Approach

The goal of evaluation is to identify the type of incontinence (i.e., stress, urge, mixed) and rule out the presence of a complex or potentially life-threatening underlying condition (e.g., spinal cord compression, normal pressure hydrocephalus, or multiple sclerosis) that warrants specialist assessment and treatment.

A significant number of women with stress incontinence can be diagnosed based on history alone.[59]​

Clinical evaluation

Urinary symptoms to be elicited include:

  • Involuntary urine leakage on effort, exertion, sneezing, or coughing (suggestive of stress incontinence)

  • Involuntary urine leakage accompanied by or immediately preceded by urgency (suggestive of urgency incontinence)

  • Nocturia

  • Dysuria, hematuria, or known history of recurrent urinary tract infections

  • Post-void dribbling

  • Frequency of urination

Particular attention to the obstetric and gynecologic history is important to determine any predisposing risk factors, including pregnancy history, as well as mode of delivery, operative vaginal delivery, and obstetric trauma and pelvic surgery.[3][7]​​​[11]​​​[14][15]​ It is also important to assess for any comorbidities that may contribute to urinary frequency or urgency (e.g., diabetes mellitus).[60]

Other important factors are:

  • Age

  • Weight

  • Ethnicity

  • Hormonal status

  • Fluid and caffeine intake

  • Alcohol consumption

  • History of smoking

  • Involvement in activities or lifestyle habits, including high-impact physical activities, which increase intra-abdominal pressure

  • History of vaginal prolapse

  • Family history of incontinence

  • History of back injury/falls

  • History of chronic constipation or fecal incontinence

  • History of childhood enuresis

  • Functional impairment

  • Long-term residence in a care facility

A complete drug review is critical as some drugs may have significant adverse effects on the urogenital system - in particular, those with anticholinergic effects such as antihistamines, antidepressants, and antipsychotics.​[11]​ Calcium-channel blockers and alpha-blockers have also been linked to urinary retention and difficulty in voiding. Diuretics may cause polyuria, frequency, and urgency.​[11]​

Some chronic medical conditions, such as chronic cough (e.g., asthma, COPD), chronic heart failure, diabetes mellitus, and obstructive sleep apnea may be associated with incontinence.[11]​​[19]

Neurologic conditions, such as spinal cord injury, cerebrovascular accidents, multiple sclerosis, and Parkinson disease may result in disruption of the neurologic control of lower urinary tract function (neurogenic bladder), detrusor overactivity, or limitations in toilet accessibility due to mobility (functional incontinence).[27]​​

Other tools, such as symptom questionnaires and a voiding diary, are used to assess patients.​[60]

  • Mental state is evaluated, as dementia is a cause of urinary incontinence, particularly in older patients.

  • Completion of a bladder diary will help to analyze fluid intake and voiding pattern with good accuracy.[60][61][62]​​​​​ It is performed over several (minimum 3) days.[63]​

  • The Urinary Distress Inventory or Incontinence Inventory Questionnaire are also useful in classifying the type of incontinence present, its severity, and its impact on quality of life.[64][65] Urogenital Distress Inventory: UDI-6 Opens in new window Incontinence Impact Questionnaire: short form IIQ-7 Opens in new window​ 

Physical examination

This will identify any anatomic or neurologic changes that may contribute to the patient's symptoms:[1]​​[11]​​​[27]

  • General assessment to evaluate gait, cognition, and frailty, which may contribute to functional impairment.

  • The abdomen and back are examined for masses and tenderness.

  • Speculum examination to evaluate the anterior vaginal wall and urethra may reveal urethral discharge or tenderness, suggesting a urethral diverticulum, carcinoma, or inflammation. Pooling of urine in the vagina prompts thorough examination to identify the presence of any fistulous tract, particularly in patients who have undergone pelvic surgery or pelvic radiation.

  • Signs of urogenital atrophy, such as mucosal pallor or erythema, indicate a deficiency in circulating estrogen to the urogenital organs. This can cause urinary urgency, frequency, and/or incontinence.

  • The presence of a vaginal bulge caused by pelvic organ prolapse, such as a cystocele, may indicate a weakness in the supporting structures of the urethra/bladder causing a variety of changes such as urethral kinking or incomplete bladder emptying or urinary retention. Other forms of prolapse (e.g., uterine prolapse or posterior support weakness such as rectocele) can impact bladder function, including bladder outlet obstruction and resultant incontinence or retention.

  • A bimanual examination also provides valuable information about the size and conformation of the pelvic organs, if present. Mechanical compression of the bladder by an enlarged, bulky uterus may cause urinary urgency and frequency by constricting the bladder's ability to distend in the already occupied pelvis.

  • Abnormal bulbocavernosus and anal wink reflexes indicate that the sacral nerve pathways, which are paramount in normal bladder function, are disrupted.

  • Rectal exam is important to check for perineal sensation and sphincter tone, fecal impaction, or rectal mass.

Investigations

The cough stress test, sitting or standing, is performed at the first visit.​[1][66]​​​​ It is demonstrated by observed leakage with cough or Valsalva in the lithotomy position with a comfortably full bladder or after backing 300 mL of water into the bladder.​[11]​ Alternatively, the empty supine stress test is performed immediately after voiding and may indicate more severe forms of stress incontinence or intrinsic sphincter deficiency.[11]​​ 

Post-void residual measurement and urinalysis are initial tests to order.​[1][60][66]​​​​ They may be performed during the first visit in no sequential order or even simultaneously. Post-void residual measurement assesses the volume of urine in the bladder after a void. It is measured by sterile catheterization or ultrasound with good accuracy, and can differentiate between adequate bladder emptying and urinary retention.[1]​​ Urinalysis can help to identify underlying medical conditions that may contribute to urinary incontinence.[60] For example, urinary tract infections and glycosuria-induced polyuria, as seen in diabetes mellitus, can produce overactive bladder symptoms.

Failure of conservative measures for urinary incontinence prompts referral to a specialist in incontinence for more advanced evaluation. Urodynamic evaluation can help to differentiate types of incontinence if unclear, especially if results of less invasive tests are inconclusive.[1]​​ It may be used as an additional diagnostic evaluation in women with complicated stress urinary incontinence before they undergo surgical treatment and in whom conservative treatment has failed.[66] It may be helpful in complicated cases (failed anti-incontinence surgery, history of pelvic surgery, or pelvic radiation) but should be avoided in women with uncomplicated stress incontinence.[7][62][63]​​​​[67][68]​​[69]​ The Q-tip test or ultrasound to assess the degree of urethral mobility and pad test (performed when urinary incontinence is unclear or to confirm a urinary source) may also be used to differentiate types of incontinence.[64][66]​​ Finally, in the evaluation of patients with hematuria or refractory urgency incontinence, cystourethroscopy is useful to exclude other pathology (i.e., fistula, foreign body, tumor, interstitial cystitis). Do not perform cystoscopy, urodynamics, or diagnostic renal and bladder ultrasound in the initial workup of an uncomplicated patient with symptoms of overactive bladder.[7]​[62]​[63]​[69]​

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