In the assessment of UI, we find the following approach most practical: First, obtain a detailed description of the leakage episodes. Second, gather pertinent information on comorbidities, functional status, social situations, and environmental factors which can affect the management options and decisions.
Obtain a detailed description of leakage episodes
Eliciting a vignette of the patient’s leakage episodes helps to clarify the timing, quality, frequency, quantity, and other factors of the incontinence. For example, leakage associated with exertion such as coughing, laughing, and sneezing (in the absence of urgency, frequency, or other pelvic symptoms) is highly predictive of stress UI (SUI); a diagnosis can easily be made with history and a physical examination alone.
It is more difficult to describe the gestalt of patients with urgency incontinence. The majority of patients describe a significant amount of urgency (“I’ve got to
go and cannot make it on time to bathroom”) prior to the leakage episode. A common misconception is that leaks due to urgency incontinence need to be preceded by urgency or some other irritative voiding complaints. In fact, it is possible for patients to have “leakage out of the blue while sitting on the couch and reading a book” without feeling any preceding urge; the absence of sensory urgency prior to leakage does not rule out urgency incontinence.
This picture can be frequently complicated by complaints of incomplete bladder emptying. A common chief complaint may be “It seems that I cannot empty my bladder and I leak all the time.” This statement can falsely lead a physician toward the diagnosis of overflow incontinence, when in reality, their symptoms may be secondary to sensory urgency. Further questioning typically will uncover a scenario such as “I just finished urinating 15 minutes ago. Right after I left the bathroom, I suddenly felt the need to urinate again. When I’m on my way to the bathroom, I leak. I don’t think I empty my bladder!”
Another important aspect in the description of urgency incontinence episodes is an assessment of triggers that provoke either urgency or leakage. Some of the most common triggers are hearing the sound of running water, doing dishes, inserting house keys into the lock, or pulling into the driveway at home. Identifying the triggers not only aids in diagnosis but also helps with the management of the condition.
The other types of incontinence (overflow incontinence and anatomic disruption of urinary tract) are encountered less frequently but should be considered. A complaint of continuous urinary leakage is highly suggestive of a fistula or abnormal ureteral implantation. If a patient states “I just leak all the time and feel like I am constantly wet,” attention should be dedicated to the onset of the symptoms. Fistulas are very rarely spontaneous and in the vast majority of cases have an identifiable preceding event: typically surgery or radiation to the pelvic area in developed countries or complicated childbirth in underdeveloped countries. Abnormal ureteral implantation in the vagina is present at birth and is typically diagnosed in a patient’s youth.
Overflow incontinence can frequently mimic stress incontinence as the majority of the most noticeable leaks will be similarly associated with external bladder compression (e.g., cough or sneeze). The key distinguishing characteristic is that patients typically report many more episodes of insensible urine loss and often suffer from conditions which make retention a more likely diagnosis. These conditions include advanced age, diabetes, and various neurologic conditions. The easiest way to distinguish overflow incontinence from SUI is to routinely incorporate a postvoid residual (PVR) check into clinical exams, as those with overflow typically present with elevated PVRs. PVRs more than 100 to 150 mL are concerning and should trigger further investigation.
The presence of nocturnal enuresis (leakage during nighttime while asleep) defines a specifically challenging subset of patients with urgency incontinence. The presence of sleep apnea is frequently associated with nocturia and subsequent nighttime leakage. An inquiry should be made into potential snoring or partner-observed short-term breathing cessation at night to see if sleep apnea testing is indicated.
The history of a patient’s prior treatments and interventions for incontinence should be gathered at this stage and their efficacy noted. Prior surgical interventions for incontinence can prompt a subsequent, more complex evaluation with the possible need for invasive studies. Prior nonsurgical treatments should be assessed for quality: For example, pelvic floor therapy with a trained professional can yield very different results for incontinence control as compared to self-guided Kegel exercises.
The type of history gathering described earlier uses a “story-telling approach” wherein the majority of symptoms are provided by the patient. The specific details are elicited by the clinician with open-ended questions such as “What makes your symptoms worse?” or “Tell me more about your leakage episodes?” This approach allows for collection of a clinical vignette which serves as a “working theory” or theoretical framework for establishing the final diagnosis. Many physicians prefer to ask a standardized set of questions, in combination with the use of validated questionnaires. Table 9.1
lists some frequently used questions.
Assess incontinence comorbidities, functional status, social situations, and environmental factors
Comorbidities and modifiable factors can affect incontinence and choice of treatment. It is important to assess for medical conditions such as constipation, diabetes, hypertension, recurrent urinary tract infections (UTIs), and overall functional status.
Defecatory dysfunction can significantly worsen urgency incontinence. Persistent presence of hard stool in the rectum due to constipation or obstructed defecation can increase pressure exerted by the rectum onto the bladder, thereby decreasing functional bladder capacity. Poorly controlled diabetes worsens incontinence especially if it is accompanied by polyuria. Diabetes not only is predictive of less optimal treatment outcomes but also raises the probability of overflow incontinence given its association with neuropathy and retention. Diuretic treatments can worsen UI by leading to shifts in urine production throughout the day. UTIs can worsen or cause urinary leakage, especially in elderly
patients whose initial presentation may be worsening incontinence rather than dysuria.
TABLE 9.1 Frequently Used Questions during Urinary Incontinence History Taking
TYPE OF INCONTINENCE
If you sneeze really hard, would you leak urine?
Do you leak urine when you exercise?
If you leak urine while running or jumping—do you leak the moment you bounce of the ground?
Does sound of running water make you leak?
Do you feel an urge before you start leaking urine?
Does urge to urinate wake you up at night?
If you leak after changing position (e.g., from sitting to standing), do you feel urge before the urine leaks down your legs?
Do you feel like you are constantly wet?
Fistula or insensible urine loss associated with urgency incontinence
Assessment of patients’ functional status is of great importance. Specifically, inquiring about their level of mobility, use of assisting walking devices, and dexterity helps in identifying functional incontinence. Access to bathrooms can be hindered for patients whose mobility status precludes them from moving quickly. Patients with altered dexterity might leak because they are unable to open bathroom doors easily or have trouble removing their undergarments. Functional status and ability to perform activities of daily living can be assessed formally or informally. Informal assessments include collecting data via simple conversation with questions such as “Did you have any trouble getting to our office? Do you like cooking? What did you cook for dinner last night?” Simple observations on how the patient moves in the room, gets up from the chair, climbs on the exam table, and/or moves into lithotomy position are revealing of patient functional status. Formal assessment can be performed by administering the Functional Status Questionnaire,5
which takes about 15 minutes to complete and can be used for initial evaluation as well as monitoring of the patient’s progress.
Cognitive impairment plays a major role in prognosis and management options. In some situations, cognitive impairment will be evident through basic patient interactions. Using a Mini-Mental State Examination is a quick and more formal way to assess mental status. Interviewing patients’ caregivers and family members is a useful way to assess the level of mental decline, and it also provides insight into the level of social support your patient has.
Fluid intake measured as the amount and type of fluid consumed is important when considering the effectiveness of behavioral modifications for incontinence control. So-called “bladder irritants” such as alcohol, soda, artificial sweetener, carbonated, and caffeinated beverages can be modifiable factors in UI treatment. Fluid overconsumption (increases in fluid intake more than 80 to 90 oz/d) can significantly worsen urgency incontinence.
With a careful and detailed history collection, a differential diagnosis for UI can be established even prior to physical examination. The first aim should be to assess so called “transient (or modifiable) causes of UI” frequently described by mnemonic “DIAPPERS” described in Table 9.2
When incontinence is established as a chronic nontransient condition, the physical examination will further assess the pelvic floor to guide the treatment plan.