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uro.urinary-incontinence-eval.v1

Urinary Incontinence — chronic outpatient evaluation (stress / urge / mixed / overflow / functional / continuous / pediatric / post-prostatectomy)

urologychronicadultgeriatricpediatricoutpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-10 initial author (2026-05-15): SCAFFOLDED with full §5.5 depth — 8 phenotypes + 2 overlay rows (DIAPPERS + elderly anticholinergic burden) = 10 severity_triggers, 2 settings (outpatient primary + home), 6-PMID anchor set, 3 regimen axes (urge / stress / pediatric), 3 sibling rows pointing at REAL existing engines (uro.bph.v1, uro.uti.uncomplicated.v1, uro.uti.complicated.v1). DIAPPERS geriatric overlay (Delirium / Infection / Atrophy / Pharmaceuticals / Psychological / Endocrine / Restricted mobility / Stool impaction) — transient causes screened BEFORE chronic phenotyping; load-bearing for elderly. Elderly safety: β3 agonist (mirabegron / vibegron) or trospium (quaternary amine) preferred over oxybutynin IR (Beers contraindicated); anticholinergic burden raises dementia risk (Gray BMJ 2015 anchor). Schema-blocked downstream: calc.iciq_ui_sf, calc.pvr (shared with BPH), protocol.bladder_diary_3d, panel.uroflow — none in registry. Calculator slot intentionally empty until calc.iciq_ui_sf lands. Pediatric enuresis pathway: alarm therapy 8–16 wk → desmopressin 0.2–0.4 mg PO nocte (counsel fluid restriction for hyponatremia) → imipramine specialist-only (cardiac toxicity overdose risk). Promoted SCAFFOLDED→INTEGRATED 2026-05-22 (shard-5 build campaign): all 6 prior placeholder PMIDs were mis-attributed (spinal myelopathy, VTE-obesity, aging white-matter, research ethics, + 2 more) and replaced with the live-verified AUA/SUFU OAB 2019 guideline (31039103); NICE UI-in-women, AGS Beers, Resnick DIAPPERS cited by name. RxCUIs corrected (7 wrong): solifenacin 1099767→322167, mirabegron 1455007→1300786, vibegron 2569961→2472254 (was menthol), desmopressin 3289→3251 (was dextromethorphan), tolterodine 37798→119565 (was terazosin), trospium 38400→236778 (was atomoxetine), oxybutynin 7715→32675 (was orphenadrine), onabotulinumtoxinA 861015→860189 (was metformin); imipramine 5691 RxNav-verified.

Entry points (9)

  • symptom
    Involuntary urine loss with cough / sneeze / exertion — stress UI (AUA OAB 2019; NICE UI 2019)
    stress_ui_leakage
  • symptom
    Urgency leakage / detrusor overactivity — urge UI / OAB (AUA OAB 2019)
    urge_ui_oab
  • symptom
    Combined stress + urge components — mixed UI (NICE UI 2019)
    mixed_ui_combined
  • symptom
    Continuous dribbling + incomplete emptying — overflow UI; route to uro.bph.v1 if BPH overlay
    overflow_ui_dribbling
  • symptom
    Leakage from inability to reach toilet (mobility / dementia) — functional UI (geriatric)
    functional_ui_cognition_mobility
  • symptom
    Continuous leakage post-obstetric / post-pelvic surgery — fistula (vesicovaginal / ureterovaginal)
    continuous_ui_fistula
  • symptom
    Nocturnal or daytime enuresis in child — pediatric enuresis pathway
    pediatric_enuresis
  • symptom
    Stress UI post-radical prostatectomy — pelvic floor PT → sling → AUS (post-RP UI sling)
    post_prostatectomy_ui
  • problem_list
    Established UI follow-up — re-tracking on ladder step
    known_ui_followup

Required inputs (20)

  • sexrequired
    demographic • used at FRAME
    Female: stress UI > urge; mid-urethral sling first-line surgical. Male: post-RP stress UI; BPH overflow overlay. Pediatric: enuresis pathway (AUA OAB 2019; NICE UI 2019)
  • agerequired
    demographic • used at CONTEXT
    Geriatric: DIAPPERS transient causes screened first; antimuscarinic anticholinergic burden caution; β3 preferred elderly. Pediatric: enuresis alarm first line (AUA OAB 2019; AGS Beers)
  • leakage_patternrequired
    symptom • used at ENTRY
    Phenotyping pivot — exertional (stress) vs urgency (urge) vs combined (mixed) vs continuous (overflow / fistula) vs functional (mobility / cognition) (AUA OAB 2019; NICE UI 2019)
  • leakage_frequency_padsrequired
    symptom • used at RISK_STRATIFICATION
    Severity — pad count / day; ICIQ-UI-SF for bother (NICE UI 2019)
  • bladder_diary_3dayrequired
    symptom • used at INITIAL_WORKUP
    3-day bladder diary — fluid intake, voiding times, leakage episodes, urgency episodes; load-bearing diagnostic artifact (AUA OAB 2019; NICE UI 2019)
  • parity_vaginal_delivery
    history • used at CONTEXT
    Stress UI risk factor in women — pelvic floor injury (NICE UI 2019)
  • pelvic_surgery_radiation
    history • used at CONTEXT
    Continuous UI from fistula (post-obstetric / post-hysterectomy / post-radiation) (NICE UI 2019)
  • prostatectomy_history
    history • used at CONTEXT
    Post-RP stress UI — pelvic floor PT first line; sling / AUS if refractory (post-RP UI sling)
  • neurologic_disease
    history • used at CONTEXT
    DM / MS / CVA / cord injury / Parkinson / dementia → neurogenic bladder overflow OR functional UI (AUA OAB 2019)
  • current_meds_ui_burdenrequired
    history • used at CONTEXT
    Anticholinergic burden (Beers/STOPP), opioid, diuretic, α-blocker — deprescribing review; β3 preferred elderly (AGS Beers)
  • cognitive_function_mmserequired
    history • used at CONTEXT
    Dementia + UI = functional UI; antimuscarinic adds anticholinergic burden / dementia risk; β3 preferred (AGS Beers; AUA OAB 2019)
  • mobility_functionrequired
    history • used at CONTEXT
    Functional UI from mobility impairment; environmental + caregiver interventions (NICE UI 2019)
  • bmi_weight
    history • used at CONTEXT
    BMI >25 → weight loss reduces stress UI (NICE UI 2019)
  • fluid_caffeine_alcohol_intakerequired
    history • used at CONTEXT
    Behavioral modification — limit caffeine / alcohol / artificial sweeteners / evening fluid (AUA OAB 2019; NICE UI 2019)
  • pelvic_examrequired
    imaging • used at INITIAL_WORKUP
    Pelvic exam (atrophic vaginitis, prolapse, urethral hypermobility, levator tone) in women; DRE in men (AUA OAB 2019; NICE UI 2019)
  • post_void_residualrequired
    imaging • used at INITIAL_WORKUP
    Bladder US PVR — high (>250 mL) = retention risk + antimuscarinic caution; gates overflow phenotype (AUA OAB 2019)
  • cough_stress_test
    imaging • used at INITIAL_WORKUP
    Cough test with comfortably full bladder → leak = stress UI (NICE UI 2019)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Rule UTI (transient cause — DIAPPERS); hematuria → AUA 2020 microhematuria workup (AUA OAB 2019)
  • creatinine
    lab • used at INITIAL_WORKUP
    Baseline renal function; obstructive uropathy workup; dose adjust antimuscarinic (AUA OAB 2019)
  • sbprequired
    vital • used at TREATMENT
    Baseline for β3 agonist (mild BP rise); mirabegron / vibegron monitoring (Chapple Lancet)

12-phase flow (12)

  1. 1FRAME
    Adult / geriatric / pediatric with chronic UI — phenotype matrix (stress / urge / mixed / overflow / functional / continuous / pediatric / post-RP); explicit pivots: AUR → uro.bph.v1; recurrent UTI → uro.uti.complicated.v1; female prolapse → out of scope (separate engine) (AUA OAB 2019; NICE UI 2019)
    inputs: sex
    advance: engine scope confirmed
  2. 2ENTRY
    Leakage pattern (exertional / urgency / continuous / functional) + bother (ICIQ-UI-SF) (AUA OAB 2019; NICE UI 2019)
    inputs: leakage_pattern, age
    advance: leakage pattern documented
  3. 3CONTEXT
    Parity, pelvic surgery / radiation, prostatectomy, neurologic disease, current meds (anticholinergic burden), cognition (dementia), mobility, BMI, fluid / caffeine / alcohol intake, transient causes (DIAPPERS) (AUA OAB 2019; NICE UI 2019; AGS Beers)
    inputs: parity_vaginal_delivery, pelvic_surgery_radiation, prostatectomy_history, neurologic_disease, current_meds_ui_burden, cognitive_function_mmse, mobility_function, bmi_weight, fluid_caffeine_alcohol_intake
    advance: context + DIAPPERS transient causes screened
  4. 4RED_FLAGS
    Hematuria → AUA 2020 microhematuria workup; recurrent UTI → workup obstruction → uro.uti.complicated.v1; obstructive uropathy + AKI → admit; saddle anesthesia / lower extremity weakness → STAT neuro / spine imaging (cauda equina) (AUA OAB 2019; AUA microhematuria 2020)
    advance: no red flags OR routed
  5. 5INITIAL_WORKUP
    Bladder diary 3-day, ICIQ-UI-SF bother, focused pelvic / DRE / neurologic exam, UA, PVR, cough stress test if stress UI suspected, creatinine (AUA OAB 2019; NICE UI 2019)
    inputs: bladder_diary_3day, leakage_frequency_pads, pelvic_exam, post_void_residual, cough_stress_test, urinalysis, creatinine
    actions: panel.ua, panel.renal
    advance: phenotype assigned
  6. 6BRANCHING_WORKUP
    Hematuria → microhematuria workup; high PVR → overflow phenotype → uro.bph.v1 if BPH overlay OR neurogenic workup; suspected fistula → cystogram / IVU / dye test; uroflowmetry + urodynamics pre-surgical or refractory only (AUA OAB 2019; AUA microhematuria 2020)
    advance: branching diagnostics complete
  7. 7DIFFERENTIAL
    Stress / urge / mixed / overflow / functional / continuous (fistula) / pediatric enuresis / post-RP / transient (DIAPPERS: delirium, infection, atrophy, pharmaceuticals, psychological, endocrine, restricted mobility, stool impaction) (AUA OAB 2019; NICE UI 2019; Resnick DIAPPERS)
    advance: phenotype + transient causes screened
  8. 8RISK_STRATIFICATION
    Severity (pad count / leakage episodes), bother (ICIQ-UI-SF), QoL impact, frailty overlay, surgical candidacy (AUA OAB 2019; NICE UI 2019)
    inputs: leakage_frequency_pads, sbp
    advance: severity + bother + surgical candidacy assigned
  9. 9TREATMENT
    Behavioral + lifestyle (all). Pelvic floor PT for stress + mixed. Antimuscarinic OR β3 for urge / OAB (β3 preferred elderly). Onabotulinumtoxin A 100 U intradetrusor for refractory OAB. SNM / PTNS third line. Mid-urethral sling for female stress UI; AUS for post-RP stress UI. Pediatric enuresis: alarm → desmopressin → imipramine. Continuous UI: surgical fistula repair. Deprescribing review (AUA OAB 2019; NICE UI 2019; post-RP UI sling; pediatric enuresis)
    inputs: current_meds_ui_burden
    advance: ladder step selected
  10. 10DISPOSITION
    Primary care + uro / urogyn referral if refractory or surgical candidate; specialty PT referral; pediatric uro for refractory enuresis (AUA OAB 2019)
    advance: disposition documented
  11. 11MONITORING
    Re-eval 12 wk on each ladder step; bladder diary; PVR on antimuscarinic / β3 (retention risk); cognition on antimuscarinic in elderly; BP on β3 (AUA OAB 2019; Chapple Lancet)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Annual re-evaluation; treatment de-escalation if stable; deprescribing review for anticholinergic burden in elderly; pediatric enuresis transition off therapy (AUA OAB 2019; AGS Beers)
    advance: follow-up scheduled