eMedicine Specialties > Urology > Incontinence

Urinary Incontinence, Surgical Therapies: Workup

Author: Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation
Coauthor(s): Sandip P Vasavada, MD, Physician, Center for Female Pelvic Medicine and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic; Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic; Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic
Contributor Information and Disclosures

Updated: May 8, 2009

Workup

Laboratory Studies

• Urinalysis and urine culture: UTIs can cause irritative voiding symptoms and urge incontinence.
• Urine cytology: Carcinoma in situ of the urinary bladder can cause symptoms of urinary frequency and urgency. Irritative voiding symptoms disproportionate to the overall clinical picture and/or hematuria warrant urine cytology and cystoscopy.
• Chem 7 profile: Blood urea nitrogen and creatinine levels are checked if compromised renal function is suggested. These tests are helpful for patients in whom poor renal function, obstructed ureters, or urinary retention is suggested.

Other Tests

• Voiding diary: A voiding diary is a daily record of the patient's bladder activity. It is an objective documentation of the patient's voiding pattern, incontinent episodes, and inciting events associated with urinary incontinence.
• Pad test
  • This is an objective test that documents urine loss. Intravesical methylene blue or oral Pyridium or Urised may be used. Methylene blue and Urised turn urine blue; Pyridium turns urine orange.
  • Patients should resume their usual physical activities while wearing a peri-pad. If the pads turn to orange or blue, the patient is experiencing urine loss. If the pads remain white, it is most likely normal vaginal fluid.
• Cotton-swab test
  • Although urethral hypermobility is usually quantitated visually, some physicians prefer to quantitate the urethral movement with a cotton-swab test, although this test has never been clinically validated. To properly perform a cotton-swab test, place the patient in a dorsal lithotomy position. Make sure the examining table is parallel to the floor. Insert a sterile, well-lubricated cotton swab into the urethra until the cotton portion is completely in the bladder. Then, gently pull back on the cotton swab until the cotton is snug against the bladder neck.
  • Measure the angle between the cotton swab and the floor with a protractor. Women with normal pelvic anatomy should have a resting cotton-swab angle of 0° with respect to the floor. Ask the patient to Valsalva (strain) and cough. An abnormal upward deflection of the cotton swab (>30°) by Valsalva maneuver is evidence of urethral hypermobility.
  • The absence of hypermobility suggests that the cause of the stress incontinence is intrinsic sphincter deficiency.
• Cough stress test
  • A critical part of the pelvic examination is the direct observation of urine using the cough stress test or Marshall test.
  • A sterile catheter is inserted into the urethra, and the bladder is filled to 200-250 mL with water. The catheter is removed. Observation of leakage during Valsalva or cough denotes a positive test result.
• Standing pelvic examination
  • A standing pelvic examination is performed if the pelvic examination results fail to demonstrate urine loss or if pelvic organ prolapse is suggested.
  • If the cough leak test is initially performed with the patient in the lithotomy position and no leakage is observed, then this test should be repeated with the patient in the standing position. Observable urine leakage in this position constitutes a positive test result.
  • If any doubt remains about pelvic organ prolapse, the patient should be examined in the standing position. The patient stands with legs apart with one foot resting on a step stool. When the patient performs the Valsalva maneuver, the force of gravity helps the pelvic organs (ie, uterus, bladder) slide down the vagina to enhance the diagnostic potential. If pelvic prolapse is present, the prolapsed organ should be pushed up either with a pessary or gauze and the cough stress test should be repeated with the patient in the standing position.

Diagnostic Procedures

• PVR volume
  • The PVR urine measurement may be a part of the basic evaluation for urinary incontinence if symptoms of failure to empty urine are noted. To determine the PVR urine volume, either a bladder ultrasound or urethral catheter may be used.
  • If the PVR volume is high, the bladder may be acontractile or the bladder outlet may be obstructed. Both of these conditions cause urinary retention with overflow incontinence.
• Uroflow test
  • Uroflow is a useful screening test mainly for evaluating bladder outlet obstruction. Uroflow is the volume of urine voided per unit of time.
  • A low uroflow rate may reflect urethral obstruction, a weak detrusor, or a combination of both. These test results alone cannot help distinguish between obstruction and acontractile detrusor. To properly diagnose bladder outlet obstruction, perform pressure-flow studies.
• Filling cystometrogram
  • In 40% of patients, stress and urge incontinence coexist. In many instances, stress incontinence may lead to the development of urge incontinence.
  • A filling cystometrogram helps assess bladder capacity, compliance, and the presence of phasic contractions. Most commonly, liquid filling medium is used. An average adult bladder holds approximately 450-500 mL of urine. During the test, provocative maneuvers help to unveil bladder instability.
• Abdominal leak-point pressure
  • An important component of multichannel urodynamic studies is the determination of ALPPs. ALPPs allow stress urinary incontinence to be classified based on the severity of intrinsic sphincter deficiency. Importantly, note that a normal leak-point pressure should approach infinity. In other words, patients with a normal continence mechanism can generate intra-abdominal pressures high enough to cause fainting but not to provoke stress incontinence. The historical references of ALPP associated with outdated classification systems are as follows:
    • Type I stress urinary incontinence - ALPP of greater than 120 cm water
    • Type II stress urinary incontinence - Urethral hypermobility and ALPP of 90-120 cm water
    • Type II/III stress urinary incontinence - Urethral hypermobility, intrinsic sphincter deficiency, and ALPP of 60-90 cm water
    • Type III stress urinary incontinence - Intrinsic sphincter deficiency and ALPP of 0-60 cm water
  • The ALPP should be measured when the bladder is half full (ie, 250 mL), and both the Valsalva and coughing maneuvers should be performed. Initially, instruct the patient to bear down in gradients (ie, mild, moderate, severe), and then note the ALPP as the lowest intravesical pressure at which leakage is observed. If Valsalva maneuvers fail to produce the desired response, instruct the patient to cough in gradients (ie, mild, moderate, severe) to obtain the ALPP. The lowest intravesical pressure at which leakage is seen is the ALPP. The ALPP obtained with a Valsalva maneuver is more accurate than the cough-induced ALPP. However, both techniques should be used if Valsalva maneuvers fail to manifest stress urinary incontinence. (see urodynamics image below)
  • Alternatively, both Valsalva and cough-induced ALPP may be repeated by increasing the bladder volume in 100-mL increments beyond 250 mL. Increasing the bladder volume reportedly increases the sensitivity of detecting ALPP.
• Voiding cystometrogram (pressure-flow study)
  • A pressure-flow study simultaneously records the voiding detrusor pressure and the urinary flow rate. This is the only test able to help assess bladder contractility and the extent of a bladder outlet obstruction.
  • Pressure-flow studies can be combined with a voiding cystogram (VCUG) and videourodynamic studies for complicated cases of incontinence.
• Cystogram
  • A static cystogram (anteroposterior and lateral) helps to confirm the presence of stress incontinence, degree of urethral motion, and presence of cystocele. Intrinsic sphincter deficiency is evident by the presence of an open bladder neck. The presence of a vesicovaginal fistula may also be noted.
  • A VCUG can help assess bladder neck and urethral function (internal and external sphincter) during both filling and voiding phases. The results of a VCUG can help identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
• Electromyography
  • Findings from electromyography (EMG) help to ascertain the presence of coordinated or discoordinated voiding.
  • Failure of the urethra to relax during bladder contraction results in discoordinated voiding (detrusor sphincter dyssynergia [DSD]).
• Cystoscopy
  • The precise role of cystoscopy in the evaluation of female urinary incontinence is controversial. Fewer than 2% of bladder tumors have been identified by routinely performing cystoscopy in incontinent women.
  • On the other hand, cystoscopy helps detect bladder lesions, such as stitch in the bladder, bladder cancer, and bladder stones, which would otherwise remain undiagnosed if only urodynamic findings are assessed. A visual inspection of the urethra helps establish the presence of urethral stricture or gross evidence of poor urethral closure.
  • The general agreement is that cystoscopy is indicated for patients with persistent irritative voiding symptoms or hematuria. Obvious causes of bladder overactivity, such as cystitis, stone, and tumor, can be easily diagnosed. This information is important in determining the etiology of the incontinence and may influence treatment decisions.
  • Many urologists perform urethroscopy to assess the structure and function of the urethral sphincter mechanism.
• Dynamic retrograde urethroscopy
  • The cystoscope is introduced into the bladder. The bladder is filled to 250 mL with irrigant. The flow of the irrigant is turned off. The cystoscope is withdrawn to the mid urethra. The activity of the urethral sphincter mechanism is observed at rest and with Valsalva maneuvers.
  • Patients with mild intrinsic sphincter deficiency have a closed bladder neck at rest and have an intact voluntary guarding reflex. Patients with severe intrinsic sphincter deficiency have an open bladder neck at rest and have an impaired voluntary guarding reflex.
• Videourodynamics
  • Videourodynamic studies are the criterion standard for the evaluation of an incontinent patient. Videourodynamic studies combine the radiographic findings of a VCUG and multichannel urodynamics. A videourodynamic study is the most sophisticated diagnostic test for an incontinent patient.
  • The testing begins by draining the bladder. A urodynamic urethral catheter (ie, 7F Cook dual-lumen pigtailed catheter), rectal tube, and EMG electrodes are then placed.
  • Rotate the patient to a sitting position and equalize the transducers. Commence bladder filling using room-temperature contrast (Conray). Cold water may evoke false-positive detrusor contractions (phasic contractions). Fill the bladder at a medium rate (eg, 60 mL/min). Assess the first sensation of filling fullness, and assess urge. Note bladder compliance, and mark the presence of uninhibited detrusor contractions.
  • When the bladder is filled to 250 mL, measure the ALPP. Instruct the patient to perform Valsalva maneuvers in gradients (ie, mild, moderate, severe), followed by cough (ie, mild, moderate, severe). Observe for urine leakage fluoroscopically and by direct inspection. At this point, assess the activity of the bladder neck, urethral mobility, and the presence of cystocele using fluoroscopy (static cystogram).
  • Upon completion of ALPP testing, finish the filling cystometrogram to completion. When the patient has a strong desire to void, perform a voiding cystometrogram (pressure-flow study). At this point, note urodynamic parameters, such as maximal flow rate and detrusor pressure at maximal flow rate.
  • During the voiding cystometrogram, note the activity of the EMG electrodes and VCUG for possible DSD. Confirm the presence of DSD by increases in EMG activity during detrusor contraction or closure of the external sphincter on VCUG images during voiding.
  • After the patient voids to completion, the videourodynamic study is complete.

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