, hesitancy, and decreased force
and caliber of stream). On examination, look for a
distended bladder, prostate hypertrophy, evidence of
spinal cord disease, or diabetic neuropathy. Postvoid
residual is more than 100 mL. Diagnostic testing includes U/A, urine culture, and determination of blood
urea nitrogen and creatinine levels.
Incontinence From Reversible Factors
(Functional Incontinence)
Medications
Sedatives, hypnotics, diuretics, anticholinergic
agents, a-adrenergic agents, and calcium channel
blockers can cause incontinence. a-Adrenergic agonists and b-adrenergic agonists increase sphincter
tone and may cause retention; they can also cause
urge incontinence. Anticholinergics, prostaglandin
inhibitors, calcium channel blockers, and narcotic
analgesics decrease detrusor tone and can produce
incontinence. Diuretics can cause incontinence because of increased production of urine, and CNS
depressants such as hypnotic-sedatives can interfere
with functional ability.
Urinary Tract Infection
The patient with a UTI has symptoms of lower or upper tract infection such as burning, dysuria, frequency,
urgency, ank pain, and fever. The urine may have a
foul odor. The patient may exhibit suprapubic or costovertebral angle (CVA) tenderness. In infants, a fever
with no localizing signs frequently indicates UTI.
Urine analysis and culture can conrm the diagnosis of
a lower UTI (see Chapter 35).
Vaginitis
Vaginitis produces incontinence as a result of local irritation. Atrophic vaginitis indicates a loss of estrogen and
a concomitant loss of the vesicourethral angle, which
predisposes women to stress incontinence. Provocative
stress testing can demonstrate stress incontinence.
Microscopy, DNA testing, or culture can conrm
vaginal infection (see Chapter 37).
Constipation and Fecal Impaction
Constipation or fecal impaction can produce obstructive overow incontinence by mechanical pressure on
the urethra. The patient may experience abdominal
pain and fecal soiling. On examination, stool may be
felt in the colon and/or ampulla.
Change in Mental or Functional Status
Depression, dementia, and confusion can all produce
incontinence (see Chapter 9). Restricted mobility can
result in incontinence because of loss of functional
ability.
Diabetes Insipidus
In DI, the kidneys are unable to concentrate urine because of a deciency in the hypothalamic production of
ADH (central DI) or a renal unresponsiveness to ADH
(nephrogenic DI). The result is polyuria, which may
cause incontinence. The patient also exhibits polydipsia. Urine specic gravity will be less than 1.015.
Diabetes Mellitus
DM often presents with excessive uid intake and
urination. The excess uid volume may result in incontinence, particularly in older adults with chronic
health problems, restricted mobility, or compromise
in mental or functional health. Urinalysis can screen
for glycosuria. Follow-up testing should check
fasting blood glucose levels and hemoglobin A1C
measurement.
Hyperthyroidism
Patients with hyperthyroidism may report urgency,
urge incontinence, nocturia, and enuresis.
Enuresis From Organic Causes
Genitourinary Causes
Genitourinary disorders that can produce enuresis
include UTI, ectopic ureter, iatrogenic damage to
the external sphincter, and urethral obstruction.
Physical examination is usually normal. Fever and
406
https://t.me/med1917
Chapter 34 • Urinary Incontinence
abdominal tenderness may be present with a UTI.
Anatomical genitourinary abnormalities may signal
an ectopic ureter. Diagnostic testing includes urinalysis, urine culture, and specic gravity to rule out
infection and DM. Referral for further evaluation
may be necessary.
Neurological Causes
Nervous system involvement can also produce enuresis. Lumbosacral disorders affect bladder innervation
and may cause enuresis. Head injury or brain tumor
can cause polyuria and polydipsia. Interference with
the nerve supply to the bladder causes neurogenic
bladder and obstruction, which can result in enuresis.
Interference in innervation can occur from congenital
or acquired causes. Diagnostic testing includes urinalysis, urine culture, and specic gravity to rule out infection and DM. Referral for further evaluation may be
necessary. Some children with sleep apnea have been
found to have an increased atrial natriuretic factor, inhibiting the renin-angiotensin-aldosterone pathway,
causing enuresis.
Enuresis From Nonorganic Causes
Primary Enuresis
Primary enuresis occurs when a child has never
achieved consistent dryness. The normal developmental patterns of micturition follow a characteristic pattern
in children, but at an individual rate. The usual progression depends on the maturation of the CNS. Generally,
the following stages are seen:
Birth to 6 months: Bladder emptying is an uninhibited
reex action.
6 to 12 months: Bladder emptying is less frequent
because of CNS inhibition of reex action.
1 to 2 years: Child consciously perceives bladder
fullness; CNS inhibition increases.
3 to 5 years: At age 5 years, most children are
aware of bladder fullness; they develop the ability to inhibit the need to void, both voluntarily
and unconsciously.
Primary enuresis may represent a developmental
delay or maturational lag. Often there is a family
history of enuresis. The enuresis usually is only nocturnal. The incidence is higher in boys than in girls,
and usually resolves as the child matures. Physical
examination is normal. Diagnostic testing includes
urinalysis, urine culture, and specic gravity to rule
out other causes.
Developmental (Secondary) Enuresis
Developmental enuresis that is secondary may be
related to changes or stresses in a child’s life. It can
also occur as the result of genital trauma, infection,
distended colon, or fecal impaction. The enuresis
occurs in a child who has had a period of dryness of
more than 6 months. Diagnostic testing includes
urinalysis, urine culture, and specic gravity to rule
out other causes.
Small Bladder
An anatomically small bladder can also produce enuresis. The child voids frequently but not an excessive
volume. Physical examination is normal. Diagnostic
testing includes urinalysis, urine culture, and specic
gravity to rule out other causes.
Sickle Cell Anemia
Children with sickle cell anemia have a concentrating defect and may experience enuresis because of
volume excess. Physical examination ndings are
consistent with the sickle cell disorder. Diagnostic
testing includes urinalysis, urine culture, and specic
gravity.
Chapter 34 • Urinary Incontinence
https://t.me/med1917
407
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Urinary Incontinence
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
INCONTINENCE FROM ANATOMICAL CAUSES
Stress incontinence Small-volume incontinence with
coughing, sneezing, laughing,
running; history of prior pelvic
surgery
Urge incontinence Uncontrolled urge to void; large-
volume incontinence; history of
CNS disorders, such as stroke,
multiple sclerosis, parkinsonism
Mixed incontinence Symptoms of both stress and urge
Overflow
incontinence
INCONTINENCE FROM REVERSIBLE FACTORS (FUNCTIONAL)
Medications
Urinary tract
infection (UTI)
Vaginitis Itching, odor Discharge, atrophic vaginitis,
Constipation/fecal
impaction
Change in mental
or functional
status
Diabetes
insipidus (DI)
Diabetes mellitus
(DM)
incontinence
Small-volume incontinence, drib-
bling, hesitancy; in men symptoms
of enlarged prostate: nocturia,
dribbling, hesitancy, decreased
force and caliber of stream; in
neurogenic bladder: history of
bowel problems, spinal cord injury,
or multiple sclerosis
Hypnotics, diuretics, anticholiner-
gic agents, a-adrenergic agents,
calcium channel blockers
Dysuria, urgency, daytime accidents Frequency, odor, fever U/A and culture
Abdominal pain Soiling; stool felt in colon
Change in mental status; impaired
mobility; new environment
History of trauma to head; thirst,
frequency
Thirsty, increased frequency Weight loss U/A; serum glucose
Pelvic floor relaxation; cysto-
cele, rectocele; lax urethral
sphincter; loss of urine with
provocative testing; atrophic
vaginitis
Normal examination; may
have neurological deficits
Finding related to stress and
urge incontinence
Distended bladder; prostate
hypertrophy, stool in
rectum; fecal impaction;
in neurogenic bladder:
evidence of spinal cord
disease or diabetic neuropathy; lax sphincter; gait
disturbance
Normal except for findings
related to other physical
conditions
evidence of sexual abuse
and/or ampulla
Impaired mental status;
impaired mobility
Weight loss U/A specific gravity
U/A and culture; PVR
normal
U/A and culture; PVR
normal; office cystometrography: ,300350-mL volume; BUN,
creatinine, urodynamic
testing
U/A and culture; PVR;
office cystometrography
U/A and culture; PVR
.100 mL; BUN,
creatinine; in neurogenic bladder, refer
for testing
U/A to rule out urinary
tract problems; blood
chemistry to rule out
systemic problem
Gram stain, KOH, culture
None
U/A and culture; blood
chemistry
.1.015
ENURESIS FROM ORGANIC CAUSES
Genitourinary
causes
Neurological
causes
UTI history; dribbling; urine
leakage
Head injury; spinal cord injury;
polydipsia, polyuria; sleep apnea
Fever, abdominal tenderness;
anatomical abnormalities
(ectopic ureter); examination may be normal
Lax sphincter, spinal tuft,
neurological deficits;
altered gait; examination
may be normal
U/A and culture; specific
gravity; referral for
testing
U/A and culture; specific
gravity; referral for
evaluation
Continued
408
https://t.me/med1917
Chapter 34 • Urinary Incontinence
DIFFERENTIAL DIAGNOSIS OF
ENURESIS FROM NONORGANIC CAUSES
Primary enuresis Child has never been dry; may have
family history
Developmental
(secondary)
enuresis
Small bladder Void frequently, not in excessive
Sickle cell anemia Family history Findings related to sickle cell
BUN, Blood urea nitrogen; CNS, central nervous system; KOH, potassium hydroxide; PVR, postvoid residual; U/A, urinalysis.
Child has been dry for 6 mo in a
row; changes or stresses in
child’s life
volume
References and Readings
Abrams P, Andersson KE, Birder L, et al: Fourth international con-
sultation on incontinence recommendations of the international
scientic committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence, Neurourol
Urodyn 29:213, 2010.
Alizadeh F1, Zargham M, Nouri-Mahdavi K, et al: Bladder involve-
ment in thyroid dysfunction, J Res Med Sci 18:167, 2013.
Alper B, Curry S: Urinary tract infection in children, Am Fam Physician
72:2483, 2005.
American College of Obstetricians and Gynecologists: Urinary
incontinence in women, Obstet Gynecol 105:1533, 2005.
Amir B, Farrell SA, Sub-Committee on Urogynaecology: SOGC
Committee opinion on urodynamics testing, J Obstet Gynaecol
Can 30:717, 2008.
Deng D: Urinary incontinence in females, Med Clin North Am
95:101, 2011.
Despande A, Craig J, Smith G, Caldwell P: Management of daytime
urinary incontinence and lower urinary tract diagnosis in children,
J Pediatr Child Health 48:E44, 2012.
Dillon BE, Zimmern PE: When are urodynamics indicated in
patients with stress urinary incontinence? Curr Urol Rep
13:379, 2012.
Common Causes of Urinary Incontinence—cont’d
Normal examination;
developmental delay
Examine for genital trauma or
abuse, infection, distended
colon, fecal impaction
None
disease
Graham K, Levy J: Enuresis, Pediatr Rev 30:165, 2009.
Hoebeke P, Bower W, Cooms D, et al: Diagnostic evaluation of
children with daytime incontinence, J Urol 183:699, 2010.
Khandelwal C, Kistler C: Diagnosis of urinary incontinence, Am
Fam Physician 87:543, 2013.
Ma JF, Shortliffe LM: Urinary tract infection in children: Etiology
and epidemiology, Urol Clin North Am 31:517, 2004.
Martin JL, Williams KS, Abrams KR, et al: Systematic review and
evaluation of methods of assessing urinary incontinence, Health
Technol Assess 10:1, 2006.
McKertich K: Urinary incontinence-assessment in women: Stress,
urge or both? Aust Fam Physician 37:112, 2008.
National Institute for Health and Clinical Excellence: The manage-
ment of urinary incontinence in women: NICE clinical guideline
CG171, 2013. Retrieved from publications.nice.org.uk/urinaryincontinence-cg171.
Rogers RG: Urinary stress incontinence in women, N Engl J Med
358:1029, 2008.
Srikrishna S, Robinson D, Cardozo L, Vella M: Management of
overactive bladder syndrome, Postgrad Med J 83:481, 2007.
U/A and culture; specific
gravity to rule out
other causes
U/A and culture; specific
gravity to rule out
other causes; screen
for glycosuria
Bladder capacity 5
child’s age 1 2, for
children ,11 yr
U/A and culture; specific
gravity
Соседние файлы в папке Библиотека им академика М.И. Перельмана