eMedicine Specialties > Urology > Incontinence

Urinary Incontinence, Nonsurgical Therapies: Differential Diagnoses & 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; Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic; Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic
Contributor Information and Disclosures

Updated: May 6, 2009

Differential Diagnoses

Other Problems to Be Considered

Transient incontinence
Ureterovaginal fistula
Vesicovaginal fistula
Urethrovaginal fistula
Ectopic ureter
Normal vaginal secretions
Vaginal voiding

Workup

Laboratory Studies

  • Urinalysis and urine culture: Cystitis can produce irritative voiding symptoms and urge incontinence.
  • Urine cytology: Patients with carcinoma in situ of the urinary bladder have symptoms of urinary frequency and urgency and show evidence of microscopic hematuria.
  • Chemistry 7 profile: These tests are helpful for patients in whom poor renal function, obstructed ureters, or urinary retention is suggested.

Imaging Studies

  • Cystogram: A lateral cystogram helps to confirm the presence of stress incontinence, the degree of urethral motion, and the presence of cystocele. These radiographs may also demonstrate intrinsic sphincter deficiency by showing a wide-open urethra on the resting films. Vesicovaginal fistula may also be documented in this fashion.
  • Magnetic resonance imaging: MRI provides excellent anatomic detail, particularly in women with pelvic organ prolapse. MRI may be useful in certain situations requiring complex surgical reconstruction. However, the cost-effectiveness of obtaining routine MRI remains controversial.

Other Tests

  • Voiding diary: 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.
  • Pad test: 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 Pyridium, or Urised may be used as a coloring agent. If the peri-pad changes color, the fluid lost is urine. The pad test may be performed during a 1-hour period or a 24-hour period. The pads may be weighed (1 g = 1 mL) to assess the severity of urine loss.
  • Q-tip test: This test is performed by inserting a sterile lubricated cotton swab (Q-tip) into the female urethra. The cotton swab is gently passed into the bladder and then slowly pulled back until the neck of the cotton swab is fit snugly against the bladder neck. The patient then is instructed to perform a Valsalva maneuver or to contract the abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is an important finding for type II stress incontinence. A Q-tip excursion angle greater than 35° indicates urethral hypermobility.
  • Cough stress test: A critical part of the pelvic examination is direct observation of urine loss using the cough stress test or Marshall test. The cough stress test is performed by filling the bladder with sterile fluid at least halfway (eg, 250 mL) and instructing the patient to bear down (Valsalva) or cough. Observation of leakage during Valsalva maneuver or cough denotes a positive test result.
  • The Marshall test, otherwise known as the Marshall-Bonney test, is performed by placing an index finger and the second finger on either side of the bladder neck. With the bladder relatively full, the patient is instructed to perform Valsalva or cough. The 2 fingers at the bladder neck serve to support the proximal urethra during Valsalva maneuver. The absence of leakage with bladder neck elevation and the presence of leakage with loss of bladder neck support confirms stress urinary incontinence due to urethral hypermobility. However, the Marshall test is neither sensitive nor specific enough to diagnose stress urinary incontinence by today's standards. Thus, the Marshall test is not widely practiced today.
  • Standing pelvic examination: A standing pelvic examination is performed if a pelvic examination fails to demonstrate urine loss or if a pelvic organ prolapse is suspected. If the pelvic prolapse is present, push the prolapsed organ up with a pessary or gauze and repeat the cough stress test in the standing position.

Procedures

  • Postvoid residual volume: The measurement of PVR volume is a part of the basic evaluation for urinary incontinence. If the PVR volume is high, the bladder may be acontractile or the outlet may be obstructed. To determine the PVR urine, either bladder ultrasonography or a urethral catheter may be used.
  • Uroflow: A useful screening test, uroflow is used mainly to evaluate bladder outlet obstruction. Consistently low flow rates generally indicate a bladder outlet obstruction but may also indicate decreased detrusor contractility. To properly diagnose bladder outlet obstruction, perform pressure-flow studies.
  • Filling cystometrogram: A filling cystometrogram (CMG) assesses bladder capacity, bladder compliance, and the presence of phasic contractions. This test may be performed using either gas or liquid to fill the bladder, with different interpretive criteria applying to each. Usually, the patient feels the first sensation as the bladder begins to fill with 100-200 mL of water. As the bladder nears capacity, 300-400 mL, the patient may begin to feel uncomfortable. True urge to void occurs when the bladder has been filled to capacity. An average adult bladder holds approximately 450-500 mL of urine.
  • Abdominal leak point pressure: An important component of multichannel videourodynamics is the determination of the abdominal leak point pressure (ALPP). ALPP allows stress urinary incontinence in women to be classified into urethral hypermobility, intrinsic sphincter deficiency, or both in combination. In patients with stress incontinence, an ALPP less than 90 cm H2 O indicates intrinsic sphincter deficiency, whereas ALPP greater than 90 cm H2 O reflects urethral hypermobility.
    • ALPP (also known as Valsalva leak point pressure) is performed by instilling 250 mL of fluid medium into the urinary bladder. The patient is instructed to bear down (Valsalva) in gradients (ie, mild, moderate, severe) to demonstrate leakage. The lowest abdominal pressure required to generate leakage is recorded as ALPP.
    • Cough leak point pressure (CLPP) is performed by instilling 250 mL of fluid medium into the urinary bladder. The patient is instructed to cough in gradients (ie, mild, moderate, severe) to demonstrate leakage. The lowest abdominal pressure required to generate leakage is recorded as CLPP.
    • Valsalva leak point pressure appears to be more sensitive than CLPP in diagnosing intrinsic sphincter deficiency because coughing and Valsalva seem to result in a different reaction of the pelvic floor. In addition, progressive bladder filling in 50-mL increments (eg, 250 mL, 300 mL, 350 mL) also appears to increase the sensitivity of leak point pressure testing. Leak point pressure testing may be performed with or without video (fluoroscopic) capabilities.
  • Voiding cystometrogram (pressure-flow study): A pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow. Voiding cystometrogram is the only test able to provide information about bladder contractility and the extent of a bladder outlet obstruction.
  • Electromyography: Electromyography (EMG) enables documentation of voiding and is used to distinguish coordinated voiding (ie, detrusor sphincter synergia) from uncoordinated voiding (ie, detrusor sphincter dyssynergia).
  • Cystoscopy: Cystoscopy allows an anatomical assessment of the bladder and the urethra. Bladder lesions, such as a tumor or carcinoma in situ, which would otherwise remain undiagnosed using urodynamics alone, can be identified. Cystoscopy is also indicated for patients experiencing persistent irritative voiding symptoms or hematuria. In some cases, unexplained persistence of symptoms is due to a stone or foreign body (eg, stitch, mesh material from prior surgery for prolapse or incontinence). Lastly, urethroscopy can be performed to assess the structure and function of the urethral sphincter mechanism.

More on Urinary Incontinence, Nonsurgical Therapies

Overview: Urinary Incontinence, Nonsurgical Therapies
Differential Diagnoses & Workup: Urinary Incontinence, Nonsurgical Therapies
Treatment & Medication: Urinary Incontinence, Nonsurgical Therapies
Follow-up: Urinary Incontinence, Nonsurgical Therapies
Multimedia: Urinary Incontinence, Nonsurgical Therapies
References
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References

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Further Reading

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Keywords

incontinence, urinary incontinence, functional incontinence, stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, Foley catheter, decompensated bladder, detrusor instability, Marshall test, Kegel exercises, detrusor hyperreflexia, overactive bladder, urinary tract infections, UTI, underpads, pant liners, shields and guards, adult diapers, disposable pad systems, urethral occlusive devices, indwelling urethral catheters, suprapubic catheters, intermittent catheterization

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Contributor Information and Disclosures

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
Raymond Rackley, MD is a member of the following medical societies: American Urological Association
Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

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
Sandip P Vasavada, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, International Continence Society, and Society for Urology and Engineering
Disclosure: pfizer Honoraria Speaking and teaching; allergan Consulting fee Consulting; ndi medical, LLC Ownership interest Review panel membership; novartis Honoraria Speaking and teaching

Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic
Disclosure: Nothing to disclose.

Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic
Farzeen Firoozi, MD is a member of the following medical societies: American Medical Association and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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