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DEFINITION

Mixed urinary incontinence (MUI) refers to an occurrence of the same patient, as secondary stress urinary loss (when an intravesical pressure exceeds the urethral resistance in absence of contraction of the detrusor) urinary loss due to vesical instability (associated to urination urgency and involuntary contraction of the detrusor).

DIAGNOSIS

The symptoms (urinary loss to effort and associated to urgency) compatible with MUI are much more frequent than the diagnosis of involuntary contractions of the detrusor in urodynamic studies. The instability of the detrusor and genuine stress urinary incontinence may coexist in 4 to 30% of patients (1,2).
When ID symptoms are evaluated (unduly frequent miction, urgency and urgeincontinence) associated to SUI prevalence increases considerably. In research done on 807 patients, over 12 attended as outpatient clinics at the School Health Center - UNESP, 29% showed some degree of urinary incontinence, of these, only 40% complained exclusively of SUI, and 60% referred to compatible symptoms of associated detrusor instability (3).
Other authors with epidemiological elevation done in Europe and the USA obtained similar results. Every 55% of the patients that are lead for an evaluation in reference centers may present detrusor instability associated to stress urinary incontinence (4). When you take into consideration patients with general incontinence of detrusor instability may be present in 9 to 55% of the cases (5).
Transitory cases of incontinence must be evaluated and treated as delirium, urinary infection, estrogen deficiency, use of medicine with an activity on the inferior urinary tract, important psychological disturbances, endocrineous causes (uncontrolled diabetes, hyperkalium) and fecaloma. The MUI frequently occurs to elderly women who use medication that act on the lower urinary tract (diuretics, muscle relaxants, medication for psychosis, anticholinergic, anti-hypertensive drugs, alfa-adrenergic). The simple change or correct judgment of the dose of the medication could be everything that is needed by the patient. The degree of discernment must be evaluated, the general state of health and the capacity of deambulation, and the dexterity in executing small movements. In certain specific situations, an evaluation of a neurologist is convenient. Some neurological illnesses begin with alterations in urinary control capacity. Illnesses like multiple sclerosis or Parkinson Disease may, in 20 to 30% of the patients, manifest themselves with complaints of urinary incontinence (8,9).

PHYSICAL EXAM

The general state of health of the patient is primordial in relation to the presence of significant clinical illnesses that may limit the options of treatment, mainly surgical. A special physical exam is important to reproduce the symptoms, confirming urinary loss to Valsalva Maneuver or coughing. It is important to evaluate if urinary loss is simultaneous with the increase of abdominal pressure and of short duration. Urinary loss that occurs after coughing is persistent, similar to urination, indicates the occurrence of an involuntary contraction of the detrusor. The region of the sacrolumbar spine must be inspected and palpated for the detection of anomalies, taking into consideration that the medullar segments S2-S4 is fundamental for urinary incontinence. The neurological exam is directed for an evaluation of the perineal sensibility of the sacral reflexes and the enervation of the inferior limbs. Rash abnormalities of the sensibility in the perineal region justify additional investigation by a neurologist. Coughing also leads, normally, to the anal sphincter. The vaginal mucosa and the urethral meatus must be examined for the classic signs estrogen deficiency fine mucous and cold, caruncle or urethral ectropion, and loss of the vaginal rugosity (Fig.1). The two fingered exam of the musculature of the pelvic floor allows an evaluation, its voluntary contractile force. The mobility of the urethro vesical junction must be evaluated after the Valsalva maneuver or coughing. Patients with a history of a previous surgery and or with a bladder neck well positioned, with no mobility to physical effort and accentuated urinary loss (suggesting incontinence by intrinsic sphincterian deficiency) are more of a candidate for surgery directed to anatomic treatment of incontinence. In these cases the suspension of the bladder neck may fail in almost 50% of the cases (8). When existent the type and degree of the prolapse (cystocele, rectocele, enterocele or uterine prolapse) must be described. In the cases of cystocele, prolapse of the vaginal vault or intense rectocele, the stress test is done initially without and, following, with a reduction of the prolapse with the help of one of the valves of the disarticulation speculum.

SUBSIDIARY EXAMS

The symptoms of dysuria, pollakiuria and episodes of urgeincontinence are common to several illnesses that attack the urinary tract, like an infection, vesical lithiosis, tuberculosis and carcinoma in situ of the bladder. It is fundamental to get urine analysis (leucocituria, hematurie) and urine culture with an antibiogram. Mainly in elderly patients, the urinary cytologic may be useful to evaluate the eventual vesical carcinoma. The ultra sonography is useful to evaluate the superior urinary tract.