Red Flag Symptoms: Urinary incontinence

A systematic approach can help make an appropriate working diagnosis, writes Dr Anna Cumisky.

Urinary incontinence can be a disabling condition that causes substantial morbidity. Many causes are treatable in primary care.

Click here to browse our resource of Red Flag alert symptoms

Incontinence in women
In any new case, urine dip and treatment of any suspected infection are important first steps. Recurrent infections should raise the concern of other pathology, such as bladder tumour or interstitial cystitis, and referral for cystoscopy should be considered.

Stress incontinence typically presents as urinary leakage provoked by a rise in intra-abdominal pressure. It is particularly common post childbirth.

Urge incontinence is the involuntary loss of urine associated with a strong desire to void. It may be due to either sensory or motor bladder dysfunction.

Time/volume charts can be done at home and help to quantify the problem. Patients should also be encouraged to try simple bladder drills as some cases resolve with retraining alone.

Red flag symtoms
  • Haematuria
  • Persistent UTI
  • Constitutional symptoms
  • Poor renal function
  • Abnormal neurology
  • Saddle anaesthesia
  • Recent back trauma
  • Recent pelvic surgery

Incontinence in men
Urinary incontinence in men is commonly secondary to prostatic change. Infection is a much less common cause in men although urine should be dipped to rule this out. Also test for haematuria.

Prostatic enlargement generally presents with lower urinary tract symptoms (LUTS).

Overflow incontinence, which commonly presents with dribbling at night, suggests chronic retention of urine. An abdominal examination should be performed to check for a palpable bladder and a prostate examination is mandatory. Renal function should be checked.

Constitutional symptoms such as weight loss and anorexia, back pain or an abnormal feeling prostate on examination should raise suspicion of prostatic pathology and should be investigated urgently.

Similarly, rapidly progressive LUTS, recurrent infection, frank haematuria or persistent microscopic haematuria or reduced renal function warrant urgent urological referral.

It should also be remembered that in both sexes and especially in the elderly, constipation or diuretic medication are common causes of urinary incontinence.

In young adults, incontinence in the absence of infection is much less common. History should focus particularly on neurological assessment and, in particular, multiple sclerosis should be considered.

Children
The age at which children develop bladder control varies.

Nocturnal enuresis is common in younger children but can persist into the teens.

History and examination should seek not only to rule out infection or constipation as the cause but also to look for change in behaviour that may highlight difficulties at school or home.

  • Dr Cumisky is a locum GP in Bath
Possible Causes
  • UTI
  • Benign prostatic hypertrophy
  • Urological malignancy
  • Constipation
  • Psychological
  • Poor pelvic muscle tone
  • Multiple sclerosis
  • Idiopathic eg children
  • Iatrogenic eg diuretic medication
  • Dementia

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