A thorough history is essential to the evaluation of urinary incontinence. The clinical presentation of urinary incontinence, based on severity, frequency, and amount of debilitation varies from patient to patient.
Patients may be reluctant to initiate discussions about incontinence; therefore, all patients, especially those older than 65 years, should be asked focused questions about voiding problems. In wording these questions, it is best to avoid nonspecific terms such as urge or nocturia, as they may have different meanings for different patients.
The clinical presentation of urinary incontinence can be varied in many respects. Patient complaints may be minor and situational or severe, constant, and debilitating. When obtaining a clinical history, determining whether the problem is a social and/or hygienic problem and the degree of disability attributable to the incontinence also is important. In addition, the following points regarding the clinical presentation should be sought when obtaining the history:
Severity and quantity of urine lost and frequency of incontinence episodes
Duration of the complaint and whether problems have been worsening
Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm)
Constant versus intermittent urine loss and provocation by minimal increases in intra-abdominal pressure, such as movement, changes in position, and incontinence with an empty bladder
Associated frequency, urgency, dysuria, pain with a full bladder, and history of urinary tract infections (UTIs)
Concomitant symptoms of fecal incontinence or pelvic organ prolapse
Coexistent complicating or exacerbating medical problems
Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies
History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures
Other urologic procedures
Spinal and CNS surgery
Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure
Patients with coexisting pelvic organ prolapse may report dyspareunia, vaginal pain upon ambulation, and a bulging sensation in the vagina. Patients with severe pelvic organ prolapse may experience herniation of pelvic organs out of the vaginal introitus, necessitating manual reduction of the uterine cervix or vaginal splinting during bowel movements.
Patients with symptomatic rectoceles report severe constipation, often necessitating digital disimpaction. Severe cystoceles may drag both ureters through the true pelvis as the bladder herniates out of the vagina, causing renal azotemia. Bilateral hydroureteronephrosis is due to compression of the ureters against the bony pelvic inlet, resulting in ureteral obstruction.
Relevant complicating or exacerbating medical problems may include the following:
Chronic obstructive pulmonary disease (COPD)
Congestive heart failure
Connective tissue disorders
CNS or spinal cord disorders
Urinary tract stones
Cancer of pelvic organs
Medications that may be associated with urinary incontinence include the following:
Cholinergic or anticholinergic drugs
Over-the-counter allergy medications
Angiotensin-converting enzyme (ACE) inhibitors
Incontinence histories can be very complex and time consuming. Most centers use some form of incontinence questionnaire as an aid. Sending the questionnaire to patients in advance so that they can give appropriate time and thought to their answers may be helpful. Part of the questionnaire should deal with the patient's quality of life, sexual and lifestyle issues, and the relationship of these factors to the incontinence disorder.
The patient also should be instructed to fill out a voiding diary and to write down any questions. A voiding diary is a daily record of the patient's bladder activity and is a useful supplement to the medical history of the patient.
Voiding diaries should record the volume and type of fluid intake and the frequency and volume of voids. Episodes of nocturia should be noted. Finally, episodes of incontinence should be recorded, including an estimate of the volume; associated activities such as coughing, straining, and dishwashing; and associated symptoms such as urgency.
Voiding diaries are helpful as a pretherapy diagnostic tool, but they have also been used to measure posttherapy outcomes. Estimates of voiding frequency and amounts obtained by history alone can be unreliable.
Voiding diaries are reproducible in the setting of stress incontinence. One study found that in patients with stress incontinence, a representative and reproducible measure of incontinence episodes and mean daily voids can be obtained with a 3-day diary.  A 1-day diary is probably too short. Fewer data exist regarding the reliability of voiding diaries in patients with urge incontinence; further research is needed.
Pace of onset
Many cases of urinary incontinence present as a gradually progressive disorder. Progression from very mild symptoms to more severe and debilitating urine loss may take many years. The patient may come to medical attention only after experiencing a progressive worsening of symptoms.
In other patients, symptoms may appear suddenly and may or may not be associated with a specific inciting event, such as pelvic/urinary tract surgery, trauma, and genitourinary tract infection. In these instances especially, associated symptoms such as pelvic pain, urgency, frequency, dysuria, and hematuria may point to a specific etiology.
Classification of urinary incontinence into types allows the clinician to make an educated guess at a particular anatomic abnormality that warrants further investigation. The major types of urinary incontinence are as follows:
Episodes of stress incontinence occur during periods of increased intra-abdominal pressure. Triggers of stress incontinence are predictable: typically, patients report involuntary urine loss during coughing, laughing, and sneezing. Incontinence worsens during high-impact sports activities such as golf, tennis, or aerobics. Leakage is more common while standing than while lying down (eg, at night).
Little urine is lost, unless the condition is severe. Typically, affected patients use thin to medium-thickness pads. The number of pads used ranges from 1-3 per day.
Irritative voiding symptoms, such as urinary frequency, urgency, and nocturia, are typically absent. The presence of irritative voiding symptoms should raise an index of suspicion for overactive bladder. Irritative voiding symptoms in combination with hematuria (gross or microscopic) warrant a complete bladder tumor workup.
Stress urinary incontinence due to severe intrinsic sphincter deficiency produces much more severe symptoms than cases due principally to urethral hypermobility. Involuntary urine loss occurs not only with coughing, laughing, and sneezing but also with standing up from a sitting position. Patients describe continuous dribbling of urine and typically require a high volume of pad use.
This degree of urine loss is similar that seen with vesicovaginal or ureterovaginal fistula. These patients complain of being wet all the time and use large amounts of thick pads to stay dry. If suspecting a fistula, be sure to ask about previous surgical history, including a hysterectomy. Although uncommon, consider ectopic ureter/ureterocele in the differential diagnoses.
Urge incontinence or symptoms of an overactive bladder are uncontrolled urine loss associated with a strong desire to void, which is often a very sudden and rapid event that occurs without any warning. Urge incontinence is a type of uncontrolled urine loss that cannot be prevented. In this situation, the entire contents of the bladder are lost rather than a few drops of urine.
Patients with symptoms of an overactive bladder are aware of the intense need to void but are unable to hold back urine. Symptoms also include urinary frequency and nocturia.
Examples of situations that may precipitate urge incontinence include turning a key in the door, washing dishes, or hearing running water. Urge incontinence may also be triggered by drinking too much water or drinking coffee, tea, or alcohol.
Patients with mixed incontinence exhibit symptoms of both stress incontinence and urge incontinence. Affected patients experience mild-to-moderate urine loss with physical activities (stress incontinence). At other times, they experience acute urine loss without any antecedent warning (urge incontinence). Urinary frequency, urgency, and nocturia complement urge incontinence symptom complex.
Most of the time, patients are not able to distinguish these 2 different symptom complexes. The symptoms of urge incontinence may unwittingly be confused with the symptoms of stress incontinence and vice versa. In this situation, the symptom complex most unbearable to the patient is treated first.
Overflow incontinence occurs when the bladder is overdistended and reaches its limit of compliance. At this point, the intravesical pressure exceeds the resting urethral closure pressure and urine overflows despite the absence of detrusor contraction. Patients experience a sense of incomplete emptying, slow-flowing urine, and urinary dribbling.
Symptoms of overflow incontinence may mimic those of mixed incontinence. Patients lose a small amount of urine when intra-abdominal pressure is increased. Patients who are affected often experience symptoms of frequency and urgency as the detrusor attempts to expel urine.
The history in these patients may suggest a cause of bladder outlet obstruction, such as benign prostatic hyperplasia, anti-incontinence surgery (eg, a pubovaginal sling operation), or use of anticholinergic or antispasmodic drugs. Alternatively, the history may identify a possible neurologic cause of a nonfunctioning detrusor, such as diabetic neuropathy.
A focused physical examination should be performed. The examination is tailored somewhat in each case, based on the specifics of the patient's incontinence complaint and pertinent medical and surgical history. Each patient should have height, weight, blood pressure, and pulse recorded. Obesity is an important contributor to stress incontinence, and the presence of obesity may influence management decisions.
The patient should provide a urine sample for urinalysis and culture. Some practitioners have the patient arrive with a full bladder, measure the volume voided, and then catheterize the patient to obtain a postvoid residual measurement. Others incorporate this step into the urodynamics portion of the evaluation if that is to be performed.
Medical illnesses and comorbidities that may be contributing to the overall incontinence disorder should be sought. Cardiac and pulmonary evaluation can be important. The abdomen should be examined for surgical scars, hernias, masses, organomegaly, and distended bladder after voiding. The presence of hernias may indicate inherent connective tissue weakness, a possible contributor to incontinence. Masses may contribute to stress incontinence and, occasionally, may cause obstructed voiding with resultant overflow incontinence.
The back should be inspected for deformity, dimpling, or hair tuft and the flank and costovertebral angles should be palpated. Tenderness, deformity, or the presence of surgical scars should prompt further investigation.
Because neurologic disorders can cause or exacerbate urinary incontinence, a focused neurologic examination should be a part of every incontinence evaluation.
Much information can be gained from simple conversation with the patient (eg, mental status) and observation of gait (eg, CNS, spinal cord, peripheral nervous system disease). Any abnormalities should prompt more in-depth investigations. Strength, sensation, and deep tendon reflexes of the lower extremities should be tested.
Sensation of the perineum and perianal area should be tested with a soft touch and light prick. Using a cotton swab, the anal wink pelvic floor reflex can be elicited by stroking laterally to the anal canal. The bulbocavernosus reflex can be elicited by gently tapping the clitoris with a cotton swab in the female patient.
The presence of these perineal reflexes ensures that a significant pudendal neuropathy does not exist. The absence of these reflexes does not diagnose neuropathy but merely raises suspicion. These reflexes may be extinguished if the patient is anxious during the examination.
Pelvic floor examination
The pelvic floor examination is an integral part of the incontinence evaluation. In female patients, in particular, incontinence disorders often coexist with pelvic floor relaxation. If a surgical approach to the incontinence is chosen, other pelvic floor defects of significance can be treated simultaneously.
The examination begins with inspection of the external genitalia and urethral meatus. Evidence of atrophy, such as pallor and thinness of tissue, may indicate estrogen deficiency. A red, fleshy lesion of the posterior urethra, a caruncle, may be another indicator of urogenital hypoestrogenism. The suburethral area should be inspected and palpated. A suburethral mass should raise suspicion for a urethral diverticulum.
Other signs of a diverticulum might include tenderness and purulent or watery discharge upon compression. Urethral and trigonal tenderness also may indicate urethritis, urethral syndrome, or interstitial cystitis. The vaginal mucosa should be inspected for pallor, thinning, loss of rugae, and other signs of hypoestrogenism. If clinically suspected, a fistula opening may be discovered during vaginal examination. At times, pooling of fluid, exudate, or granulation tissue may indicate a nearby fistula tract.
A detailed pelvic floor examination should be performed for signs of pelvic organ prolapse. A systematic examination is conducted for cystocele, rectocele, uterine or vaginal prolapse, enterocele, and perineal laxity. A bivalve speculum should be used to visualize the cervix or vaginal apex. With the patient straining maximally, the speculum is withdrawn slowly, and any descent of the cervix or vaginal cuff is noted.
The speculum is then disarticulated, and a single blade examination is performed, inspecting the anterior vaginal wall during straining with the posterior wall retracted. If a cystocele is observed, then a ring forceps or similar instrument is inserted over the speculum blade and opened to support the lateral vagina. The tips of the ring forceps should be against the bilateral ischial spines. If the cystocele is present with the patient straining and the lateral vagina supported, then a midline defect exists either in isolation or with a paravaginal defect.
Another clue to a midline defect is the loss of rugae with straining. If the cystocele is no longer present with lateral support, then a pure paravaginal defect is present.
Another clue to paravaginal defects is collapsing side walls during bivalve speculum examination. If anterior wall prolapse is present with lateral support, then the next maneuver is to use the closed ring forceps to provide midline anterior vaginal support while the patient is straining again. If some cystocele is still noted, then a combined central and paravaginal cystocele is present. If no bulge is noted, then the defect is purely central.
Next, attention is turned to the posterior vaginal wall. The half speculum is used to retract the anterior wall of the vagina, while the posterior wall is examined during Valsalva maneuver. The presence or absence of a rectocele should be noted. If a double bump is observed when the patient strains, an enterocele may be present in addition to the rectocele.
Next, the perineal body is inspected. The height and thickness of the tissue is noted. A badly compromised perineal body may be short and consist of mostly skin with little or no underlying muscle. The levator muscles are palpated, and the resting tone is noted. Then, the patient is instructed to squeeze the examining fingers, and the levator strength can be appreciated. A rectovaginal examination is performed to determine the thickness of the rectovaginal septum.
The patient then is asked to strain. Tissue felt sliding through the examining fingers may indicate an enterocele. Resting and squeezing rectal sphincter tone is noted. As the rectal finger is withdrawn, the external anal sphincter should be palpated between this finger and the thumb. The absence or attenuation of this body of muscle indicates a sphincter laceration.
If any doubt remains about pelvic organ prolapse, examine the patient in the standing position. Instruct the patient to stand with legs apart and one foot resting on a step stool. When the patient performs the Valsalva maneuver, the force of gravity helps the pelvic organs (eg, uterus, bladder) slide down the vagina and helps enhance diagnostic capability.
In the male patient, levator ani muscle tone and strength can be tested during a rectal examination. The prostate should be palpated for tenderness, enlargement, and nodularity.
Cotton Swab Test
The cotton swab test is used to assess urethral mobility in women. To perform the test, place the patient in a dorsal lithotomy position. Make sure the examining table is parallel to the floor. Insert a lubricated sterile cotton swab through 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. The swab is pulled back until increased resistance is met, indicating that the cotton tip is entering the urethra.
Women with normal pelvic anatomy should have a resting cotton-swab angle of 0° with respect to the floor. The patient then is instructed to perform a Valsalva maneuver or to contract the abdominal muscles. Having the patient put forth a maximal effort is important. The examiner should not use a posterior vaginal retractor. Part the labia if the tissue is touching the wooden shaft of the swab because this may impair movement during straining.
The change in angle when the swab is deflected upward with maximal strain, indicated by the arc of the wooden end of the swab, is measured with a goniometer or estimated visually. A change of greater than 30° indicates urethral hypermobility. (See the images below.)
A positive finding does not confer a specific diagnosis, and older women have a high false-negative rate.  However, hypermobility is present in most cases of stress incontinence. If hypermobility is not present and stress incontinence is diagnosed, intrinsic sphincter deficiency should be suspected.
A study that used receiver-operating characteristic analysis of the swab test found that the optimal cut-off point for the change in angle from resting to straining was 30° or more, which had a sensitivity of 82% and a specificity of 54%. The very best discriminator was an absolute straining angle of 40° or more, which had a sensitivity of 83% and specificity of 64%.  No resting angle value had sufficient discriminatory power to be useful.
The authors cautioned that the cotton swab test does not have sufficient discriminatory power to make urodynamics unnecessary. They do believe that the test has a role in conjunction with urodynamics and may be used as a screening test in situations where urodynamic testing is not readily available.
A pad test is a useful adjunct to the patient's history and physical examination. The pad test is an objective test that determines whether the fluid loss the patient is experiencing is in fact urine. Intravesical methylene blue, oral phenazopyridine (Pyridium), or oral Urised (methenamine, methylene blue, phenyl salicylate, benzoic acid, atropine sulfate, hyoscyamine) may be used as a coloring agent. Methylene blue and Urised turn the urine blue; phenazopyridine turns the urine orange.
Pad tests may be short term or long term. Short-term tests have the advantage of convenience and assured compliance. Long-term tests may be more representative of daily incontinence.
Short-term tests generally involve the subject drinking a known volume of liquid or undergoing retrograde filling of the bladder. A preweighed sanitary pad is applied. The individual is instructed to perform specific activities such as coughing, running in place, bending and lifting, and hand washing. The testing interval can range from 15 minutes to 2 hours. At the end of the test period, the pad is removed and weighed.
Long-term tests are conducted under normal living conditions for 24-48 hours. Each pad is preweighed and then weighed again after use by the patient at home, or, alternatively, the pad is placed in an airtight plastic bag and weighed later by the clinician.
Every 1 g increase in weight is equivalent to 1 mL of urine. The International Continence Society considers the finding of a weight change of less than 1 g during its standardized 1-hour test to be a negative result. Vaginal discharge and sweat can be other physiologic sources of pad weight gain. Testing should not be conducted during menstruation, for obvious reasons.
Paper Towel Test
A paper towel test provides a quick estimate of the degree of stress urine loss.  The patient is asked to cough repetitively and forcefully with a paper towel held a short distance from the urethra.
Standardization is accomplished by dripping known volumes of liquid onto the same type of paper towel to be used in the test. The area of the visible spread of the liquid on the towel is calculated for each known volume. The area of staining on the paper towel used by the patient with incontinence can be measured and the volume of the loss estimated.
A critical part of the pelvic examination is direct observation of urine loss using the cough stress test. This test evaluates stress-induced leakage when the bladder is full. This test is very sensitive but can be misleading in inhibited patients and in those with low bladder volume. 
The cough stress test is performed by filling the bladder with sterile fluid at least halfway (eg, 200-250 mL). Have the patient in the lithotomy position or standing. While directly visualizing the urethra, instruct the patient to bear down (Valsalva) or cough. Observation of leakage during Valsalva maneuver or cough denotes a positive test result.
Urine loss directly observed from the urethral meatus at the peak of the increase in intra-abdominal pressure is strongly suggestive of stress incontinence (see the image below). Characteristically, patients with stress incontinence display immediate loss of a few drops to a brief squirt of urine. Delayed loss or prolonged loss raises the question of stress-induced detrusor instability.
If no urine loss is observed, the test can be repeated with the patient in another position or repeated at another date. If more than mild pelvic organ prolapse is present, reduction of the prolapse should be performed with a half speculum, a pessary, or the examining fingers during the stress test. Care must be taken not to compress the urethra, regardless of which reduction method is used.
A small study showed that when the diagnosis of stress urinary incontinence was made on the basis of a negative finding on cystometrogram and a positive result on cough stress test, the reproducibility of a positive stress test result 1-4 weeks later was 100%.  If the initial diagnosis was mixed incontinence, stress leakage was demonstrated on a second cough stress test 80% of the time. Conversely, if the initial diagnosis was detrusor instability with a negative result on cough stress test, the repeat cough stress test result was negative 86% of the time.
The authors point out that in the setting of pure stress incontinence, the cough stress test may be more useful than complex urodynamic cough profiles. Some believe that, in some cases, the presence of catheters may be sufficiently obstructive to cause a small number of false-negative test results. If mixed incontinence is diagnosed by a cystometrogram and cough stress test, more complex testing may be required to confirm the diagnosis. False-positive stress test results due to cough-induced detrusor overactivity may occur in this situation.
Positive stress test findings in the supine position with a relatively empty bladder and with position change or other minimal increases in intra-abdominal pressure raise the question of intrinsic sphincter deficiency. Complex urodynamic testing would be indicated in such cases. Pad testing can be used if the history strongly suggests stress incontinence, stress test findings are negative, and detrusor instability is ruled out.
Standing cough stress test
If the cough leak test is initially performed with the patient in the lithotomy position and leakage is not observed, repeat this test with the patient in the standing position.
The patient stands upright with feet shoulder-width apart. Place a large towel under patient's feet. If pelvic prolapse is present, the prolapsed organ should be pushed up either with a pessary or gauze. Instruct patient to perform the Valsalva maneuver and cough in gradients (ie, mild, moderate, strong). Observable urine leakage in this position constitutes a positive test.
If the cough stress test is positive, a Marshall test (also known as the Marshall-Bonney test) may determine if the urine loss is caused by urethral hypermobility. This test consists of stress testing with support provided for the proximal urethra.
The Marshall test is performed by placing an index finger and the second finger on either side of the bladder neck, to support the proximal urethra. With the bladder relatively full, the patient is instructed to perform Valsalva or cough. The absence of leakage with bladder neck elevation and the presence of leakage without of bladder neck support confirms stress urinary incontinence due to urethral hypermobility.
In addition to examiners’ fingers, a number of other ways to provide elevation and support of the urethrovesical junction for this test have been described, including ring forceps, large cotton-tipped swabs, and specialized instruments. Data do not exist to recommend one method over another definitively.
The Marshall test has been criticized for susceptibility to examiner error. If one is not careful, the supporting fingers may accidentally occlude the urethra (ie, rather than supporting the bladder neck) and cause a false-positive result. A negative result (ie, incontinence persists despite support to the hypermobile urethra) may also be useful, however, in that it might dictate a more aggressive surgical approach, such as performing a sling procedure rather than a Burch retropubic urethropexy.
Nevertheless, the Marshall test is neither sensitive nor specific enough to diagnose stress urinary incontinence by current standards. Thus, this test is no longer widely used.
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- Approach Considerations
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