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uro.urinary-incontinence-eval.v1PRODUCTION
uro.urinary-incontinence-eval.v1

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

urologychronicadultgeriatricpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Patient inputs (20)

Geriatric: DIAPPERS transient causes screened first; antimuscarinic anticholinergic burden caution; β3 preferred elderly. Pediatric: enuresis alarm first line (AUA OAB 2019; AGS Beers)

Anticholinergic burden (Beers/STOPP), opioid, diuretic, α-blocker — deprescribing review; β3 preferred elderly (AGS Beers)

Dementia + UI = functional UI; antimuscarinic adds anticholinergic burden / dementia risk; β3 preferred (AGS Beers; AUA OAB 2019)

Functional UI from mobility impairment; environmental + caregiver interventions (NICE UI 2019)

Behavioral modification — limit caffeine / alcohol / artificial sweeteners / evening fluid (AUA OAB 2019; NICE UI 2019)

Phenotyping pivot — exertional (stress) vs urgency (urge) vs combined (mixed) vs continuous (overflow / fistula) vs functional (mobility / cognition) (AUA OAB 2019; NICE UI 2019)

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)

3-day bladder diary — fluid intake, voiding times, leakage episodes, urgency episodes; load-bearing diagnostic artifact (AUA OAB 2019; NICE UI 2019)

Pelvic exam (atrophic vaginitis, prolapse, urethral hypermobility, levator tone) in women; DRE in men (AUA OAB 2019; NICE UI 2019)

Bladder US PVR — high (>250 mL) = retention risk + antimuscarinic caution; gates overflow phenotype (AUA OAB 2019)

Rule UTI (transient cause — DIAPPERS); hematuria → AUA 2020 microhematuria workup (AUA OAB 2019)

Severity — pad count / day; ICIQ-UI-SF for bother (NICE UI 2019)

Baseline for β3 agonist (mild BP rise); mirabegron / vibegron monitoring (Chapple Lancet)

Stress UI risk factor in women — pelvic floor injury (NICE UI 2019)

Continuous UI from fistula (post-obstetric / post-hysterectomy / post-radiation) (NICE UI 2019)

Post-RP stress UI — pelvic floor PT first line; sling / AUS if refractory (post-RP UI sling)

DM / MS / CVA / cord injury / Parkinson / dementia → neurogenic bladder overflow OR functional UI (AUA OAB 2019)

BMI >25 → weight loss reduces stress UI (NICE UI 2019)

Cough test with comfortably full bladder → leak = stress UI (NICE UI 2019)

Baseline renal function; obstructive uropathy workup; dose adjust antimuscarinic (AUA OAB 2019)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalseverecontinuous_ui_fistula
    Continuous UI — fistula (vesicovaginal / ureterovaginal) post-obstetric / post-surgical / post-radiation (NICE UI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateurge_ui_oab
    Urge UI / OAB — urgency leakage; detrusor overactivity (AUA OAB 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemixed_ui
    Mixed stress + urge UI (NICE UI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateoverflow_ui_bph_overlay
    Overflow UI — continuous dribbling + high PVR; route to uro.bph.v1 for BPH overlay; neurogenic bladder workup if no obstruction (AUA OAB 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_prostatectomy_ui
    Post-radical-prostatectomy stress UI — pelvic floor PT first → sling → artificial urinary sphincter (AUS) (post-RP UI sling)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateelderly_anticholinergic_burden
    Elderly patient on antimuscarinic with cognitive decline / dementia / fall risk — switch to β3 OR deprescribe; oxybutynin IR contraindicated per Beers (AGS Beers; AUA OAB 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildstress_ui_predominant
    Stress UI predominant — leakage with cough / sneeze / exertion; positive cough test (NICE UI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildfunctional_ui_dementia_mobility
    Functional UI — leakage from inability to reach toilet (mobility / dementia) — environmental + caregiver intervention (NICE UI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpediatric_enuresis
    Pediatric nocturnal or daytime enuresis — alarm therapy first; desmopressin second; imipramine third (AUA pediatric; NICE pediatric)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmilddiappers_transient_cause
    DIAPPERS — Delirium / Infection (UTI) / Atrophy / Pharmaceuticals / Psychological / Endocrine (DM polyuria, hypercalcemia) / Restricted mobility / Stool impaction — transient cause; rule out BEFORE chronic phenotyping (Resnick DIAPPERS)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Urge UI / OAB — AUA 2019 ladder: behavioral → antimuscarinic OR β3 → botox → SNM / PTNS
axis: urge_ui_oab_ladderstep 1 - Tier 1 — Behavioral + lifestyle (all phenotypes)
Selected step "Tier 1 — Behavioral + lifestyle (all phenotypes)" — All UI phenotypes; first-line for all
  • Behavioral therapy — bladder training, timed voiding, urge suppression, fluid timing
    first line
    lifestyle
    triggers: all_phenotypes
    AUA OAB 2019 / NICE UI 2019 first-line for all phenotypes (PMID 31039103;)
  • Lifestyle modification — caffeine / alcohol / artificial sweetener reduction, weight loss if BMI >25, smoking cessation, bowel regimen
    first line
    lifestyle
    triggers: all_phenotypes
    AUA OAB 2019 / NICE UI 2019

outpatient playbook — drug actions (4)

  1. 1. oxybutynin ER OR solifenacin OR trospium
    Oxybutynin ER 10 mg PO daily; solifenacin 5 mg daily; trospium 20 mg BID (preferred elderly) • PO • daily / BID
    trigger: Urge UI / OAB phenotype (AUA OAB 2019)
    Antimuscarinic ladder; trospium preferred elderly
  2. 2. mirabegron OR vibegron
    Mirabegron 25 mg PO daily titrate to 50 mg; vibegron 75 mg daily • PO • once daily
    trigger: Urge UI / OAB; elderly / cognitive concern / antimuscarinic intolerance (AUA OAB 2019)
    β3 agonist preferred elderly (Chapple Lancet)
  3. 3. onabotulinumtoxinA intradetrusor
    100 U intradetrusor • intradetrusor • q6mo PRN
    trigger: Refractory OAB; willingness to self-cath (AUA OAB 2019)
    Refractory OAB; ~70% efficacy at 6 mo
  4. 4. desmopressin (pediatric)
    0.2–0.4 mg PO nocte • PO • nightly
    trigger: Pediatric enuresis failed alarm (AUA pediatric)
    Vasopressin analog reduces nocturnal output

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Involuntary urine loss with cough / sneeze / exertion — stress UI (AUA OAB 2019; NICE UI 2019); Urgency leakage / detrusor overactivity — urge UI / OAB (AUA OAB 2019); Combined stress + urge components — mixed UI (NICE UI 2019).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Urinary Incontinence — chronic outpatient evaluation (stress / urge / mixed / overflow / functional / continuous / pediatric / post-prostatectomy)** (uro.urinary-incontinence-eval.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Urge UI / OAB — AUA 2019 ladder: behavioral → antimuscarinic OR β3 → botox → SNM / PTNS** — step "Tier 1 — Behavioral + lifestyle (all phenotypes)".
1. Behavioral therapy — bladder training, timed voiding, urge suppression, fluid timing (lifestyle, first line) — AUA OAB 2019 / NICE UI 2019 first-line for all phenotypes (PMID 31039103;)
2. Lifestyle modification — caffeine / alcohol / artificial sweetener reduction, weight loss if BMI >25, smoking cessation, bowel regimen (lifestyle, first line) — AUA OAB 2019 / NICE UI 2019

Setting playbook (outpatient) — Comprehensive eval at index visit; phenotype diagnosis at visit 2; ladder step at visit 3; 12 wk re-check on each step (AUA OAB 2019; NICE UI 2019)
3. oxybutynin ER OR solifenacin OR trospium Oxybutynin ER 10 mg PO daily; solifenacin 5 mg daily; trospium 20 mg BID (preferred elderly) PO daily / BID — Urge UI / OAB phenotype (AUA OAB 2019) (Antimuscarinic ladder; trospium preferred elderly)
4. mirabegron OR vibegron Mirabegron 25 mg PO daily titrate to 50 mg; vibegron 75 mg daily PO once daily — Urge UI / OAB; elderly / cognitive concern / antimuscarinic intolerance (AUA OAB 2019) (β3 agonist preferred elderly (Chapple Lancet))
5. onabotulinumtoxinA intradetrusor 100 U intradetrusor intradetrusor q6mo PRN — Refractory OAB; willingness to self-cath (AUA OAB 2019) (Refractory OAB; ~70% efficacy at 6 mo)
6. desmopressin (pediatric) 0.2–0.4 mg PO nocte PO nightly — Pediatric enuresis failed alarm (AUA pediatric) (Vasopressin analog reduces nocturnal output)

Non-pharmacologic actions:
- Bladder training schedule (AUA OAB 2019)
- Pelvic floor PT referral for stress / mixed UI (NICE UI 2019)
- Weight loss counseling if BMI >25 (NICE UI 2019)
- Caffeine / alcohol / artificial sweetener reduction counseling (AUA OAB 2019)
- Surgical referral for refractory or surgical candidate (uro / urogyn) (NICE UI 2019)
- Deprescribing anticholinergic burden (AGS Beers)
- Caregiver + environmental intervention for functional UI (dementia / mobility) (NICE UI 2019)
- Pediatric enuresis alarm therapy + family education (AAP / AUA pediatric)

AVOID / contraindication checks:
- Antimuscarinic_avoid_in_narrow_angle_glaucoma (AUA OAB 2019)
- Antimuscarinic_avoid_in_PVR_gt_250mL (AUA OAB 2019)
- Antimuscarinic_dementia_risk_elderly_oxybutynin_IR (AGS Beers)
- Beta3_BP_monitoring (AUA OAB 2019)
- Botox_AUR_risk_self_cath_teaching_mandatory (AUA OAB 2019)
- Deprescribing_anticholinergic_burden_elderly (AGS Beers)

Monitoring

Regimen monitoring:
- PVR at 12wk on antimuscarinic or botox (AUA OAB 2019)
- cognition MMSE at 6mo on antimuscarinic elderly (AGS Beers)
- BP HR q3mo on beta3 (AUA OAB 2019)
- bladder diary at each visit (AUA OAB 2019)
- ICIQ UI SF at each visit (NICE UI 2019)

Setting (outpatient) monitoring:
- 12 wk re-eval on each ladder step (AUA OAB 2019)
- Bladder diary at each visit (AUA OAB 2019)
- PVR on antimuscarinic / botox (AUA OAB 2019)
- Cognition q6mo on antimuscarinic in elderly (AGS Beers)
- BP / HR on β3 (AUA OAB 2019)

Follow-up plan: 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)
- Close-out criterion: follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: outpatient — Comprehensive eval at index visit; phenotype diagnosis at visit 2; ladder step at visit 3; 12 wk re-check on each step (AUA OAB 2019; NICE UI 2019)

Disposition criteria:
- Stable on ladder step → annual re-eval (AUA OAB 2019)
- Refractory → uro / urogyn referral for surgical evaluation (NICE UI 2019)
- Surgical candidate → uro / urogyn surgical pathway (NICE UI 2019)

Escalation triggers (move to higher acuity):
- Hematuria → AUA 2020 microhematuria workup → STAT urology + cystoscopy (AUA microhematuria 2020)
- Recurrent UTI → uro.uti.complicated.v1 workup (CDC STI 2021)
- Saddle anesthesia / lower extremity weakness → STAT neuro / spine imaging (cauda equina) (AUA OAB 2019)
- AUR with palpable bladder → STAT ED for Foley + uro.bph.v1 workup (AUA BPH 2021)
- Refractory to ≥3 ladder steps → uro / urogyn surgical evaluation (NICE UI 2019)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Continuous UI — fistula (vesicovaginal / ureterovaginal) post-obstetric / post-surgical / post-radiation (NICE UI 2019)
- [MODERATE] Urge UI / OAB — urgency leakage; detrusor overactivity (AUA OAB 2019)
- [MODERATE] Mixed stress + urge UI (NICE UI 2019)

Citations

- AUA OAB 2019 + NICE UI in women 2019 + AGS Beers (anticholinergic burden) + post-RP UI sling + AUA pediatric enuresis + Resnick DIAPPERS [PMID:31039103](https://pubmed.ncbi.nlm.nih.gov/31039103/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AUA OAB 2019 + NICE UI in women 2019 + AGS Beers (anticholinergic burden) + post-RP UI sling + AUA pediatric enuresis + Resnick DIAPPERS — PMID:31039103