Urinary Incontinence in Adults

Introduction to MCCQE1 Preparation

Urinary incontinence (UI) is a prevalent condition affecting a significant portion of the Canadian adult population, particularly the elderly. For the MCCQE1, this topic is high-yield under the Urology and Geriatric Medicine objectives. Candidates must demonstrate competence in differentiating types of incontinence, applying the CanMEDS roles (particularly Health Advocate due to the stigma associated with UI), and formulating a management plan based on Canadian guidelines.

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Canadian Context: In Canada, urinary incontinence affects approximately 1 in 4 women and 1 in 10 men. It is a leading cause of admission to long-term care facilities. Understanding the social and economic burden is crucial for the Health Advocate role in the MCCQE1.

Classification and Pathophysiology

Understanding the mechanism of leakage is the cornerstone of diagnosis. The MCCQE1 frequently tests the ability to distinguish between the following types based on patient history.

Stress UI

Stress Urinary Incontinence (SUI)

Pathophysiology: Involuntary leakage on effort or exertion, or on sneezing or coughing. Caused by urethral hypermobility or intrinsic sphincter deficiency.
Risk Factors: Multiparity, vaginal delivery, obesity, menopause (estrogen deficiency), pelvic surgery (prostatectomy in men).
Key Symptom: “I leak when I laugh, sneeze, or lift heavy objects.”

Transient Causes of Incontinence

Before diagnosing chronic UI, rule out reversible causes. Use the mnemonic DIAPPERS:

Mnemonic: DIAPPERS

Delirium
Infection (UTI)
Atrophic Vaginitis / Urethritis
Pharmaceuticals (Diuretics, Anticholinergics, Sedatives)
Psychological disorders (Depression)
Excessive urine output (Hyperglycemia, Hypercalcemia)
Reduced mobility
Stool impaction (Constipation)

Clinical Assessment for MCCQE1

The MCCQE1 assesses your ability to gather focused data. Follow this stepwise approach:

Step 1: Focused History

Determine the type and severity.

Characterize leakage: Triggers (cough vs. urgency), frequency, volume.
Fluid intake: Caffeine, alcohol, total volume.
Obstetric/Gynecologic history: Parity, mode of delivery, menopause.
Review of Systems: Neurologic symptoms, hematuria, dysuria.
Medication Review: Look for alpha-blockers, alpha-agonists, diuretics, ACE inhibitors (cough).

Step 2: Physical Examination

Abdominal Exam: Palpate for bladder distension (globus).
Pelvic Exam (Females): Assess for atrophic vaginitis, pelvic organ prolapse, and perform the Cough Stress Test (observe leakage while coughing).
Rectal Exam (Males & Females): Assess prostate size (males), sphincter tone (neuro), and check for fecal impaction.
Neurologic Exam: Perineal sensation, bulbocavernosus reflex.

Step 3: Initial Investigations

Urinalysis (Mandatory): Rule out UTI, hematuria, glycosuria.
Post-Void Residual (PVR): Essential to rule out overflow incontinence.
- PVR < 50 mL is normal.
- PVR > 200 mL suggests inadequate emptying.
Bladder Diary: A 3-day record of intake and output. Gold standard for objective assessment.

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Red Flags Requiring Referral (Urology):

Microscopic or gross hematuria (risk of bladder cancer).
Recurrent UTIs.
Pelvic pain.
History of pelvic radiation.
Previous incontinence surgery failure.
Suspected fistula.

Management Strategies

Management should be hierarchical: Conservative $\rightarrow$ Pharmacologic $\rightarrow$ Surgical.

1. Conservative Management (First-Line)

All patients should start here.

Lifestyle Modifications: Weight loss (highly effective), smoking cessation, reducing caffeine/alcohol, fluid management.
Pelvic Floor Muscle Training (PFMT): First-line for Stress UI and Mixed UI. Kegel exercises.
Bladder Training: First-line for Urgency UI. Scheduled voiding with progressive increases in intervals.

2. Pharmacologic Management

Used when conservative measures fail. Primarily for Urgency UI/OAB. Meds are generally not effective for Stress UI.

Drug Class	Mechanism	Examples	Adverse Effects
Anticholinergics	Block muscarinic receptors (M3) to inhibit detrusor contraction.	Oxybutynin, Tolterodine, Solifenacin	Dry mouth, constipation, blurred vision. Caution in elderly (cognitive decline).
Beta-3 Agonists	Stimulate Beta-3 receptors to relax the detrusor muscle.	Mirabegron	Hypertension (monitor BP), headache. Preferred in elderly over anticholinergics.
Topical Estrogen	Rejuvenates urogenital tissues.	Vaginal cream/tablet	Minimal systemic absorption. Useful for atrophic vaginitis.

3. Surgical Management

Considered when conservative and medical therapies fail.

Stress UI: Mid-urethral slings (TVT/TOT), Bulking agents, Colposuspension.
Urgency UI: OnabotulinumtoxinA (Botox) injections, Sacral Neuromodulation.
Overflow UI: Catheterization (CIC is preferred over indwelling), TURP (for BPH).

Canadian Guidelines (CUA & SOGC)

For MCCQE1, adherence to Canadian guidelines is mandatory.

Choosing Wisely Canada: Do not treat asymptomatic bacteriuria with antibiotics in the elderly unless there are specific urinary tract symptoms. Confusion alone is rarely a symptom of UTI in the absence of fever or dysuria.
CUA Guidelines on OAB:
1. Diagnosis is primarily clinical; urodynamics are not routinely required for uncomplicated cases.
2. Use extended-release formulations of anticholinergics to minimize side effects.
3. Consider Mirabegron in patients at risk of cognitive dysfunction (e.g., elderly).
SOGC Guidelines on SUI:
1. PFMT is the recommended first-line treatment.
2. Pessaries can be offered as a non-surgical option for SUI and prolapse.

Key Points to Remember for MCCQE1

Differentiation is Key: Differentiating Stress vs. Urge vs. Overflow dictates management.
First-line is always non-invasive: Lifestyle changes and physio (PFMT/Bladder training) before drugs.
Elderly Care: Be extremely cautious with anticholinergics in the elderly (delirium risk).
Investigation: Urinalysis is the single most important initial lab test.
Red Flags: Painless hematuria in a patient with irritative voiding symptoms requires cystoscopy to rule out bladder cancer.

Sample Question

Clinical Scenario

A 58-year-old female presents to her family physician complaining of involuntary loss of urine. She reports that this occurs primarily when she coughs, sneezes, or lifts her grandchildren. She denies any sudden urge to void prior to leakage, dysuria, or hematuria. She has no history of neurologic disease. Her BMI is 32 kg/m². Physical examination reveals a small amount of urine leakage with coughing in the supine position. Urinalysis is unremarkable.

Question

Which one of the following is the most appropriate initial management for this patient?

A. Prescription for oral oxybutynin
B. Referral for mid-urethral sling surgery
C. Urodynamic testing
D. Pelvic floor muscle training
E. Cystoscopy

Click to reveal answer and explanation

Explanation

The correct answer is:

D. Pelvic floor muscle training

Detailed Explanation:

Diagnosis: The patient’s history (leakage with increased intra-abdominal pressure: coughing, sneezing, lifting) and lack of urgency suggest Stress Urinary Incontinence (SUI).
Option D (Correct): According to SOGC and CUA guidelines, the first-line management for uncomplicated SUI is conservative therapy, specifically Pelvic Floor Muscle Training (PFMT) and weight loss (given her BMI of 32). This is non-invasive and has a high success rate for symptom improvement.
Option A (Incorrect): Oxybutynin is an anticholinergic used for Urgency Incontinence (Overactive Bladder). It is not effective for Stress Incontinence.
Option B (Incorrect): Surgery (mid-urethral sling) is highly effective for SUI but is reserved for patients who have failed conservative management. It is not the initial step.
Option C (Incorrect): Urodynamic testing is not indicated for the initial evaluation of uncomplicated SUI. It is reserved for complex cases or prior to surgery.
Option E (Incorrect): Cystoscopy is indicated if there are red flags (hematuria, pain, recurrent infections) or diagnostic uncertainty. This patient has a classic presentation and normal urinalysis.

References

Canadian Urological Association (CUA). Guideline for the diagnosis and treatment of overactive bladder (OAB) in the adult population. Can Urol Assoc J.
Society of Obstetricians and Gynaecologists of Canada (SOGC). Conservative Management of Urinary Incontinence. J Obstet Gynaecol Can.
Medical Council of Canada. Objectives for the Qualifying Examination (MCCQE) Part I.
Choosing Wisely Canada. Geriatrics and Urology recommendations. available at choosingwiselycanada.org .
Toronto Notes. Urology Chapter, Urinary Incontinence section.