Urinary Incontinence

A detailed continence history, bladder diary, physical examination, and measurement of residual urine in the bladder after voiding are components of a continence assessment. Commonly questions are asked about congenital abnormalities, attainment of continence, previous urinary tract infections, obstetric history, neurologic diseases, and previous gynecologic surgery. Some medications have an adverse influence on lower urinary tract function and may promote incontinence. Questions about the quality, type, and timing of fluid intake over a twenty-four hour period; and about smoking, bowel pattern of function, sexual function, and quality of life, can identify reversible lifestyle factors. A one-week bladder diary captures frequency of voiding and wet (incontinent) events. A bladder diary can be repeated after treatment to show objective improvement. If continence pads are used, the number and type are noted. In some instances, measurement of the voided volume is helpful. The loss of urine with stress maneuvers such as coughing, sneezing, or exercise, or loss of urine with urgency may suggest the underlying mechanism of incontinence. Sometimes these symptoms occur together.

In women, the physical examination includes vaginal inspection for signs of post-menopausal estrogen deficiency, pelvic organ prolapse, urogenital fistula, and assessment of voluntary contraction of the muscular pelvic floor. In men, digital rectal examination assesses the size, symmetry, and consistency of the prostate gland, and the examination helps rule out prostate cancer.

Neurologic examination rules out diseases such as stroke, multiple sclerosis, and Parkinson’s disease, and also assesses the nerve and muscular function of the anal sphincter and sacral sensation. Mental state and mobility are also assessed in the elderly. The former will rule out dementia and assess the person’s ability to learn behavioral interventions.

Any urine remaining in the bladder after voiding is usually abnormal and can be measured by passing a catheter in and out through the urethra. Noninvasive assessment can be done by ultrasound examination of the bladder. Further in-depth assessment of the bladder and urethral structure may be indicated using a cystoscope inserted into the bladder through the urethra. The coordinated function of the bladder and urethra may be evaluated by further sophisticated urodynamic tests. These tests are indicated if there is no improvement with conservative behavioral interventions and drug therapy, or if surgery is contemplated.