Urinary Incontinence
Involuntary loss of urine due to impaired bladder storage or sphincter function, classified as stress, urge, overflow, or functional incontinence.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Stress urinary incontinence (SUI) | Leakage with cough/sneeze/exertion; multiparous woman; +ve cough test [1] | 「咳嗽嗰陣會唔會漏尿？」 | ~35% |
| Mixed incontinence (SUI + UUI) | Both stress and urge features | 「兩種情況都有？」 | ~30% | |
| Overactive bladder / Urge incontinence (UUI) | Urgency with involuntary leakage; frequency ≥8/day; no specific clinical signs in women with detrusor overactivity [1] | 「有冇突然好急但忍唔到漏咗出嚟？」 | ~25% | |
| Serious Not To Miss | Bladder carcinoma | Painless haematuria, >50y, smoking history | 「小便有冇血？你有冇食煙？」 | ~1% |
| Spinal cord compression (tumour/MS) | Progressive neuro deficit + bladder dysfunction | Neurological exam: UMN signs in LL, sensory level | <1% | |
| Cauda equina syndrome | Saddle anaesthesia, bilateral leg weakness, faecal incontinence, acute onset | 「坐嗰度有冇冇感覺？兩隻腳有冇突然冇力？」 | <1% | |
| Pitfalls | UTI causing/worsening urgency | Dysuria, fever, cloudy/smelly urine — reversible! | 「小便有冇赤痛？有冇臭味？」 | ~10% |
| Pelvic organ prolapse with occult SUI | Prolapse reduces SUI symptoms; unmasked after prolapse repair [1] | 「有冇覺得下面有嘢跌咗落嚟？」 Cough test after prolapse reduction | ~8% | |
| Overflow incontinence (BPH / neurogenic) | Constant dribbling + palpable bladder + large PVR [2] | Palpable bladder on abdominal exam | ~5% | |
| Masquerades | Drugs (diuretics, anticholinergics, α-blockers, sedatives) | Temporal relationship between drug initiation and incontinence [2] | 「最近有冇轉藥或者加藥？」 | ~10% |
| Depression | Apathy → functional incontinence; antidepressants may worsen | 「心情點呀？有冇唔開心？」 | ~5% | |
| Diabetes mellitus → autonomic neuropathy → overflow incontinence [4] | Polyuria, polydipsia, peripheral neuropathy, large PVR | 「有冇糖尿病？有冇手腳痹？」 | ~3% | |
| Normal pressure hydrocephalus | Classical triad: frontal dementia, apraxic gait, urinary incontinence [5] | 「行路有冇唔穩？記性有冇差咗？」 | <1% | |
| Trying to Tell Me Something? | Embarrassment / social isolation | Avoids social outings, sexual avoidance | 「呢個問題有冇令你唔敢出街或者影響你同伴侶嘅關係？」 | ~30% |
| Fear of cancer / surgery | Hidden concern driving consultation | 「你最擔心啲咩？」 | ~10% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀，我係X醫生。今日想了解下你嘅情況，方唔方便傾下？」「我會問你幾條問題，之後睇下點樣幫到你，好唔好？」 | Interpersonal marks: greeting, signposting, permission |
| 0:30–2:00 | HPI: characterise the incontinence | 「可唔可以話我知，你漏尿嘅情況大概幾時開始？」「係咳嗽、打乞嚏嗰陣漏，定係突然好急忍唔住漏？」「一日大概幾多次？有冇著護墊？」「瞓覺時有冇漏？」 | Determines type: stress vs urge vs overflow vs mixed — the key diagnostic branch |
| 2:00–3:00 | Red flags + associated symptoms | 「有冇見到尿入面有血？」「有冇腰痛或者下腹痛？」「有冇發燒？小便有冇赤痛？」「有冇覺得兩隻腳痹或者冇力？大便有冇失禁？」 | Screens for haematuria (malignancy), UTI, cauda equina, neurological causes |
| 3:00–4:00 | PMHx, DHx, O&G/surgical Hx, social Hx | 「你有冇長期病？例如糖尿、中風、柏金遜？」「食緊咩藥？」「你生過幾多個BB？係順產定開刀？」「有冇收經？」「呢個問題對你日常生活有咩影響？」 | Obstetric/menopause Hx crucial for pelvic floor; drugs may cause/worsen incontinence; functional impact = biopsychosocial |
| 4:00–4:45 | ICE + hidden agenda | 「你自己覺得呢個問題係咩原因？」(Idea) 「最擔心啲咩？」(Concern) 「你今日嚟最希望我幫到你啲咩？」(Expectation) | ICE marks; uncovers hidden agenda — patient may fear cancer, worry about needing surgery, or be embarrassed about social limitations |
| 4:45–5:30 | Summarise, check understanding | 「等我總結返：你嘅情況主要係咳嗽嗰陣會漏尿，已經影響到你唔敢出街……我有冇講漏咩？」 | Shows active listening, earns summary marks |
| 5:30–6:00 | Plan + safety net + empathic close | 「我哋可以先驗下小便，之後教你做盆底肌肉運動。如果情況冇改善可以再商量其他方法。有冇嘢想問？」「多謝你今日嚟，我哋會跟進。」 | Brief safe management, safety net, closing courtesies |
Uncovering the hidden agenda: The symptom is incontinence, but the reason for attending today may be: embarrassment limiting social activities, fear of cancer (haematuria), relationship/sexual impact, or a specific trigger (e.g. worsening after new medication, recent fall). Always ask: 「點解揀今日嚟睇呢個問題？」(Why did you choose to come today about this?)
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Type | Leak with cough/sneeze/exercise? | 「咳嗽、打乞嚏或者跑步嗰陣會唔會漏尿？」 | Stress urinary incontinence (SUI): leakage a/w ↑abdominal pressure [1] | SUI — pelvic floor weakness |
| Type | Sudden urge, can't hold, leak before reaching toilet? | 「有冇試過突然好急，去到廁所之前已經漏咗？」 | Urge incontinence (UUI): strong desire to void that is difficult to defer [1][2] | Overactive bladder / detrusor overactivity |
| Type | Constant dribbling, feeling of incomplete emptying? | 「有冇成日一滴滴咁漏？去完廁所覺得未去清？」 | Overflow incontinence: constant dribbling with associated retention [2] | BOO, detrusor underactivity, neurological |
| Volume/frequency | How many pads per day? How often do you void? | 「一日要換幾多塊護墊？日頭去幾多次廁所？夜晚要起身幾多次？」 | Quantifies severity; nocturia frequency | Severity grading; nocturnal polyuria |
| Red flag: haematuria | Any blood in urine? | 「小便有冇血？」 | Must exclude bladder/renal malignancy | Bladder Ca, renal Ca, UTI, stones |
| Red flag: neuro | Leg weakness, numbness, saddle-area numbness, faecal incontinence? | 「兩隻腳有冇痹或者冇力？坐嗰度有冇冇感覺？大便有冇失禁？」 | Cauda equina syndrome — must not miss | Cauda equina, spinal cord lesion |
| UTI symptoms | Burning on urination, fever, smelly urine? | 「小便有冇赤痛？有冇發燒？尿有冇臭味？」 | UTI can cause/worsen urgency incontinence | Acute UTI as reversible cause |
| O&G Hx | Number of births? Vaginal or C-section? Menopause? | 「你生過幾多個BB？係順產定開刀？收咗經未？」 | Vaginal delivery and menopause are key predisposing factors for pelvic floor dysfunction [1][3] | SUI, pelvic organ prolapse |
| Prolapse | Feeling of lump/heaviness in vagina? | 「有冇覺得下面有嘢跌咗落嚟，或者有墜墜脹脹嘅感覺？」 | Pelvic organ prolapse commonly associated with SUI [3] | Genital prolapse |
| PMHx | DM, stroke, Parkinson's, spinal surgery? | 「你有冇糖尿病、中風、柏金遜症？有冇做過脊骨手術？」 | Neurological conditions → neurogenic bladder; DM → autonomic neuropathy [4] | Overflow/urge incontinence |
| Drug Hx | Diuretics, anticholinergics, α-blockers, sedatives? | 「食緊咩藥？有冇食去水丸、安眠藥？」 | Potentially reversible transient causes — drugs [2] | Drug-induced incontinence (DIAPPERS mnemonic) |
| Fluid/caffeine | How much tea/coffee/water per day? | 「你一日飲幾多杯茶、咖啡？飲幾多水？」 | Excess caffeine/fluid → worsens urgency & frequency | Lifestyle-modifiable factor |
| Functional | Can you get to toilet in time? Any mobility issues? | 「你行動方唔方便？去唔去到廁所嗰度？」 | Functional incontinence: leakage due to inability to get to toilet [2] | Functional incontinence in elderly |
| Constipation | Chronic constipation? Straining? | 「有冇便秘？去大便要唔要好用力？」 | Chronic straining weakens pelvic floor; faecal impaction → urinary retention | SUI worsening; overflow |
| Social/psych impact | Does it affect going out, sleep, mood, relationships? | 「呢個問題有冇影響你出街、瞓覺、心情，或者同屋企人嘅關係？」 | Captures psychological & social BPS problems | Depression, social isolation, sexual dysfunction |
| FHx | Anyone in family with similar problem? | 「屋企人有冇類似嘅問題？」 | Genetic component to pelvic floor weakness | Connective tissue weakness |
Case Report Form Answer Builder
Write: "Urinary incontinence for [duration]."
High-yield HPI points to capture:
- Type: stress / urge / mixed / overflow / functional
- Onset, duration, progression
- Triggers: cough, sneeze, exercise (SUI) vs. sudden urge (UUI) vs. constant dribble (overflow)
- Severity: pads/day, frequency of episodes, nocturia
- Associated LUTS: FUN-DISH mnemonic
- Red flags: haematuria, neurological symptoms, fever/dysuria
- O&G: parity, mode of delivery, menopausal status
- PMHx: DM, neurological disease, pelvic surgery
- DHx: diuretics, anticholinergics, sedatives
- Functional impact: ADL, social, psychological
| Likely RFC Examples | How to Phrase |
|---|---|
| Worsening leakage affecting daily activities | "Increasing urinary incontinence affecting quality of life" |
| Embarrassment / can't go out | "Social embarrassment due to urinary leakage" |
| Concern about underlying serious cause | "Worried about the cause of urinary incontinence" |
| Wants treatment / referral | "Seeking management options for urinary incontinence" |
Tip: The RFC is the patient's main driver — listen for the emotional/social trigger, not just the symptom. Use the patient's own words.
| Component | Likely Content | Exam Wording |
|---|---|---|
| Idea | "I think it's because I had so many children" / "Maybe it's my age" | Patient attributes incontinence to multiparity / aging |
| Concern | "I'm worried it might be cancer" / "I'm afraid I need surgery" / "I'm embarrassed to go out" | Patient concerned about malignancy / need for surgery / social embarrassment |
| Expectation | "I want medication" / "I want to know if exercises can help" / "I want referral to specialist" | Patient expects pharmacological/conservative treatment or specialist referral |
For a middle-aged / postmenopausal multiparous woman in FM:
Most likely: Stress urinary incontinence (SUI) — supported by: leakage on cough/sneeze/exertion, multiparity, menopause, positive cough test [1][2]
If history shows predominant urgency:
Overactive bladder (OAB) with urge incontinence — supported by: urgency, frequency ≥8/day, nocturia, no leakage on exertion
If older male: consider overflow incontinence secondary to BPH — obstructive LUTS + palpable bladder + enlarged prostate on DRE [6]
| DDx | Key Discriminator |
|---|---|
| 1. Overactive bladder / Urge incontinence | Urgency-predominant, no association with exertion, frequency/nocturia |
| 2. Mixed incontinence (SUI + UUI) | Both stress and urge features present |
| 3. Overflow incontinence (e.g. BPH, neurogenic) | Constant dribbling, incomplete emptying, palpable bladder, large PVR |
(Adjust if male patient: swap SUI for BPH-related overflow; add UTI as reversible cause)
| Domain | Problem |
|---|---|
| Biological | Urinary incontinence causing recurrent perineal skin irritation / UTI risk |
| Psychological | Embarrassment, low self-esteem, depressive symptoms due to incontinence |
| Social | Avoidance of social activities / exercise; impact on sexual relationship; increased healthcare costs (pads) |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Stress urinary incontinence | Positive cough test [1] | Ask patient to cough with a comfortably full bladder (standing or supine); observe for leakage from urethral meatus | Demonstrates leakage synchronous with ↑intra-abdominal pressure = SUI |
| Overactive bladder / UUI | No specific clinical signs in women with detrusor overactivity [1] — best clue is the history pattern | N/A — diagnosis is clinical + urodynamics if needed | Absence of physical signs; diagnosed by urgency/frequency history |
| Overflow incontinence | Palpable distended bladder on abdominal exam [2] | Palpate and percuss suprapubic area post-void | Indicates urinary retention → overflow mechanism |
| Pelvic organ prolapse | Visible/palpable vaginal wall prolapse on speculum/Sim's exam | Valsalva manoeuvre during pelvic exam | Prolapse a/w and may mask SUI [1][3] |
| BPH (male) | Smooth enlarged prostate >3 finger-breadths on DRE, median sulcus present [6] | Digital rectal examination | Enlarged prostate → BOO → overflow incontinence |
| Cauda equina | Absent anal reflex / reduced perianal sensation (S2-4) | Stroke perianal skin, check anal tone on DRE | Loss of sacral nerve function → neurogenic bladder |
| NPH | Apraxic (magnetic) gait | Observe gait — broad-based, shuffling, "feet glued to floor" | Part of classical triad: gait apraxia + dementia + incontinence [5] |
Must-Not-Miss Red Flags
- Haematuria → exclude bladder / renal malignancy (urgent referral for cystoscopy if >50y + painless haematuria)
- Neurological symptoms (saddle anaesthesia, bilateral leg weakness, new faecal incontinence) → cauda equina syndrome — surgical emergency
- Acute urinary retention with overflow → needs urgent catheterisation
- Rapidly progressive cognitive decline + gait disturbance + incontinence → NPH (potentially reversible with VP shunt)
Top traps that lose marks:
| Trap | How to Avoid |
|---|---|
| Failing to differentiate SUI from UUI from overflow | Always ask about triggers (exertion vs urgency vs constant dribble) |
| Forgetting obstetric/menopause Hx in a woman | Parity and menopausal status are key predisposing factors [1][3] |
| Not asking about drugs causing incontinence | Always take a full drug history — DIAPPERS mnemonic (Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excess fluid, Restricted mobility, Stool impaction) [2] |
| Assuming incontinence = normal aging | Incontinence increases with age but is NOT part of normal aging [2] |
| Missing the hidden agenda / ICE | Explicitly ask ICE — many patients are embarrassed and won't volunteer concerns |
| Not offering a physical sign for SUI | Cough test is the go-to sign for a brief FM station [1] |
| Writing "OAB" for physical sign | No specific clinical signs in women with detrusor overactivity — state this explicitly and rely on history [1] |
Shortest safe management / safety-net line:
「我哋會先驗小便排除感染，然後教你做盆底肌肉運動，呢個係第一線治療。如果持續冇改善，我哋可以轉介專科。如果你見到尿有血、或者突然兩隻腳冇力，請即刻返嚟或者去急症室。」
(We will check urine to exclude infection first, then teach you pelvic floor exercises as first-line treatment. If no improvement, we can refer to specialist. If you see blood in urine or sudden leg weakness, come back immediately or go to A&E.)
High Yield Summary
What to ASK: Type of incontinence (stress vs urge vs overflow vs functional); triggers; severity (pads/day); red flags (haematuria, neuro symptoms); O&G history (parity, menopause); drug history; functional and psychosocial impact; ICE.
What to WRITE: Chief complaint with duration and type; RFC in patient's words; ICE explicitly; most likely diagnosis = SUI (female) or OAB/overflow (context-dependent); 3 DDx with discriminators; 3 BPS problems; physical sign = cough test (SUI) or palpable bladder (overflow).
What NOT to MISS: Haematuria (malignancy), cauda equina (neuro emergency), drugs as reversible cause, NPH triad, and the fact that OAB has no specific physical sign in women [1] — say this in the exam if asked.
Active Recall - Family Medicine Clinical Test
[1] GC 116. I felt a lump below urinary incontinence in females; genital prolapse.pdf (Physical examination slide, Diagnosis slide) [2] Ryan Ho Urogenital.pdf (Section 8.1 Approach to Urinary Incontinence, pp. 159–161) [3] Block C - O&G Theme Case 4.pdf (Learning objectives: pelvic floor dysfunction) [4] Ryan Ho Endocrine.pdf (Diabetic autonomic neuropathy — genitourinary manifestations, p. 98) [5] Ryan Ho Psychiatry.pdf (Normal pressure hydrocephalus — classical triad, p. 82) [6] Maksim Surgery Notes.pdf (Section 2.4 LUTS & BPH, p. 315)
Tremor
Tremor is an involuntary, rhythmic, oscillatory movement of a body part produced by alternating or synchronous contractions of opposing muscle groups.
Urinary Urgency / Frequency
Urinary urgency and frequency refer to the sudden, compelling need to urinate and an abnormally increased number of voidings, often resulting from bladder irritation, detrusor overactivity, or underlying urologic or neurologic conditions.