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A healthy 51-year-old stockbroker comes to the clinic for an annual checkup. She states that over the past year she has gained 25 lbs and attributes the weight gain to giving up jogging and jazzercise classes. She relates that running and jumping sometimes cause her to leak urine, which is uncomfortable and embarrassing. She now uses a heavy panty liner at all times to avoid wetting herself. She is upset that she is "developing a bladder like my 80-year-old mother."

  • What is the most likely cause of her urinary incontinence?
  • What additional questions should you ask her to better characterize her incontinence?
  • What are the risk factors for the exercise-induced incontinence that she describes?
  • What are the differences in the prevalence of the different types of incontinence between younger and older patients and between men and women?

Occasional involuntary leakage of urine is common, affecting approximately 5% of men age 19 to 44 and 21% of men over age 65.1 At least monthly urinary leakage is reported by 13% to 25% of women over age 18, 40% of women over age 64, and 55% of women over age 80.2,3 When urinary incontinence (UI) is severe, it can result in social isolation, depression, and even institutionalization. In the United States, the average annual out-of-pocket cost of UI for women has been estimated at greater than $250 (2005 dollars).4

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IncontinenceThe involuntary leakage of urine. There are several types: urge, detrusor disinhibition, stress, overflow (includes detrusor hyperactivity with impaired contractility and detrusor-sphincter dyssynergy), functional, and mixed.
UrgeInvoluntary detrusor contractions cause an urgent need to void. After a variable latency period (seconds to minutes), the contractions exceed bladder outlet resistance (normally produced by the internal sphincter), resulting in incontinence (Figure 44–1). Also called detrusor hyperreflexia and idiopathic overactive bladder with incontinence.
Detrusor disinhibitionSpontaneous triggering of the spinal reflex voiding mechanism when the bladder reaches a threshold volume and there is inadequate inhibition of bladder contractions by the central nervous system. Urine loss may occur with or without warning. Also called neurogenic detrusor overactivity.
StressLeakage caused by an increase in intra-abdominal pressure, as produced by a cough, sneeze, laughing, standing up, or heavy lifting (Figure 44–2). Also called sphincter incompetence.
OverflowDue to urinary retention, pressure in the bladder exceeds outlet (sphincter) resistance, causing leakage until the bladder pressure drops below outlet resistance.
Detrusor hyperactivity with impaired contractility (DHIC)Found mainly in debilitated older persons. Despite an overactive bladder, detrusor contractions are ineffective, resulting in bladder distention and overflow incontinence.
Detrusor-sphincter dyssynergyFailure to synchronize bladder contractions with release of sphincter, due to multiple sclerosis or other conditions causing suprasacral spinal cord lesions.
FunctionalIncontinence despite a normally functioning bladder due to the inability to reach a toilet in time.
MixedIncontinence from multiple etiologies, most commonly stress and urge.
Idiopathic overactive bladderInvoluntary ...

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