Basic Evaluation
Effective treatment of urinary incontinence depends upon
appropriate patient evaluation and individualization of treatment. Many people with
urinary incontinence delay or do not seek professional help with its management, and it
has been suggested that promotion of strategies to enable care-seeking for incontinence is
a health care priority. A recent study indicates that primary care practitioners could
routinely screen for urinary incontinence by simply asking patients if accidental loss of
urine interferes with day-to-day activities or is bothersome, and by obtaining a short
urinary history on voiding and leaking patterns.
Although urinary incontinence has traditionally been
evaluated by specialists, its prevalence in the general population is high, and it is
clear that primary health care professionals are key in initiating the basic evaluation.
The general principles of diagnostic evaluation include confirming the presence of urinary
incontinence, identifying conditions that contribute to the problem, and recognizing those
patients who require further evaluation before therapy is initiated. The basic evaluation
for urinary incontinence includes a history, physical examination, and urinalysis. The estimation of post void residual (PVR) volume is also part of the basic evaluation1, but this test may need to be
administered by a specialist.
History
A complete urinary history should include a review of
symptoms, medications, and any current or past medical conditions. The duration and
characteristics of urinary incontinence should be discussed, and the frequency, timing,
and number of continent voids and incontinence episodes detailed. In addition, the
precipitants of incontinence may be identified. Fluid intake patterns should be elicited
and alterations in bowel habits or sexual function noted. In the elderly, a mental status
evaluation and assessment of social and environmental factors may be particularly
important in evaluating the problem. Patient voiding diaries can be particularly helpful
in identifying the characteristics of incontinence.
Physical Examination
The physical exam may include a general evaluation of
neurologic status and examination of the abdomen, rectum, genitals, and pelvis. The cough
stress test, in which the patient is asked to cough vigorously while the examiner observes
the urethra, allows direct observation of any urine loss. When instantaneous leakage
results from coughing, stress incontinence is a likely diagnosis. In cases where leakage
is delayed or persists after the cough, detrusor instability may be the cause. The cough
stress test should be performed initially in the lithotomy position (pap smear test
position); if no leakage is observed, the test should be repeated with the patient in the
upright position.
Urinalysis
Routine evaluation of the urine allows identification of
conditions that may be associated with urinary incontinence. Bacteriuria, glucosuria, glycosuria, hematuria, proteinuria, and pyuria are all conditions that may cause or
contribute to the symptoms of urinary incontinence.
Specialized Testing
When urinary incontinence and its symptoms persist after
appropriate evaluation and treatment, additional testing may be warranted. Specialists use
a number of urodynamic, endoscopic, and imaging tests to allow a more extensive evaluation
of the lower urinary tract than can usually be provided by the primary care physician.
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Postvoid Residual
Volume
An accurate assessment of PVR volume requires catheterization or pelvic ultrasound;
quantification of the PVR volume via abdominal or bimanual pelvic examination is not
considered definitive. The patient should void just before the PVR volume is measured. If
possible, this initial void should be observed so that any signs of hesitancy, straining,
or interrupted flow can be identified by the clinician. A PVR volume of less than 50 mL is
generally considered indicative of adequate bladder emptying, while repetitive volumes of
100 to 200 mL (or higher) are thought to represent inadequate emptying. PVR volume may
vary and is influenced by whether the patient is ready to void and by the environment or
clinical setting; repeated measurements may be necessary in some patients.
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Urodynamic Tests
The anatomic and functional status of the urinary bladder and urethra may be measured
using cystometry. While simple cystometry is useful in detecting abnormal detrusor
compliance, abdominal pressure is not measured and the results must be evaluated with some
caution. The multichannel or subtracted cystometrogram allows simultaneous measurement of
intra-abdominal, total bladder, and true detrusor pressures, allowing differentiation of
involuntary detrusor contractions from increases in intra-abdominal pressure.
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Endoscopic Tests
Cystoscopy may be indicated when urodynamic testing fails to duplicate symptoms
or there are new symptoms (eg, cystitis, pain) or findings (eg, sterile hematuria or pyuria) associated with urinary incontinence; however, its role in the incontinence
evaluation is controversial. Although cystoscopy identifies bladder lesions and foreign
bodies, the incidence of metaplastic and neoplastic lesions detected in patients with
incontinence is quite low.
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Imaging Tests
Radiographic evaluation and ultrasound testing may be useful in evaluating
anatomic conditions associated with urinary incontinence. Upper tract imaging is not used
routinely, but imaging of the lower tract before, during, and after voiding may be helpful
in examining the anatomy of the urinary bladder and urethra.
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