• Decline in the maximal urethral closure pressure and length (women)

• Decreased ability to delay voiding

• Decreased bladder capacity

• Decreased detrusor contractility

• Decreased sensation of filling

• Decreased urinary flow rates

• Increased post-void residual

• Increased prevalence in bladder outlet obstruction related to prostatic enlargement (men)

Diffuse
	Distal symmetric sensorimotor polyneuropathy
	Autonomic neuropathy
	Sudomotor     Cardiovascular     Gastrointestinal     Genitourinary
	Symmetric proximal lower limb motor neuropathy (amyotrophy)
Focal
	Cranial neuropathy
	Radiculopathy/plexopathy
	Entrapment neuropathy
	Asymmetric lower limb motor neuropathy (amyotrophy)

Date: Time	Amount/type of drink	Urination (in toilet)	Incontinent episode (s = small, l = large)	Activity (eg, coughing, getting up, walking)	Bowel movement
6-7 am
7-8 am
8-9 am
9-10 am
10-11 am
11 am-12 pm
12-1 pm
1-2 pm
2-3 pm
3-4 pm
4-5 pm
5-6 pm
6-7 pm
7-8 pm
8-9 pm
9-10 pm
10-11 pm
11 pm-6 am

Symptom	Condition/possible Urodynamic findings	Etiology	Management strategies
Urge urinary incontinence (overactive bladder)	Involuntary leakage with or immediately preceded by urgency Urodynamics: detrusor overactivity (involuntary detrusor contraction), inability to inhibit detrusor contraction, low capacity	Idiopathic, neurogenic, urinary tract infection, bladder cancer, outlet obstruction	Bladder training, timed toileting Fluid and constipation management Medication review Pelvic muscle exercises ± biofeedback Estrogen Anticholinergic/antimuscarinic agents Incontinence pads Environment modifications (eg, bedside commode) Sacral nerve neuromodulation, augmentation cystoplasty, urinary diversion (rare)
Stress urinary incontinence	Involuntary leakage on effort, exertion, sneezing, or coughing Urodynamics: incompetent urethral closure mechanism and/or leakage during increased abdominal pressure in the absence of a detrusor contraction	Pelvic floor prolapse, prior urethral bladder or pelvic surgery, neurogenic	Weight loss Fluid increase or decrease Smoking cessation Constipation management Pelvic muscle exercises ± biofeedback Pessary Incontinence pads Alpha agonists Pubovaginal sling Periurethral bulking agents
Mixed incontinence (urge and stress)	Involuntary leakage associated with urgency and exertion, effort, sneezing, or coughing		Combination of above Initial focus is on the dominant symptom
Overflow	Retention of urine with incontinence (associated with chronic urinary retention from poorly contractile bladder or outlet obstruction). May have reduced or absent bladder sensation, slow or intermittent stream, hesitancy, straining, a feeling of incomplete emptying, or dribble after micturition	Poorly contractile bladder as a result of neurogenic causes (diabetes, Parkinson's disease, multiple sclerosis, spinal compression from cauda equina or meta-static cancer, dyssynergia)	Referral to urologist or urogynecologist Relief of obstruction if present Clean intermittent catheterization Medication review Alpha blockers Indwelling catheter (last resort)
	Urodynamics: diminished sensation during filling cystometry, increased capacity, detrusor underactivity, inability to initiate flow, reduced flow with increased detrusor pressure (obstruction), increased PVR	Outlet obstruction from benign prostatic hypertrophy, prostatic or bladder cancer, cystocele, constipation, forgotten pessary

Classification	Mechanism of action	Dose	Side effects	Contraindications
Drugs for detrusor overactivity (overactive bladder, urge UI)
Anticholinergics/ antimuscarinics: Oxybutynin, oxybutynin XL	Antispasmodic and slight analgesic effect on smooth muscle; inhibits acetylcholine in smooth muscle Metabolized primarily by liver	2.5 to 5 mg od to qid Oxybutynin XL available in 5, 10 mg	Constipation, dry mucosa (mouth, vagina, eyes); may cause confusion, impaired cognition in elders; blurred vision; urinary retention (monitor PVR)	Anticholinergic medications contraindicated in narrow angle glaucoma, GI obstruction or atony, ulcerative colitis, myasthenia gravis, urinary retention, or increased PVR (can use with intermittent catheterization)
Tolterodine Tolterodine LA	More selective on muscarinic (M3) receptors than oxybutynin, resulting in fewer anticholinergic side effects	1-2 mg bid, may take up to 8 weeks to reach optimum benefit; LA 4 mg	Caution: gradually increase dose; low doses effective in some older patients Explain that empty LA capsule will be excreted in feces As above, but less pronounced because of selectivity of M3 bladder receptors over salivary receptors	As above; adjust dosage if concurrent use of CYP- 450 3A4 inhibitors (fluoxetine increases concentration 4.8 times)
Propantheline bromide	Nonselective anticholinergic and antispasmodic	15-30 mg PO q6h daily	As above	As above
Tricyclic antidepressants: imipramine, doxepin, desipramine, nortriptyline		25 mg qhs, up to 25 mg tid	As above, orthostatic hypotension also can be an issue in elders, increasing risk for falls; monitor BP lying and standing	Decrease in nocturnal UI,side effects common. Not a drug of choice in older adults
Drugs that increase urethral sphincter tone (for stress UI)
Alpha adrenergic agent: Pseudoephedrine	Stimulates alpha fibers at bladder neck and sphincter, increasing tone	75 mg q 12h	Hypertension, insomnia, tremor, agitation	Hypertension, narrow angle glaucoma. Should not be prescribed for those on MAO inhibitors. Use with caution in older adults
Hormone replacement therapy: Premarin vaginal cream Slow-release estradiol ring	Reduces irritation from atrophic vaginitis (does not provide systemic effects/benefits because of low dose)	Cream: 1-2 gm qhs × 2 weeks, then 2 × per week at hs Estradiol ring: change q 3 months	May cause sore breasts, spotting. Apply intravaginally, not on labia	Endometrial, ovarian, or breast cancer
Drugs that decrease urethral sphincter tone (obstruction from benign prostatic hypertrophy)
Alpha adrenergic blockers (antagonists): Terazosin, prazosin, doxazosin	Blocks alpha 1A fibers at the bladder neck and sphincter, decreasing tone and improving voiding in men with mild obstruction	Start with low dose, gradually increase until therapeutic effect achieved	Postural hypotension, syncope, fainting (especially with first dose). Increased risk of falls, so monitor BP lying and standing	Concurrent antihypertensive treatment may need dose titration
5-alpha reductase inhibitors: Finasteride	Inhibits the conversion of testosterone, testosterone to dihydro-testosterone reducing prostrate size and improving voiding	5 mg daily	Taken long-term; prostate will begin to enlarge again when it is stopped	Food may delay rate and extent of oral absorption; not indicated in urinary obstruction unless monitored by a urologist
Drugs that increase the activity of the detrusor (detrusor underactivity)
Cholinomimetics (muscarinic agonists): Bethanechol	Activate muscarinic receptors triggering detrus or contraction and relaxing the bladder trigone and sphincter	10-25 mg po daily 5 mg sc for acute retention	Clinically, has not been shown to be consistently effective Nausea, vomiting, sweating, blurred vision, bradycardia, intestinal colic	Obstructs bladder outlet; may aggravate respiratory conditions (eg, asthma)
Cholinesterase inhibitors: Neostigmine	Indirectly act as cholinomimetic by inhibiting acetylcholinesterase and increasing concentration of acetylcholine at neuromuscular receptor sites	15 mg po 0.5-1 mg sc for acute retention	As above, plus restlessness	As above

Glycemic control	Diet, exercise, weight loss
	Oral glucose lowering agents
	Insulin stimulators (secretagogues)
	Sulfonylureas (eg, glyburide, gliclazide)
	Meglitinides (eg, repaglinide)
	Insulin sensitizers
	Biguanides (eg, Glucophage)
	Thiazolidinediones (eg, rosiglitazone, pioglitazone)
	Alpha glucosidase inhibitors (eg, acarbose)
	Insulin
Voiding Strategies	Scheduled toileting
	Follow up PVR measurement needed to assess bladder emptying
	Double voiding
	Bladder expression
	Use only if urodynamics demonstrate no vesicoureteral reflux
Catheterization	Intermittent catheterization (if voiding strategies ineffective)
	Indwelling catheterization (last resort)
Nocturnal polyuria	Fluid management: avoid caffeinated beverages at night, take most of fluids during the day
	Empty bladder before going to bed