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Incontinence affects a woman's quality of life, and it is an uncomfortable and embarrassing problem. The psychosocial impact on the patient as well as her family is enormous. Women with urinary incontinence are reported to be more depressed, to have lower self-esteem, and to be ashamed about their appearance and the odor. Urinary incontinence impacts sexual desire and reduces sexual activity. This can curb social interactions to the point where individuals become isolated and even entirely homebound.

History

The first step in evaluating an incontinent patient is a thorough history. The nature and extent of the patient's lower urinary tract symptoms (LUTS) should be elucidated. Knowledge of the duration, frequency, and severity of the urinary incontinence is essential to understanding the social implications and its impact on the patient's life and aids the clinician in determining the direction and extent of diagnostic and therapeutic measures (Table 45-2). A multitude of diagnostic and imaging studies are available, but taking a thorough but focused urogynecologic history can isolate many of the easily reversible causes of incontinence (Table 45-3). Knowledge of the use of protective items, such as sanitary napkins, panty liners, absorbent pads, or adult diapers, is useful in quantitating urinary loss. Including questions about menopausal status and use of hormone treatment, history of urinary tract infections, previous surgery to remedy incontinence, and the patient's mental and functional status are essential.

Patient Questionnaires

Survey instruments can be valuable in helping to identify and determine the severity of patient symptoms. Although initially designed for clinical research, short forms of longer questionnaires exist and can be used for clinical care. Surveys such as the Urinary Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) can be easily filled out by a patient to facilitate diagnosis and to follow treatment interventions.

Voiding Diary

A voiding diary, or urolog, that quantitates frequency and volume is a helpful tool. For a 24- to 48-hour period the patient records all fluid intake, and measures and records all urine output, including frequency and episodes of leakage (Fig 45-4). Numerous studies have validated the voiding diary as a reliable tool in the diagnosis and management of urinary urgency or urge incontinence. These data are beneficial to the physician because they clarify home voiding patterns, particularly in the elderly. They are often useful to patients as well because they provide a focus on the problem and can serve as a baseline for treatment interventions such as behavioral training, bladder drills, and pharmacologic management.

Figure 45-4. Urinary diary (urolog).

Urinalysis

Examination of the urine is an essential part of the work-up of urinary incontinence for any patient with LUTS. Infection is a common cause of urinary complaints, including frequency, urgency, and incontinence. A clean-catch voided specimen is suitable for routine urinalysis; however, a sterile "in and out" catheterized specimen is appropriate for patients unable to correctly perform collection or if urine culture has been previously equivocal because of skin flora contamination.

Urinary protein, glucose, ketones, hemoglobin, casts, and nitrates can indicate primary renal disease or injury. Microscopic evaluation of the urinary sediment may indicate renal tubular damage with the presence of casts or indicate infection by the presence of leukocytes and red blood cells. More than 6-8 white blood cells per high-power field along with the presence of bacteria are very suggestive of urinary tract infection.

Physical Examination

A general gynecologic and neurologic examination should be performed on all patients, with a focus on the vaginal walls and pelvic floor. The patient should come to the clinic with a comfortably full bladder for spontaneous uroflowmetry and postvoid residual assessment. An examination should be performed with the patient in the lithotomy position. The examination should begin with an assessment of the vulvar area. In postmenopausal patients, atrophy and change in labial architecture may be due to estrogen deficiency. Vulvar dermatoses may be coexistent with vulvar complaints ascribed to incontinence. The presence of inflammation or irritation from chronic moisture or pad usage should be noted. The presence of discharge should be noted because this may mimic urinary incontinence. Examination of the urethra with palpation of the anterior vaginal wall under the urethra for fluctuance, masses, or discharge may reveal signs of urethral diverticulum, infection of the urethra, or rarely carcinoma. Tenderness may point to urethral pain syndrome, a condition marked by episodic urethral pain usually with voiding, and by daytime frequency and nocturia.

Vaginal wall integrity must be assessed. Vaginal rugae, or the folds in the epithelium, are normal and tend to be absent if the underlying supportive endopelvic fascia is detached. The presence of anterior wall defects (cystoceles), posterior vaginal wall defects (rectoceles), and apical defects (enteroceles) can be quantified. The uterocervical position, or, if the woman has had a hysterectomy, the cuff position and its descent should be recorded. The position of the vaginal walls should be noted in the lithotomy position at rest and with Valsalva/straining maneuver. A Sims' speculum or the lower blade of a Graves' speculum allows easy visualization of either the anterior or posterior vaginal wall. The severity of vaginal laxity, which may be masked in the supine position, can often best be elicited by repeating the examination in the standing position while the patient places 1 foot on the step of the examination table or on a small portable step.

Cotton Swab Test

Mobility at the level of the bladder neck can be quantified with the use of a sterile cotton-tipped swab (Q-tip) test. The Q-tip test is 1 of the most commonly used tests to evaluate women with urinary problems because it effectively quantifies the degree of anatomic rotation of the support of the urethra and bladder neck. With the patient in the dorsolithotomy position, the labia are separated and urethral meatus swabbed with antiseptic. A sterile Q-tip lubricated with 1-2% lidocaine (Xylocaine) jelly is inserted transurethrally into the bladder and then withdrawn slowly until definite resistance is felt. This places the tip of the Q-tip at the level of the bladder neck just distal to the internal urethral meatus. Using a standard protractor, resting angle is measured. The patient is then asked to perform a Valsalva maneuver or to cough, and the maximum straining angle is noted. Net deflection is equal to the change from resting to maximum straining position (Fig 45-5). An angle greater than 30 degrees is considered abnormal. Urethral hypermobility must be interpreted with caution because it may be present in women without incontinence. The utility of this simple test is that an angle greater than 30 degrees is certainly present in the majority of women with genuine stress incontinence. In the absence of hypermobility, the physician must question the diagnosis of anatomic stress incontinence and entertain the possibility of a fixed and damaged urethral sphincter (also called intrinsic sphincteric deficiency) to explain stress-related urinary loss.

Figure 45-5. The cotton-tipped swab (Q-tip) test for assessment of urethral and bladder support. A: Angle of the Q-tip at rest. B: Angle of the Q-tip with Valsalva maneuver or cough (straining). The urethrovesical junction descends, causing upward deflection of the Q-tip.

Urinary Cough Stress Test

Having the patient perform a Valsalva maneuver or to cough forcefully multiple times to reproduce urine loss at the beginning of the examination may reveal the presence of incontinence. Observation of urine lost immediately with the cough or Valsalva maneuver may obviate the need for more complex urodynamic testing if the complaint is minor. If no urine loss is exhibited, the patient is asked to stand with legs shoulder width apart and asked to cough. Immediate loss of urine suggests a diagnosis of SUI.

Bimanual examination to evaluate the uterine size, position, and descent within the vaginal canal and palpation of the ovaries should be performed. A rectovaginal examination permits adequate assessment of the posterior vaginal wall. Anal sphincter tone can be assessed at rest and with anal tightening. The presence of fecal impaction must be ruled out because this condition has been shown to be a contributing factor to urinary incontinence, particularly in the elderly population.

The description of pelvic organ prolapse is critical.

Neurologic Examination

The control of micturition is complex and multitiered, with both autonomic and voluntary control. In addition to a complete history and screening for neurologic symptoms, a thorough physical examination is important because many neurologic diseases may present with voiding dysfunction in the absence of overt neurologic findings.

Mental status, cranial nerves, motor strength, sensory function, deep tendon reflexes, and sacral spinal cord integrity should all be assessed. Testing the patient's orientation to place and time and assessing speech and comprehension skills will help to ascertain her mental status. Motor control may be diminished in focal brain or cord lesions, most commonly Parkinson's disease, multiple sclerosis, and cerebrovascular accident. Motor strength is tested in the lower extremities by assessing hip, knee, and ankle flexion, as well as ankle eversion and inversion. Deep tendon reflexes are tested at the patella, ankle, and foot planus. Sensation can be tested at the dermatomes using light touch and pinprick over the perineum and thigh area. Deficits should be noted, but it should be kept in mind that there is considerable overlap in sensory innervation in the sensory nerve roots. The sacral spinal cord nerve roots 2-4 contain vital neurons controlling micturition. The anal wink reflex and the bulbocavernosus reflex can confirm integrity of neurovisceral and urethral reflex functions. These reflexes can be evoked by stroking the perianal area and looking for an external anal sphincter contraction, and by tapping or gently squeezing the clitoris and watching for contraction of the bulbocavernosus muscle, respectively. These reflexes are often easier to elicit at the beginning of the examination, but their absence is not always indicative of neurologic deficit. Clinically observed neurologic deficits should lead to a neurologic consultation.

Urodynamics

A urodynamic study is any test that provides objective dynamic information about lower urinary tract function. Many methods and tests are available (Table 45-4). Some methods are simple, such as diaries that track frequency and volume of urination, and some methods are more complex, requiring special equipment and training. A cystometrogram is necessary to rule out unstable bladder, overflow incontinence, reduced bladder capacity, or abnormalities of bladder sensation. A cystometrogram can be performed using water manometry or more advanced methods. Complex urodynamic testing increases the diagnostic accuracy and may often identify the reason for failure of previous therapy. Uroflowmetry can be performed to measure detrusor pressure and flow rate to evaluate for voiding dysfunction. If a poorly functioning urethra, such as intrinsic sphincter deficiency (ISD), is suspected, urethral pressure profile (UPP) or abdominal leak point pressure (ALPP) can be measured to evaluate urethral closure pressures. Such testing is particularly helpful in difficult or complex cases.

The indications for more complex testing in the form of multichannel urodynamics are not standardized, and each patient must be assessed individually (Table 45-5). However, some basic criteria, if met, indicate a need for urodynamic evaluation, which can aid in more accurate diagnosis and thus appropriate medical or surgical management.

Cystourethroscopy

Endoscopic evaluation is an invaluable adjunct for the diagnosis and management of the urogynecologic patient. It is a simple office procedure that can yield important data when performed by experienced operators. Cystourethroscopy is indicated for hematuria, irritative voiding symptoms, obstructive voiding, suspicion of diverticula or fistula, persistent incontinence, and as a preoperative evaluation prior to reconstructive pelvic surgery.

Imaging Tests

Radiologic studies can be an integral component of the evaluation of lower urinary tract dysfunction and abnormalities. However, these modalities are of limited use in the evaluation of all but the most complex of incontinent patients. Magnetic resonance imaging (MRI) has become more extensively used in patients with pelvic floor dysfunctions and prolapse. As the technique becomes less costly, applications for the uses of MRI to aid in the urogynecological work-up will expand.