Urinary Incontinence – How to Make the Diagnosis in Your Office and When to Refer
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Contrast stress, urge and mixed incontinence 2. Explain the cough stress test and postvoid residual urine volume assessment
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
The Women’s Preventive Services Initiative (WSPI), is a US coalition of 21 professional organizations, supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) and led by ACOG. WSPI released guidelines (August 2018) supporting standardized screening for urinary incontinence. (Screening tools can be found in studies listed in ‘Learn More – Primary Sources’ below)
The WPSI recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whether it affects their activities and quality of life. The WPSI recommends referring women for further evaluation and treatment if indicated. (weak-level recommendation on the basis of the American College of Physicians guideline grading system)
Screening should include the use of validated assessment instruments that include questions about whether a woman has symptoms of urinary incontinence; the type and degree of incontinence; and how symptoms affect her health, function, and quality of life.
Several brief clinician- or self-administered questionnaires for primary care settings identify women with stress, urge, or mixed incontinence and may be used to guide diagnostic evaluations and management.
Key Elements in the Office Evaluation
Incontinence is defined as the involuntary loss of urine and can be characterized as
Urge incontinence: Described as an intense urge to urinate followed by leakage of urine
Stress incontinence: Described as leakage with coughing, laughing, exercise, sneezing, etc.
Frequency | Duration Effect on daily living | Fluid intake | Precipitating events | Bother | Severity
Midstream or catheterized specimen to assess for
American Urological Association 2016: Microscopic hematuria > 3 RBC/HPF
Note: ACOG/AUGS 2017: No further evaluation required for ≤ 25 RBC/HPF in women at low risk (≤0.5%) for malignancy (see ‘Related ObG Topics’ below)
Pelvic support | Pelvic floor tone
Screening neurologic evaluation
Mental status | Sensory and motor function of the perineum and both lower extremities
Tone | Fecal impaction (associated with voiding incontinence in older women that can be improved with resolution of impaction)
Cough Stress test
Fill bladder to at least 300 cc, and have patient cough and observe for leakage
Assess urethral mobility
Resting angle or displacement angle of the urethra-bladder neck with Valsalva of at least 30 degrees from horizontal
Can use cotton swab in the urethra or POP-Q (see ‘Learn More – Primary Sources’ below)
Postvoid Residual urine volume
Should be less than 150 cc by bladder ultrasound or catheter
If elevated, requires urodynamic studies
Urgency incontinence, also referred to as overactive bladder (OAB) should be considered when urinary urgency is associated with frequency and nocturia. Mixed incontinence is suggested by a combination of involuntary loss of urine associated with both (1) urgency and (2) with physical exertion, sneezing or coughing. Overflow incontinence can occur with chronic urinary retention whether neurologic or iatrogenic. Treatment options vary by incontinence type.
If office evaluation fails to yield a clear diagnosis, additional urodynamic testing to determine bladder capacity, compliance, contractions, urethral relaxation and tone may be necessary
Cystometry | Uroflowmetry | Pressure flow studies | Measures of urethral function | Electromyography of pelvic muscles
Cystourethroscopy should be considered to evaluate
Microscopic hematuria | Acute or refractory urge incontinence | Recurrent urinary tract infections | Suspicion for fistula or foreign body after gynecologic or urogynecologic surgery
Because determination of etiology is paramount to the management plan, consider early referral to a physician with expertise in pelvic support evaluation when necessary
It is important to evaluate the etiology and severity of symptoms along with the patient’s goals and expectations
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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