Lesson
Name the Leakage Phenotype
Urinary incontinence is a symptom with several mechanisms. The timing, trigger, urge, emptying pattern, mobility, and continuous nature of leakage usually reveal the first diagnostic branch.
- Urgency incontinence
- Stress incontinence
- Mixed incontinence
- Overflow
- Functional incontinence
A sudden difficult-to-defer urge precedes leakage
Cough, exertion, or laughter exceeds outlet support
Retention, mobility, cognition, or environment drives leakage
Separate the patterns
Urgency incontinence follows a sudden difficult-to-defer urge. Stress incontinence occurs with cough, exertion, laughter, or pressure. Mixed incontinence contains both. Overflow reflects incomplete emptying or retention. Functional incontinence reflects barriers to reaching or using a toilet despite potentially intact storage.
Recognize other patterns
Continuous leakage, leakage without awareness, post-void dribbling, nocturnal enuresis, and leakage after pelvic surgery or radiation can indicate fistula, ectopic anatomy, sphincter injury, neurologic disease, or another process outside routine idiopathic OAB.
Use burden, not embarrassment, to set priority
Record episode frequency, volume, pads, skin effects, falls, sleep, work, sexual health, and patient goals. The dominant mechanism and the most disruptive symptom may differ, especially in mixed incontinence.
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Lesson
Evaluation and Red-Flag Triage
The initial evaluation confirms the phenotype, detects reversible contributors, identifies poor emptying, and avoids unnecessary routine invasive testing.
- History
- Urinalysis
- Voiding diary
- Post-void residual
- Red flags
Symptoms, triggers, volumes, medicines, bother, and goals
Look for infection, support, neurologic change, and reversible causes
Measure emptying and escalate only when risk or uncertainty warrants it
Build the core assessment
Ask about storage and emptying symptoms, onset, triggers, obstetric and pelvic history, neurologic disease, diabetes, bowel function, sleep, fluids, mobility, cognition, sexual symptoms, surgery, radiation, and every medication. Perform a focused abdominal, neurologic, pelvic, prostate, and functional examination as appropriate and obtain urinalysis.
Add measurements with purpose
A three-day bladder diary can capture time, intake, voided volume, urgency, and leakage. Measure post-void residual when emptying symptoms, retention risk, prior surgery, neurologic disease, or a treatment such as botulinum toxin makes it relevant. Routine cystoscopy, imaging, and urodynamics are not required for an uncomplicated initial OAB evaluation.
Escalate the exception
Gross or persistent microscopic hematuria, recurrent infection, fever, pelvic pain, fistula suspicion, new neurologic deficit, marked retention, renal injury, pelvic mass, prior complex reconstruction, or diagnostic uncertainty requires targeted evaluation or referral.
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Lesson
Storage, Signaling, and Emptying
Continence depends on a compliant detrusor, a closed outlet, intact sensation, central inhibition, coordinated autonomic signaling, and voluntary pelvic-floor control.
- Detrusor
- Muscarinic M3
- Beta-3
- Outlet
- Central control
Beta-3 signaling and central inhibition support filling
Sphincter and pelvic floor maintain urethral resistance
M3 detrusor contraction pairs with outlet relaxation
Store at low pressure
During filling, sympathetic beta-3 signaling promotes detrusor relaxation while outlet tone and pelvic-floor support preserve closure. Afferent signals report filling to the spinal cord and brain, where social context and voluntary control influence timing.
Empty through coordination
Voiding requires parasympathetic acetylcholine signaling, especially at M3 receptors, to contract detrusor muscle while the outlet and pelvic floor relax. Contracting the bladder against a closed outlet or relaxing the bladder in a patient who cannot empty can worsen dysfunction.
Understand OAB as a syndrome
Idiopathic OAB is urgency, usually with frequency and nocturia, with or without urgency incontinence, in the absence of infection or another obvious pathology. Detrusor overactivity on urodynamics can support a mechanism but is not required to diagnose the clinical syndrome.
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Lesson
Behavioral and Pelvic-Floor Therapy
Behavioral care is active treatment for every OAB plan and is also foundational for stress incontinence, but the program must match the mechanism and the patient's ability to carry it out.
- Bladder training
- Pelvic floor muscle training
- Fluid timing
- Constipation
- Mobility
Map intake, voids, urgency, leakage, and nighttime production
Extend intervals and recruit the correct muscles
Treat constipation, access, mobility, sleep, and skin needs
Train the bladder
Timed voiding, gradual interval extension, urge-suppression strategies, and a diary can reduce urgency and frequency. Avoid indiscriminate fluid restriction, which can worsen dehydration, constipation, infection risk, or concentrated-urine irritation.
Train the correct muscle
Pelvic floor muscle training improves urethral support for stress leakage and can help suppress urgency. A pelvic health professional can confirm that the patient contracts the pelvic floor rather than bearing down, holding breath, or substituting abdominal and gluteal muscles.
Remove practical barriers
Treat constipation, optimize diabetes and sleep apnea, review caffeine and alcohol, adjust diuretic timing when clinically appropriate, improve toilet access and clothing, protect skin, and use continence products without presenting them as failure.
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Lesson
Antimuscarinic Therapy
OAB antimuscarinics reduce cholinergic detrusor signaling but can create dry mouth, constipation, blurred vision, retention, and central cognitive harm.
- Oxybutynin
- Tolterodine
- Trospium
- Solifenacin
- Anticholinergic burden
Limit involuntary detrusor contractions during storage
Dry mouth, constipation, vision, retention, and cognition can change fit
Formulation, brain access, organ function, and interactions alter risk
Use the class deliberately
Oxybutynin, tolterodine, trospium, solifenacin, darifenacin, and fesoterodine improve urgency and leakage. Extended-release and transdermal oxybutynin often produce less dry mouth than immediate release. Trospium is quaternary and has lower expected central penetration, but no product should be labeled cognitively risk free.
Respect contraindications and interactions
Use extreme caution with narrow-angle glaucoma, impaired gastric emptying, and a history of urinary retention. Review constipation, cognitive vulnerability, heat intolerance, QT considerations where relevant, CYP3A4 interactions, renal or hepatic adjustment, and additive anticholinergic medicines.
Discuss long-term cognition
Current AUA and SUFU guidance requires discussion of the potential dementia and cognitive-impairment association with chronic antimuscarinic use. A beta-3 agonist may be preferred before chronic antimuscarinic therapy when its safety profile fits. Reassess efficacy and adverse effects rather than renewing indefinitely.
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Lesson
Beta-3 Agonists
Mirabegron and vibegron relax detrusor muscle during storage and avoid muscarinic blockade, but their blood-pressure, interaction, organ-function, and retention profiles are not identical.
- Mirabegron
- Vibegron
- Blood pressure
- CYP2D6
- Urinary retention
Blood pressure, CYP2D6, renal, hepatic, and retention review
Digoxin, angioedema, administration, and retention review
Measure symptoms, pressure when relevant, emptying, and interactions
Differentiate the products
Mirabegron is generally started at 25 mg once daily and can be increased to 50 mg. Vibegron is 75 mg once daily and may be crushed in applesauce. Both can improve urgency, frequency, and urgency incontinence, and both require attention to urinary retention in susceptible patients.
Use mirabegron precisely
Measure blood pressure and avoid mirabegron in severe uncontrolled hypertension. Mirabegron inhibits CYP2D6 and can raise exposure to substrates with a narrow therapeutic range. Renal and hepatic function affect the allowable dose.
Use vibegron precisely
Vibegron does not carry mirabegron's severe-uncontrolled-hypertension warning or CYP2D6 inhibition, but it can increase digoxin exposure and requires digoxin monitoring. Review hypersensitivity, angioedema, bladder outlet obstruction, concurrent antimuscarinic therapy, and new retention symptoms.
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Lesson
OnabotulinumtoxinA and Neuromodulation
Minimally invasive OAB treatment can be selected without forcing a patient to fail every oral option, but each procedure creates a distinct monitoring and maintenance commitment.
- OnabotulinumtoxinA
- Post-void residual
- Tibial nerve stimulation
- Sacral neuromodulation
- Catheterization
Reduce acetylcholine release with infection and retention planning
Modulate afferent pathways through repeated or implanted treatment
Use adjustable neural control with device and revision tradeoffs
Reduce acetylcholine release
Intradetrusor onabotulinumtoxinA 100 Units is a labeled OAB option after inadequate response or intolerance to anticholinergic medication. Obtain post-void residual before treatment and assess for active urinary infection. The patient must be willing and able to catheterize if retention develops.
Monitor after injection
Urinary tract infection, dysuria, and retention are major risks. In patients not already catheterizing, current labeling calls for post-void residual assessment within two weeks and periodically as appropriate for up to 12 weeks. Units are product specific and cannot be substituted across botulinum toxin products.
Modulate neural circuits
Percutaneous or implantable tibial nerve stimulation and sacral neuromodulation alter bladder neural signaling without systemic anticholinergic exposure. Compare visit burden, implant and revision issues, device compatibility, maintenance, goals, and preference.
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Lesson
Stress, Overflow, and Functional Incontinence
Stress, overflow, and functional incontinence do not become OAB because leakage is present. Their treatment targets support, emptying, environment, or a correctable cause.
- Stress test
- Pessary
- Retention
- Mobility
- Surgery
Pelvic floor, pessary, urethral support, or a selected procedure
Resolve obstruction, contractility, neurologic, or medication causes
Improve mobility, access, clothing, cognition, and assistance
Support stress continence
Confirm the pressure-linked pattern and evaluate pelvic support, urethral mobility, urinalysis, and residual urine when relevant. Pelvic floor muscle training, continence pessaries, and urethral support devices are conservative options. Bulking agents, midurethral slings, autologous fascial slings, and colposuspension have different durability and risk profiles.
Do not invent a stress-incontinence drug
No oral medication is FDA approved in the United States specifically for female stress urinary incontinence. Duloxetine is not US approved for this indication. Sympathomimetics have limited efficacy and clinically important cardiovascular and sleep harms, so the older RxPrep suggestion should not be converted into routine treatment.
Restore emptying and access
Overflow management begins with post-void residual, obstruction, detrusor contractility, neurologic disease, constipation, and medicine review. Functional incontinence requires toilet access, transfer support, clothing changes, cognition and caregiver planning, mobility treatment, and scheduled assistance.
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Lesson
Nocturia and Longitudinal Care
Nocturia can arise from OAB, nocturnal polyuria, global polyuria, sleep disruption, edema redistribution, medicines, or systemic disease. Desmopressin fits only one of those mechanisms.
- Nocturnal polyuria
- Desmopressin
- Serum sodium
- Fluid restriction
- Follow-up
Separate nocturnal polyuria, global polyuria, OAB, and sleep-driven waking
Address fluid timing, edema, apnea, diabetes, medicines, heart, and kidney disease
Restrict fluid, monitor sodium, and stop during destabilizing illness
Classify nighttime urine production
Record bedtime, wake time, each nighttime void, first morning void, and 24-hour volume. Treat sleep apnea, edema, diabetes, heart or kidney disease, excessive evening intake, and diuretic timing when relevant. A complaint of waking to void does not prove that urine production caused the awakening.
Use sublingual desmopressin safely
NOCDURNA is indicated for adults who awaken at least twice nightly because of nocturnal polyuria. The sublingual dose is 27.7 mcg for women and 55.3 mcg for men one hour before bedtime without water. Empty the bladder first and minimize fluid from one hour before through eight hours after dosing.
Prevent hyponatremia
Confirm normal sodium before treatment, within seven days, at about one month, and periodically thereafter, with more frequent checks at age 65 or with other risk. Hyponatremia history, excessive fluid intake, loop diuretics, systemic or inhaled glucocorticoids, eGFR below 50, uncontrolled hypertension, heart failure, SIADH, and acute fluid or electrolyte illness can make treatment unsafe or contraindicated.
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Module test
Check the connections.
Each attempt draws 10 questions from the complete 104 question bank.
Each attempt draws a fresh set and rearranges the answer choices.