(Upper) Clitoral and (lower) Bulbocavernosus reflexes. Gentle tapping the clitoris or light stroke to the labia majora produce a reflex contraction of the external anal sphincter muscle.
Rectal examination
Health-care providers should check for fecal impaction, masses, presence of piles, or rectal mucosal prolapsed. The rest of the rectal examination is actually a detailed neurologic examination because the same sacral roots (S2–S4) innervate the external urethral sphincter and the anal sphincter. This will be dealt with later with the neurological examination.
Neurological assessment
A brief neurological examination should be part of any assessment for urinary incontinence. The patient’s history should rule out any history of spinal cord trauma, tumor, multiple sclerosis, central lumbar disc prolapse, pelvic surgery, or irradiation.
Mental state cognitive function should be assessed, especially in elderly ladies. If concern is raised regarding memory deficits, confusion, or depression, referral for formal testing is essential.
Mobility is assessed by observing the patient while walking into the examining room and getting on and off the examining table. The patient’s gait, balance, and the needs of assistance should be noticed.
If a neurological condition is suspected, a detailed neurological assessment is needed.
The ability of the patient to voluntarily contract the external anal sphincter should be assessed during a rectal examination.
Pudendal nerve (supply pelvic floor muscles and striated urinary sphincter and anal sphincter) and pelvic nerves (innervate the detrusor smooth muscle of the bladder and internal urinary sphincter) arise from the sacral segments (S2–S4).
The following reflexes could be of value in assessing patients with suspected neurological condition: ankle reflex (S1–S2), planter reflex (S2–S3), anal reflex (wink) (S2–S4), and bulbocavernousus reflex (S2–S4).The anal reflex and bulbocavernosus reflex are absent in 20% of normal people; hence, the absence of these reflexes are not necessarily pathologic.
Bladder diary
A bladder diary is a 24-hour record of the type and amount of fluid consumed, the number and volume of voids and leaks per hour, and what the patient was doing at the time of each leak. It serves as a diagnostic tool as well as a record of each patient’s baseline condition. Events associated with incontinent episodes can help guide the diagnosis (e.g., leaking while unlocking the front door suggests an overactive bladder). The document can also uncover problematic types of intake such as excessive caffeine consumption or drinking after dinnertime, which can lead to increased nocturia. The bladder diary also serves as a good reference to judge the success of treatment. NICE has recommended encouraging women to complete a diary for a minimum of three days covering variations in their usual activities, such as both working and leisure days.
Quality-of-life questionnaire
Several studies have shown that clinicians tend to underestimate the degree of interference perceived by patients due to urinary incontinence.[15] Therefore an objective assessment of the impact of UI on quality of life is an essential part of evaluating patients. It includes assessment of the physical, functional, social, and emotional well-being of an individual. The International Continence Society (ICS) has recommended the use of a quality-of-life questionnaire (QoL) to evaluate the impact of urinary incontinence on patient life and to audit the effectiveness of treatment. There are several QoLs available, many of which are validated for different languages. The following incontinence-specific QoLs have been validated and recommended when therapies are being evaluated: ICIQ, BFLUTS, I-QoL, SUIQQ, UISS, SEAPI-QMM, ISI, and KHQ.[11]
Investigation
Laboratory tests
Urinalysis
Urinalysis should be performed in all cases at the initial assessment to exclude underlying pathology.[16] A clean catch urinalysis should be obtained. NICE has recommended that the urine dipstick needs to include the followings: blood, glucose, protein, leukocytes and nitrites in the urine (Figure 20-2).[11] Urine specific gravity should be checked, especially in patients who are suspected to have polydipsia, nocturia, or renal concentration abnormalities.
Post-void residual
The measurement of post-void residual (PVR) urine volume should be part of the initial assessment. The most accurate method of determining PVR urine volumes is catheterization, which is associated with increased risk of urinary infection and discomfort for the patient. Bladder ultrasound scanning has been introduced as an alternative noninvasive method. PVR of less than 100 mL is normal and more than 200 mL may be associated with obstruction or reduced bladder contractility. In older patents, PVR of 25% of total bladder volume is considered normal.[16]
Pad test
The pad test provides objective information about the severity of incontinence. To standardize the test, the ICS introduced the one-hour pad-weighing test, which measures the urine loss and weight gain of a perineal pad during a standard provocation exercise. Weight gain of more than 2 g per hour is considered as positive.[8] NICE has recommends not to use pad tests in the routine assessment of women with UI.[11]
Special tests
Special tests such as cystourethroscopy or urodynamics may be of assistance in diagnosis. These tests should be applied in a select fashion and be used to address specific diagnostic questions.
Urodynamic study
Urodynamics (UDA) is a general term used for all tests of bladder and urethral function. It is used to obtain information about urine storage and emptying. It is widely used as an addition to clinical diagnosis, to confirm diagnosis, and to provide prognostic information or when clinical diagnosis is difficult because of unclear history.
Several studies did not recommend the routine use of urodynamics before surgery for women who are likely to have genuine stress incontinence. The use of UDA did not improve outcome, and clinical evaluation alone was not found to be inferior to UDA.[17, 18]
NICE recommends not performing multichannel cystometry, ambulatory urodynamics, or videourodynamics before starting conservative management or for women where pure stress incontinence is diagnosed based on detailed history and examination. UDA can be performed in women who have symptoms of OAB leading to a clinical suspicion of detrusor overactivity, symptoms suggestive of voiding dysfunction, anterior compartment prolapse, or had previous surgery for stress incontinence. Ambulatory urodynamics or videourodynamics can be considered after conventional urodynamics if the diagnosis is unclear.[11]
Treatment
Before planning for treatment, it is important to discuss whether the patient wants to receive treatment, the extent of treatment that is acceptable to the patient, patient goals and expectations of treatment, available patient care, and systems for support.
The aim of treatment is to reduce urinary incontinence and improve quality of life. A personalized and tailored multicomponent, stepped approach that is focused on symptoms the patient considers most bothersome is the key to successful outcome.[19]
Regardless of the approaches used, it is up to the individual patient to determine whether she considers her incontinence to be successfully managed. Different women will have different perceptions of what is bothersome and what is tolerable.
Conservative management
Conservative treatment does not involve surgery. These include lifestyle interventions; physical, behavioral, drug and, complementary therapies; and nontherapeutic interventions (such as products that collect or contain leakage). Physical and behavioral therapies and/or lifestyle interventions are also considered preventive measures.
The ICS defines “conservative treatment” as therapies that are usually low cost and managed principally by the person with UI with instruction/supervision from a health-care professional. They differ from other forms of incontinence management, in that they have a low risk of adverse effects and do not prejudice other subsequent treatments.[8]
Nonpharmacologic options
Lifestyle modifications
There is a lack of high-quality prospective controlled trials evaluating the effects of modifying lifestyle factors in women with UI or OAB. However, there is some evidence to suggest that weight loss for moderately and morbidly obese women will reduce UI episodes. Dietary change such as avoiding foods and drinks that can adversely affect normal bladder function (caffeinated products, alcohol, and acidic or spicy products) may be of value. Small clinical trials do suggest that decreasing caffeine intake improves continence, and carbonated drinks increase the risk of OAB.
Although no conclusive association between smoking and urinary incontinence has been found, there are some studies that have shown smoking to be a possible risk factor for UI.[20] Certainly the cough that smoking can cause can be an aggravating factor in stress incontinence. Smoking cessation for patients with stress UI or stress-predominant mixed UI should be offered.
Patients often reduce their fluid intake in an effort to control UI symptoms. To avoid the risk of urinary tract infections, constipation, and dehydration, patients generally should not lower their intake below six to eight 8-oz glasses of fluid each day. Because excessively small or large urine output can contribute to urinary incontinence, reduction of fluid intake in patients who are drinking excessive amounts should be encouraged to adjust their fluid intake to produce a 24-hour urinary output of between 1,000 mL and 2,000 mL.[21]
Patients should avoid constipation as chronic straining may be a risk factor for urinary incontinence and genital organ prolapse.
Drugs that influence bladder function need to be reviewed; anticholinergics and beta blockers can cause overflow incontinence.
Urinary incontinence can be caused or exacerbated in patients with impaired mobility; reduction of physical barriers to toileting and mobility (e.g., selecting clothing that is easier to manage, mobility aids, and living area rearrangement) is important.
These same interventions are also effective for prevention of incontinence.
Physical therapy
Physical therapy should be offered as first-line therapy for the management of urgency, stress, and mixed urinary incontinence. Physical therapy has been found to be more effective and to provide more sustained improvement in symptoms than pharmacologic therapy.[21, 22]
Pelvic floor muscle exercises
Pelvic floor muscle exercises (PFME) should be offered as first-line conservative therapy for women with stress, urgency, or mixed urinary incontinence.
PFME are based on the principle of strength training and involve squeezing and releasing the pelvic floor muscles. These contractions increase the strength and tone of the pelvic floor. This increases the force of urethral closure, which in turn prevents stress incontinence during an abrupt increase in intra-abdominal pressure. An assessment of pelvic floor muscle function should be undertaken prior to instigation of any pelvic floor muscle intervention.[21] Digital vaginal assessment is suitable for measuring pelvic floor muscle strength and endurance.
PFME are effective in the treatment of stress and mixed urinary incontinence, but there is insufficient evidence to assess their efficacy in the treatment of urge incontinence. Expert opinion suggests that pelvic floor muscle exercises may have a role in treatment of urge incontinence in combination with bladder training.[21]
A wide range of pelvic floor muscle training (PFMT) regimens are reported in the literature. Programs need to be tailored for the individual patient. The basic recommended regimen involves three sets of 8–12 slow-velocity contractions sustained for 6–8 seconds each, performed 3–4 times a week and continued for at least 20 weeks.[19] NICE recommends that pelvic floor muscle training programs comprise at least eight contractions performed three times per day.[11] Besides occasional cases of pain or discomfort, no other adverse effects were noted. In studies of up to one year, higher intensity PFMT regimens confer greater subjective cure or improvement than lower intensity regimens. Perineometry or pelvic floor electromyography should not be used as biofeedback as a routine part of PFMT.[11]
Biofeedback
Most data regarding biofeedback relate its use in conjunction with PFME, rather than as an isolated intervention. Biofeedback was found to be no more effective than pelvic floor muscle exercises alone in alleviating symptoms of urinary incontinence.[21]
Evidence does not indicate additional benefit from biofeedback with PFME in comparison with PFMT alone in treating UI. Biofeedback with PFME is more costly than PFME alone and therefore is not cost-effective given a lack of additional benefit.[11]
Vaginal cones
Two high-quality systematic reviews found that the use of weighted vaginal cones is effective in reducing symptoms of stress incontinence.[21] No evidence was found to suggest that use of vaginal cones is more effective than PFME alone. Compared with PFMT, cones are associated with more adherence problems. Vaginal cones are not suitable for all women and are inappropriate for use in some circumstances, such as when there is a moderate to severe prolapse, too narrow or too capacious a vagina causing difficulty with insertion or misplacement of the cone, untreated atrophic vaginitis, vaginal infection, or during menstruation or pregnancy.[11]
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