Evaluation of Urinary Incontinence
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Urinary incontinence can be a symptom of which patients complain, a sign demonstrated on examination, or a condition that can be confirmed by definitive studies. The history and physical examination are the first and most important steps in the evaluation. A preliminary diagnosis can be made with simple office and laboratory tests, with initial therapy based on these findings. For the vast majority of women presenting with complaints of urinary incontinence who have not had prior failed anti-incontinence operations or the history of neurologic disease, the simple evaluation may be all that is needed. With a detailed history, physical examination and the neurologic examination of the lower extremities and perineum, a diagnosis can usually be established accurately in approximately 90% of patients. If complex conditions are present or if surgery is being considered, definitive specialized studies are necessary.
The detailed description of the patient's main complaint, including duration and frequency of urinary problems should be taken. A clear understanding of the severity of the problem or disability and its effect on quality of life should be sought. Helpful questions in the evaluation of female urinary incontinence are:
- Do you leak urine when you cough, sneeze, or laugh?
- Do you ever have such an uncomfortable strong need to urinate that if you do not reach the toilet you will leak?
- If "yes" to question 2, do you ever leak before you reach the toilet?
- How many times during the day do you urinate?
- How many times do you void during the night after going to bed?
- Have you wet the bed in the past year?
- Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry?
- Do you leak during or after sexual intercourse?
- How often do you leak?
- Do you find it necessary to wear a pad because of your leaking?
- Have you had bladder, urine, or kidney infections?
- Are you troubled by pain or discomfort when you urinate?
- Have you had blood in your urine?
- Do you find it hard to begin urinating?
- Do you have a slow urinary stream or have to strain to pass your urine?
- After you urinate, do you have dribbling or a feeling that your bladder is still full?
A complete list of the patient's medications (including non prescription medications) should be sought to determine whether individual drugs might influence the function of the bladder or urethra, leading to urinary incontinence or voiding difficulties. Medications that can affect lower urinary tract function are:
|Medications||Lower Urinary Tract effects|
|Diuretics||Polyuria, frequency, urgency|
|Anticholinergic agents||Urinary retention, overflow incontinence|
|Alcohol||Sedation, impaired mobility, diuresis|
|Narcotic analgesics||Urinary retention, fecal impaction, sedation, delirium|
|Anticholinergic actions, sedation
Anticholinergic actions, sedation
Sedation, muscle relaxation, confusion
|Alpha-adrenergic blockers||Stress incontinence|
|Alpha-adrenergic agonists||Urinary retention|
|Beta-adrenergic agonists||Urinary retention|
|Calcium-channel blockers||Urinary retention, overflow incontinence|
The menopausal status of the patient is also important. If patient has any evidence of hypoestrogenism, or history of vaginal repairs, pelvic radiotherapy should be carefully noted for proper treatment.
Patient histories regarding frequency and severity of urinary symptoms are often inaccurate and misleading. Urinary diaries are more reliable and require the patient to record volume and frequency of fluid intake and of voiding, usually for a 1 to 7 day period. Episodes of urinary incontinence and associated events or symptoms such as coughing or urgency are noted. The number of times voided volume also provided each night and any episodes of bedwetting are recorded the next morning. Amount of fluid intake is carefully noted and if the symptoms are because of excessive fluid intake, it should be restricted. It may improve the symptoms of stress and urge incontinence.
The pelvic examination is of primary importance. Vulvar and vaginal atrophy consistent with hypoestrogenemia suggests that the urethra and periurethral tissues are also atrophic. The amount or severity of prolapse in each vaginal segment should be measured and recorded. A bimanual examination is performed to rule out coexistent gynecologic pathology, which can occur in up to two thirds of patients. Rectal examination is important to rule out any pathology of fecal impaction. Detection of fistula or neurologic disease immediately directs further evaluation.
Urinary incontinence may be the presenting symptom of neurologic disease. The screening neurologic examination should evaluate mental status as well as sensory and motor function of both lower extremities. Mental status is determined by noting the patient's level of consciousness, orientation, memory, speech, and comprehension. Evaluation of the motor and sensory systems may identify an occult neurologic lesion or can help determine the level of a known lesion. Common diseases associated with motor abnormalities that can produce urologic disturbances include Parkinson's disease, multiple sclerosis, cerebrovascular disease, infections, and tumors. Sacral segments 2 through 4, which contain the important neurons controlling micturition, are particularly important. To test motor function, the patient extends and flexes the hip, knee, and ankle and inverts and everts the foot. The strength and tone of bulbocavernous muscle and external anal sphincter are estimated digitally. The patellar, ankle and planter reflex responses are tested. Sensory function is tested by using light touch and pinprick on the perineum and around the thigh and foot.
Two reflexes may help in the examination of sacral reflex activity. In the anal reflex, stroking the skin adjacent to the anus causes reflex contraction of the external anal sphincter muscle. The bulbocavernosus reflex involves contraction of the bulbocavernosus and ischiocavernosus muscles in response to tapping or squeezing of the clitoris.
Measuring Urethral Mobility:
It aids in the diagnosis of genuine stress incontinence and in planning treatment specially the surgical procedure (bladder neck suspension versus periurethral injection of bulking agents). These are;
1. Q-Tip Test:
Placement of a cotton swab in the urethra to the level of the vesical neck and measurement of the axis change with straining can be used to demonstrate urethral mobility. To perform Q-Tip test, a sterile, lubricated cotton-tipped applicator is inserted transurethrally into the bladder, then withdrawn slowly until definite resistance is felt, indicating that the cotton tip is at the bladder neck. This is best accomplished with the patient in supine lithotomy position during a pelvic examination. The patient is then asked to cough and perform a Valsalva maneuver, and the maximum straining angle from the horizontal is measured. Results are affected by the amount of urine in the bladder. The maximum straining angle measurements greater than 30 degrees are generally considered to be abnormal.
2. Radiologic Assessment:
Lateral cystourethrography in the resting and straining view can identify mobility of fixation of the bladder neck, funneling of the bladder neck and proximal urethra, and degree of cystocele. The voiding component can identify a urethral diverticulum, fistula, obstruction, or vesicoureteral reflux. Videocystouretrography allows a dynamic assessment of the anatomy and function of the bladder base and urethra during retrograde filling with contrast material and during voiding. It is most helpful in sorting out causes of complex incontinence problems. However, it is invasive, expensive, and not widely available.
This technique appears to hold promise as a non-invasive and accurate method of evaluating the position and mobility of the urethrovesical junction and proximal urethra in incontinent women.
Few laboratory tests are necessary for the evaluation of incontinence. A clean midstream or catheterized urine sample should be obtained for dipstick urinalysis. Urine culture and sensitivity should be obtained when the dipstick test indicates infection. Blood testing (BUN, creatinine, glucose, and calcium) is recommended if compromised renal function is suspected or if polyuria, in the absence of diuretics, is present. Patients with hematuria or acute onset of irritative voiding symptoms in the absence of urinary tract infection require cystoscopy and cytology to exclude bladder neoplasm.
Post-void Residual Urine:
Measurement of the post-void residual urine either directly with the use of a catheter or indirectly by ultrasound or fluoroscopy is an essential part of any evaluation of urinary incontinence. It is important to evaluate whether an occasional patient is suffering from overflow incontinence where the patient's bladder almost always remains fully distended, with the patient voiding very small amounts and rapidly refilling to her maximal bladder capacity. By obtaining a post void residual urine one can rapidly assess that this is not genuine stress incontinence, but instead overflow incontinence possibly due to peripheral neurologic injury and afferent dysfunction.
Authors vary on what is abnormal residual urine with most people concluding that the residual urine should be less than 30-50 ml. On a functional basis, residual urine less than 100 ml may even be acceptable as long as the cause of this mild voiding dysfunction is well understood. Patients who consistently have residual urine greater than 50 ml should undergo more extensive evaluation with voiding pressure studies or voiding cystourethrogram.
The physicians must recognize that even under the most typical clinical situations, the diagnosis of incontinence based only on clinical evaluation may be uncertain. The diagnostic uncertainty may be acceptable if medical or behavioral treatment is planned. When surgical treatment of stress incontinence is planned, Urodynamic testing is recommended to confirm the diagnosis. Whenever objective clinical findings do not correlate with or reproduce the patient's symptoms, Urodynamic testing is indicated for diagnosis. Finally, when trials of therapy are used, patients must be followed up periodically to evaluate response. If patient fails to improve to her satisfaction, appropriate further testing is indicated.
The Urodynamic tests (UDTs) will be discussed in separate chapter in detail.
Based on the clinical evaluation, the physician can formulate a presumptive diagnosis, and initiate treatment. After evaluation, patients can be categorized as having probable genuine stress incontinence or probable detrusor instability (with or without coexistent stress incontinence). For either diagnosis, appropriate behavioral or medical therapy can be given and a substantial percentage of patients expected to respond. Even patients with mixed disorders respond to various forms of conservative therapy in about 60 % of cases.
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- Hendrix Sl, Cochrane BB, Nygaard IE et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA 2005;293:935-948
- Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women. Obstet Gynecol 2008;111:324-331
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