Urinary%20incontinence Diagnosis

• Onset & course of UI
• Associated lower urinary tract symptoms
  • Urgency, urinary frequency, nocturia, hesitancy, straining during urination, interrupted voiding, incomplete emptying

Voiding Diary

• Patient should be asked to complete a voiding diary that includes the following:
  • Frequency, volume & timing of incontinence, largest single volume voided
  • Precipitants to incontinence (eg coughing, sneezing, caffeine, alcohol, exercise, sounds of running water)

• Optimum duration of diary is between 24 hr to 7 days

Other Components of History

• Pregnancies & mode of delivery
• Past surgeries, sexual function, bowel function (including constipation & fecal incontinence)
• Impact on quality of life
• History of prolapse
• Prior incontinence therapies, including surgical treatments undertaken

Medication History

• Drugs causing urinary retention w/ or w/o urinary frequency
  • Alpha-adrenergic agonists (Pseudoephedrine, Phenylpropanolamine)
  • Anticholinergic medications (tricyclic antidepressants, sedating antihistamines, Benzatropine, antipsychotics)

• Drugs causing stress incontinence
  • Alpha blockers (Prazosin, Terazosin, Doxazosin)
  • ACE inhibitors if they induce cough
  • Loop diuretics & alcohol may overwhelm ability to get to the bathroom in time

• Use of conjugate equine estrogens increases the risk of developing UI & worsens pre-existing UI

• Helps in categorizing UI to stress, urge or mixed UI

Voiding Diary

• Patient should be asked to complete a voiding diary that includes the following:
  • Frequency, volume & timing of incontinence
  • Precipitants to incontinence (eg coughing, sneezing, caffeine, alcohol, exercise, sounds of running water)

• Optimum duration of diary is between 24 hr to 7 days
• Also known as micturition time charts, frequency/volume charts, bladder diaries

Others

• Past surgeries, sexual function, bowel habits (including constipation & fecal incontinence)
• Impact on quality of life
• Medication history

Physical Exam (Women)

Comprehensive physical exam should include the following:

• Examine the general condition of the patient
• Cardiovascular exam to assess the presence of volume overload
• Palpate abdomen for mass or tenderness
• Genital exam
  • Inspect vaginal mucosa for atrophy, narrowing of introitus, vault stenosis & inflammation
  • Bimanual exam to evaluate presence of masses or tenderness
  • Assess whether pelvic support is adequate or not
  • Check for urethral hypermobility
  • Check for presence of cystocele, rectocele & enterocele

• Direct observation of urine loss using cough stress test
• Rectal exam
  • Assess sphincter tone & bulbocavernosus reflex

• Neurologic exam
  • Observe gait & look for presence of muscular atrophy or neurologic deficits
  • Check vibration & peripheral sensation for the presence of peripheral neuropathy

• Abdominal, rectal, sacral, neurological
• Digital rectal exam to assess prostate size, shape & consistency & to check for other rectal pathologies

Diagnostic Exams (Women)

• Urinalysis w/ or w/o urine culture
  • Urine cytology, in the presence of hematuria or pelvic pain

• Serum creatinine & BUN to check for renal function

• Urinalysis w/ or w/o urine culture
  • Should be part of the initial assessment
  • If infection found, treat then reassess

Post Void Residual (PVR) Volume

• Amount of urine that remains in the bladder after voiding
  • Indicates poor voiding efficiency

• Should be part of the initial assessment in the male patient as its presence is associated w/ UI symptoms
• Catheterization is most accurate, but ultrasound may be preferred to avoid infection risk & it has higher patient acceptability
• Presence of voiding dysfunction is considered in patients w/ persistent PVR >100 mL

Flow Rate

• Determined by detailed clinical history

Pad testing

• By using an absorbent pad worn over a period of time or during a protocol of physical exercise, urine loss is measured
• Can be used to quantify the presence & severity of UI & also patient’s response to treatment

Note: Consider specialist referral in a patient w/ a complex history (eg recurrent incontinence or incontinence associated w/ hematuria, pain, recurrent urinary tract infections, prostate irradiation, pelvic surgery or radiotherapy, &/or voiding symptoms).

Imaging (Women)

• Voiding cystogram to check for stress incontinence, cystocele & degree of urethral motion
• Intravenous pyelogram to rule out developmental abnormalities, tract anomalies & presence of fistula
• Renal ultrasound
• In the evaluation of women w/ uncomplicated stress incontinence, imaging studies of the upper or lower urinary tract should not be routinely done

Screening (Women)

Cough Stress Test

• Patients who have not recently voided urine may be asked to stand over a pad, then they should cough vigorously
• Observe if there is leakage of urine on the pad
• Abrupt leakage gives a diagnosis of stress incontinence while delayed leakage suggests mixed incontinence

Post Void Residual Volume (PVRV)

• Consider if patient has symptoms of voiding dysfunction or history of recurrent urinary tract infection, previous anti-incontinence surgery, significant pelvic prolapse or spinal cord injury
• Catheterization is the most accurate method, but ultrasound may be preferred for higher patient acceptability & to avoid infection
  • PVRV <50 mL is considered adequate emptying while PVRV >200 mL is inadequate

Note: Consider specialist referral in a patient w/ a complex history (eg recurrent incontinence or incontinence associated w/ hematuria, pain, recurrent urinary tract infections, suspected fistula, pelvic surgery or radiotherapy, pelvic organ prolapse, &/or voiding symptoms)