Urinary Incontinence – How to Make the Diagnosis in Your Office and When to Refer

CLINICAL ACTIONS:

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

History

• 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.
• Determine
  • Frequency | Duration Effect on daily living | Fluid intake | Precipitating events | Bother | Severity

Urinalysis

• Midstream or catheterized specimen to assess for
  • Infection
  • Hematuria
    • 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)

Physical exam

• Bimanual exam
  • Pelvic support | Pelvic floor tone
• Screening neurologic evaluation
  • Mental status | Sensory and motor function of the perineum and both lower extremities
• Rectal examination
  • 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

SYNOPSIS:

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.

KEY POINTS:

• 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

Learn More – Primary Sources:

Screening for Urinary Incontinence in Women: A Recommendation From the Women’s Preventive Services Initiative

ACOG/ AUGS Practice Bulletin 603: Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment

The University of Michigan Incontinence Symptom Index (M-ISI): a Clinical Measure for Type, Severity, and Bother related to Urinary Incontinence (open) 

ABSST: Validation of a bladder symptom screening tool in women with incontinence due to overactive bladder (open)

A comparison study of two lower urinary tract symptoms screening tools in clinical practice: The B-SAQ and OAB-V8 questionnaires

Validation of an overactive bladder awareness tool for use in primary care settings

Validation of a 3-item OAB awareness tool

ACOG & AUGS Practice Bulletin 155: Urinary Incontinence in Women

AUGS POP-Q Tool