History and Physical
To diagnose your problem, the physician first will ask
questions about your medical history and symptoms. In particular, the physician will look
for clues about the type of incontinence by noting your pattern of urination and urine
leakage (when? how often? how severe?), as well as any symptoms of straining or discomfort
when voiding. Also, you will be asked about your bowel habits. Because the intestines and
urinary tract share a common support structure (the pelvic floor) and nerve supply,
problems in one system may be associated with problems in the other. Additional clues to
your diagnosis will include factors such as your history of illness, prior operations
(especially procedures in the pelvic region), pregnancy (number of pregnancies, vaginal or
cesarean births), sexual activity and use of medications. If possible, you should give
your physician the following information:
-
a list of all the medications you are currently taking
(including nonprescription products)
-
the dates and results of any surgical procedures or
bladder-related tests that you've had
-
a bladder record or voiding diary
Next, a physical exam will be performed to identify signs of
medical conditions that could cause incontinence, such as stool impaction, poor reflexes
or sensations (evidence of nerve problems), or tumors blocking the urinary tract.
To find out whether or not your bladder muscles are normal,
the physician may measure your bladder capacity (amount of urine held by the bladder) and
residual urine (amount of urine left in the bladder after voiding). The physician will ask
you to drink a large amount of fluid and then urinate into a measuring pan; afterwards, he
or she will measure any urine that is left over in the bladder.
Tests
Even if your medical history and physical exam do not
pinpoint your incontinence problem, they may suggest the additional tests that are needed.
Below is a list of diagnostics and tests a doctor may perform when beginning a diagnosis
of urinary incontinence. For more information about a diagnostic or test, click on the
title. If you know the type of incontinence you have, choose from the list of types on the
upper left to see specific diagnostics.
Urinalysis
Cystoscopy
Urodynamics
Cystometrogram
Uroflowmetry
Leak Point Pressure
Pressure Flow Study
Urethral Pressure Profile
(UPP)
Electromyography (EMG)
Q-Tip Test
Voiding Diary
Incontinence Questionnaire
Urinalysis
Urinalysis is a test in which a urine sample is analyzed in the laboratory for signs of
infection, blood, urinary stones or other abnormalities. A clean-catch (midstream) or
catheterized urine sample should be obtained for this study. Sometimes a urine culture is
performed to determine the type of infectious organisms that may be present in the urinary
tract. urinary tract infection (UTI) is defined as a urine sample that contains bacteria
in the amount of 105 CFU/ml or more. If blood, glucose (sugar), or protein are also
present in the urine sample, further testing is indicated.
Cystoscopy
Cystoscopy, or cystourethroscopy, is a test that lets the physician see the inside of the
bladder, bladder neck and urethra. A cystoscope (a thin, telescope-like tube with a tiny
attached camera) is inserted into the bladder through the urethra. The physician then
moves the cystoscope to detect any abnormalities in the urinary tract, such as
trabeculation (strands of connective tissue), diverticula (sacs caused by abnormal holes
in the organ), fistula (abnormal passages), an ectopic (displaced) ureter, ureterocele
(ballooning of the lower end of the ureter), tumor, or changes in the lining of the
urinary tract.
Urodynamics
Urodynamic studies are conducted to measure pressure in the bladder and to evaluate the
flow of urine. Urodynamic studies are particularly useful for the diagnosis and
confirmation of intrinsic sphincter deficiency and uncertain cases with
mixed
incontinence, overflow,
urgency or total incontinence.
Cystometrogram
The cystometrogram is the most important of the urodynamic tests. It is used to examine
the different phases of bladder function, such as filling and voiding. During cystometry,
the intra-abdominal pressure (pressure within the pelvic cavity) and the detrusor pressure
(downward-pushing pressure of the bladder) are electronically recorded and subtracted.
In tests of filling cystometry, the bladder is filled to
capacity, then tested for volume, sensation, involuntary instability (contraction, or
muscle squeezing) and compliance (yielding to pressure). Any change in detrusor pressure
may indicate an abnormality, especially if it mimics the patient's symptoms, such as
urgency and increased frequency of urination. The patient is asked to cough and strain
with a full bladder. Urine leakage without a change in detrusor pressure may indicate a
diagnosis of stress incontinence. By contrast, patients with
urge incontinence may experience detrusor contractions, with urine leak
during filling and a related sensation of urgency.
Voiding cystometry tests usually are normal in patients with
stress
incontinence, urge
incontinence, and mixed
incontinence. However, patients with intrinsic
sphincter deficiency may lose urine without any indication of detrusor contraction. In
addition, patients with an acontractile (noncontracting, nonsqueezing) bladder -- for
example, patients with diabetes, spinal cord injury or prior pelvic surgery -- will have a
low detrusor pressure during voiding and a pattern of straining.
Uroflowmetry
Uroflowmetry is a simple test that is not by itself diagnostic, but often is performed
along with cystometry. The patient drinks fluids until the bladder is full. He or she then
is asked to cough or strain while sitting in a flow chair (a special chair used to measure
urine). The voided urine is measured, and volume of urine left in the bladder is
calculated by sonography (ultrasound waves used to get an image of the bladder) or
catheterization. Other variables, such as voiding time and urine flow rates, are also
determined. stress
or urge
incontinence patients usually have a normal or increased urinary flow rate unless
there is an obstruction in the urinary tract, in which case the flow rate is decreased.
Urinary flow rates increase throughout childhood and reach their highest level in young
adults.
Leak Point Pressure
Leak point pressure is a relatively new test that is used to assess the function of the
urethra. It is measured during a cystometrongram. There are different types of leak point
pressure tests. The first, abdominal (or stress/Valsalva) leak point pressure (ALLP)
measures the ability of the urethra to resist the force of abdominal pressure. Detrusor
(or bladder) leak point pressure (BLLP) measures the resistance of the urethra to the
voiding force of the bladder. The two measurements are not related to each other.
Valsalva: The abdominal leak point pressure (ALLP) is the
lowest total bladder pressure at which leakage occurs during prompted increases in
abdominal pressure. The patient's bladder is filled by a catheter. The Valsalva maneuver
(a forced exhale with a closed nose and mouth) then is used to increase abdominal pressure
and to spur urine leakage. If the Valsalva maneuver does not, by itself, result in urine
leakage, the patient is asked to perform a series of coughs. Fluoroscopy (X-ray projection
on a fluorescent screen) can be used to detect the lowest total bladder pressure for
leakage. An abnormal ALLP indicates that something is wrong with the internal sphincter
muscle. Therefore, the ALLP test can accurately determine the presence or absence of
stress
incontinence.
Bladder: The bladder leak point pressure (BLLP) is the
highest total bladder pressure achieved at the time that urine begins to leak. The BLLP
may occur at very large urine volumes and very high pressures in some patients. A high
(greater than 40 cm water pressure) BLLP may suggest a tendency towards deterioration
(breakdown) of the upper urinary tract.
Pressure Flow Study
Pressure-flow is one of the most important and difficult urodynamic studies to perform and
interpret. Yet pressure-flow measurement is essential for the proper understanding of
altered mechanisms in urinary incontinence. In particular, pressure-flow study can help to
define problems such as bladder outlet obstruction (blockage), which is a major factor in
the treatment of men with
Benign
Prostatic Hyperplasia (noncancerous overgrowth of the prostate) and in the
pre-operative assessment of women who are considering surgery for incontinence.
To conduct the test, the patient is catherized with a
pressure sensor and the bladder is filled. When the patient feels a strong desire to
urinate, he or she is asked to void around the catheter into the uroflowmeter (combining a
uroflow with a cystometrogram). Soon afterward, technicians measure the amount of urine
remaining in the patient's bladder. The patient may undergo placement of a rectal catheter
(a tube-like instrument positioned in the anus, the opening of the large intestine). The
pressure-flow recording is made when the patient feels the urge to urinate.
As previously noted, the analysis of a patient's pressure
flow results can help to diagnose bladder outlet obstruction. Pressure flow study plays an
important role in the evaluation of male patients with lower urinary tract symptoms
(LUTS). Pressure flow study in women is not as clear-cut as in men, because women tend to
void in a different manner and at different pressures. Moreover, women may respond to
obstruction by reducing their urine flow, rather than by raising detrusor (bladder muscle)
pressure. Therefore, some experts recommend pressure flow studies in female LUTS patients
only after prior incontinence therapy or surgical repair of the urinary tract.
Urethral Pressure
Profile (UPP)
Many experts believe that recordings of urethral pressures, or urethral pressure profiles
(UPP), are of limited value for the diagnosis of incontinence. This is because there is
much overlap between normal and abnormal urethral pressure values in patients with
incontinence.
UPP was one of the first diagnostic tests developed for
urodynamic measurement. A UPP catheter is placed in the patient's urethra, and static or
resting pressure values are recorded along the length of the patient's urethra.
Unfortunately, such resting values alone do not represent urethral function in cases where
incontinence is likely to occur.
Electromyography (EMG)
Electromyography, or EMG, is used to evaluate the electrical activity of urinary tract
muscles in patients who are suspected of having nerve disorders (multiple sclerosis,
spinal cord injuries, lesions, or disease) or functional incontinence. EMG also can be
used for biofeedback and medicolegal (medical/legal) cases.
The patient is placed in a comfortable, supine (lying with
the face upward) position, with extended legs. Needle electrodes are placed in test
muscles (for example, the bulbocavernosus [urethra-tightening] muscle in men), surface
electrodes are placed on the skin (for example, the vaginal lining in women), and catheter
electrodes are mounted on a catheter that is placed in the urethra. These electrodes
detect electrical activity in the urinary tract muscles when the patient is told to hold
urine. Patients with neurologic (nervous system) disorders may show dyssynergia
(incoordination) between the detrusor and sphincter muscles, involuntary muscle spasms, or
detrusor instability (unstable bladder).
Q-Tip Test
The Q-tip test is a simple procedure that helps the physician to measure the
degree of hypermobility (dropping down) that occurs in a patient's urethra and bladder
neck during urination. Although subjective and nonspecific, this test may be useful for
the diagnosis of stress incontinence.
The patient lies on his or her back, and a long,
well-lubricated Q-tip is inserted 1 to 2 cm into a cleansed urethra. The patient is asked
to strain and perform a Valsalva maneuver (a forced exhale with a closed nose and mouth).
An exaggerated, upward deflection of the Q-tip (by an angle of more than 35 degrees) is
considered evidence of urethral and bladder neck hypermobility.
Voiding Diary
A voiding diary is a record of urinary habits over a 24-hour period. It can help your
physician to determine the exact nature and severity of your bladder control problem. Some
of the information gathered from a voiding diary may include:
Incontinence Questionnaire
Your physician may ask you to complete a questionnaire about your medical history
(medications used, surgeries, illnesses, allergies, etc.) as well as a questionnaire about
your bladder-related symptoms and quality of life. Such questionnaires may be sent to you
before your office visit, or they may be given to you when you arrive for your
appointment. In either case, your physician will use the information that you provide to
help evaluate your condition.
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