The assessment of urinary incontinence involves a combination of history taking (i.e. description of symptoms) in combination with physical examination. In most people this allows categorisation of incontinence into one of the main types of incontinence such as stress urinary incontinence (SUI), urge urinary incontinence (UUI) and mixed urinary incontinence (MUI).
History taking helps:
- Define the type of incontinence
- E.g. triggers to stress incontinence such as coughing, sneezing, jumping, high impact activities, exercise, lifting
- E.g. triggers to urge incontinence such as “key in the door” urgency on arriving home, hearing running water, hand washing
- Overactive bladder symptoms e.g. urgency without loss of urine
- Define the causes and precipitants of incontinence
- Assess the severity of the problem
- By its impact on quality of life and restriction or avoidance of activities because of the incontinence
- By use of incontinence products e.g. pad usage
- Exclude other conditions that may cause, mimic or worsen incontinence such as:
- urinary tract infections
- blockage of the drainage of urine (e.g. by prostatic enlargement in men or prolapse in women)
- bladder conditions (e.g. bladder stones, bladder cancers)
- neurological (nervous system) disorders such as previous strokes, Parkinson’s disease, Multiple Sclerosis, spinal cord problems
- Identify risk factors for stress incontinence in women such as number of pregnancies, history of delivery of large babies as well as forceps and breech deliveries, chronic cough and obesity
- Identify factors which worsen urge incontinence such as:
- excessive intake of caffeine (coffee, tea, cola and energy drinks) and alcohol both which of act as bladder irritants and diuretics
- certain medications which can worsen incontinence
In women the physical examination includes an abdominal examination as well as a pelvic (internal or vaginal) examination.
The abdominal examination looks for a distended bladder, which may indicate problems with incomplete bladder emptying.
The pelvic examination (similar to when having a Pap smear) assesses:
- Leakage with “stress test” or cough test i.e. coughing and straining to look for stress incontinence
- Pelvic organ prolapse and its severity
- Pelvic floor contraction – the ability to perform a pelvic floor contraction and its strength
- Other pelvic pathology e.g. pelvic mass or tenderness
- The nature of the pelvic tissues e.g. the presence of dry tissues (“atrophic change”) due to oestrogen deficiency in postmenopausal women.
In men the physical examination includes an abdominal examination as well prostate examination (also known as DRE or digital rectal examination as it is performed via the back passage).
- Basic investigation includes a urine test preferably with a mid-stream urine specimen (MSU) to exclude urinary tract infection and look for abnormalities such as blood or pus cells in the urine which may indicate a problem in the bladder lining
- It is advisable to have an assessment of bladder emptying to exclude overflow incontinence. This is most easily performed with an ultrasound which checks the amount of urine retained in the bladder after urination.
- The bladder diary
- Other tests which may be performed include:
- blood tests of kidney function
- urinary cytology -looking for abnormal cells in the urine
- PSA testing in men
The Bladder Diary
The bladder diary (also known as a frequency volume chart) is a very useful investigation to assess urinary symptoms, educate the patient and monitor the effectiveness of treatments.
The simplest form of bladder diary involves charting the:
- time of all urination episodes over 24 hour periods (usually for 3 days but not necessarily consecutive)
- volume of urine passed each time (in millilitres by passing urine into a measuring container or jug)
- frequency of incontinence episodes e.g. by charting how often leakage occurs with an assessment of severity (such as “small”, “medium”, “large” loss of urine)
More complex bladder diaries can include a record of fluid intake (which is usually reflected in the total urine output).
Although it is a nuisance and inconvenient to fill out, the bladder diary provides extremely valuable information about bladder function that is essential in guiding management of incontinence problems. As well as making a person more aware of their bladder habits and forming the basis for bladder retraining, it gives the doctor objective information about:
- number of day time voids
- number of night time voids
- total urine output over 24 hours
- urine output overnight
- bladder capacity
- leakage frequency and severity
Summary of Assessment of Urinary Incontinence
It is important to understand that in most people the initial assessment of urinary symptoms and incontinence by
- history taking
- physical examination
- urine testing
- measurement of bladder emptying with ultrasound and
- bladder diary
is sufficient to make a diagnosis and start treatment.
More complex testing such as a urodynamic study is NOT required before starting treatment in straightforward cases of stress or urge incontinence or overactive bladder. Indications for urodynamic study and cystoscopy are discussed.