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Probability diagnosis

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Stress incontinence

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Cystitis

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Overactive bladder (detrusor instability)

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Outflow obstruction e.g. prostatism

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Post pelvic surgery

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Enuresis

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Serious disorders not to be missed

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Infection:

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  • Prostatitis

  • Chronic UTI

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Cancer/tumour:

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  • Bladder

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Other:

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  • Dementia

  • Fistula

  • Ectopic urethra

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Pitfalls (often missed)

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Neurogenic: multiple sclerosis, neuropathy, others

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Interstitial cystitis (women)

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Rarities:

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  • Bladder calculus

  • Post pelvic fracture

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Masquerades checklist

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Diabetes: polyuria

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Drugs (see list in history)

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Endocrine: diabetes insipidus

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Spinal dysfunction incl. cauda equina lesion

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Urinary tract infection

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Is the patient trying to tell me something?

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Functional (?psychogenic)

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Key history

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Focus on the duration and patterns of voiding, bowel function, drug use, obstetric and pelvic surgery history. A voiding diary is helpful to pinpoint the cause. Use of a severity index questionnaire is very helpful. Obstructive symptoms in men with detrusor overactivity. Consider a sleep related problem. Check drug history: diuretics, alcohol, sedatives, antidepressants, α-adrenergic blockers e.g. prazosin, caffeine, psychoactive agents, anticholinergics, calcium channel blockers e.g. nifedipine.

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Key examination

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Based on neurological, pelvic and rectal examinations

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Key investigations

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First line:

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  • urinalysis

  • MSU

  • KFTs

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Consider (based on specialist referral):

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  • cystoscopy

  • cystometry

  • urodynamic studies

  • selective imaging e.g. ultrasound, micturating cystourethrogram, IVU

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Diagnostic tips

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Classify incontinence into the main categories: stress, urge and continuous (overflow).

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