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