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Karen McKertich
MBBS, FRACS(Urol), is a urological surgeon, Cabrini
Medical Centre and The Alfred Hospital, Melbourne,
Victoria.
Urinary incontinence
Assessment in women: stress, urge or both?
Urinary incontinence in women is very common, with the
Background
prevalence in community dwelling women ranging from
The aims of assessing urinary incontinence in women are
1040%.1 Stress incontinence appears to be the most common,
to define the diagnosis, exclude other pathology and guide
management. Treatment can be initiated when urinary and was the only symptom in 50% of women in a community
incontinence is categorised as stress, urge or mixed incontinence. survey. About a third of adults have mixed incontinence. With
Once conservative measures have been exhausted, the aging there is an increased prevalence of both urge and mixed
management of stress incontinence is largely surgical, while that incontinence.1,2 With our aging population it is important
of urge urinary incontinence is largely medical. to address urinary incontinence as it impacts greatly on
quality of life.
Objective
This article discusses the clinical assessment of urinary
incontinence in women with emphasis on the primary care Urinary incontinence in women can be categorised as:
assessment and indications for specialist referral. stress urinary incontinence (SUI)
urge urinary incontinence (UUI)
Discussion
mixed urinary incontinence (MUI)
History taking is the cornerstone of urinary incontinence
assessment and in combination with physical examination overflow urinary incontinence (OUI)
allows categorisation of patients into stress, urge or mixed fistula related, and
urinary incontinence. Basic assessment includes investigations functional incontinence.
such as urine testing, bladder residual volume measurement, Features of each category are outlined in Table 1. It is important
and a bladder diary. Urodynamic testing is not required in all to distinguish these categories as the type of incontinence guides
patients or before initiating conservative treatment. Indications management. In the majority of cases the cause of incontinence can
for specialist referral and urodynamic testing are discussed. be ascertained by a careful history and basic clinical assessment.
History
History taking can be divided into four components:
define the type of incontinence
define the causes and precipitants
exclude other pathology
assess the severity and impact on the patients life.
112 Reprinted from Australian Family Physician Vol. 37, No. 3, March 2008
sudden severe need to void (UUI) Defining the causes and precipitants of incontinence
urgency without loss of urine (overactive bladder dry) It is important to take a full urinary tract history in order to exclude
constant versus intermittent leakage other conditions that can mimic incontinence such as urinary tract
amount of urine loss. infections (UTIs), bladder cancers and calculi, and to assess for risk
Reprinted from Australian Family Physician Vol. 37, No. 3, March 2008 113
theme Urinary incontinence assessment in women: stress, urge or both?
factors predisposing to all of the listed conditions.2,3 neurological symptoms which may point to a neuropathic
A general urinary tract history includes an assessment of: bladder as the cause of UUI (eg. new onset paraesthesia,
urinary frequency day versus night weakness, back pain, visual disturbances, altered bowel habit
factors which worsen urge incontinence diuretics and bladder with constipation or faecal incontinence).
irritants such as caffeine intake (including coffee, tea, cola and Patients who have atypical features, severe symptoms and those not
energy drinks) and alcohol responding to treatment should be considered for early specialist
reversible causes of urinary incontinence such as diuretics, lithium referral and are likely to warrant full assessment with cystoscopy
(which may cause excess fluid intake), -blockers (reduce urethral and urodynamic study.24
tone), and poorly controlled diabetes
Assessing the impact of incontinence
risk factors for SUI including parity, history of large babies,
forceps and breech deliveries, chronic cough, obesity Severity of incontinence and impact are not necessarily the same.
previous urinary tract and gynaecological surgery including It is important to obtain some idea of both incontinence severity
incontinence and prolapse procedures, hysterectomy and impact. Incontinence pad usage is often used as a guide to
constipation which can worsen voiding symptoms. incontinence severity. However, this can be deceptive as some
women will change pads frequently, even with minimal urine loss, for
Excluding other pathology
hygienic reasons. Standardised incontinence pad weight tests (used
Patients who have typical SUI and UUI should not have any of the in specialist practice) are a more objective measure of urine loss.
following features on history, examination or investigation: The impact of the symptoms on the patient, or
haematuria either macroscopic or persistent microscopic; bothersomeness, can be gauged by the lifestyle changes that
requires renal imaging to exclude tumours, calculi, and cystoscopy have been made to accommodate symptoms, and restriction
to exclude bladder pathology (eg. bladder cancer, calculi) in activities. Ask about: the need for incontinence pad use,
pain either suprapubic or dysuria suggests pelvic or other reducing or stopping activities such as social engagements and
urinary tract pathology rather than SUI or UUI playing sport, degree of disruption to day to day activities, and
recent or acute onset of symptoms the usual history is of a the emotional impact. Impact can also be assessed objectively
gradual onset by validated incontinence specific questionnaires such as the
obstructive symptoms (eg. straining to void, sensation of Urogenital Distress Inventory (UDI-6) and the Incontinence
incomplete bladder emptying) Impact Questionnaire (IIQ-7).5 The patients treatment goals and
recurrent UTIs preferences must also be determined.
114 Reprinted from Australian Family Physician Vol. 37, No. 3, March 2008
Urinary incontinence assessment in women: stress, urge or both? THEME
Physical examination Figure 1. Example of bladder diary showing polyuria driving urinary frequency
Abdominal and pelvic examination is mandatory in the assessment and leakage
of incontinence in women. Important physical examination features
are listed in Table 2.3,6
Basic investigations
All patients require urinalysis and urine culture if urinalysis
is abnormal. It is advisable to have an assessment of bladder
emptying with a postvoid residual volume (either with ultrasound
or catheterisation) which will essentially exclude overflow
incontinence.2,4,7 In clinical practice, a postvoid residual volume
of less than 50 mL is regarded as normal and in general, residual
volumes greater than 150200 mL are regarded as abnormal. In older
women, residual volumes up to 100 mL may be regarded as normal,
depending on the circumstances.2
Reprinted from Australian Family Physician Vol. 37, No. 3, March 2008 115
theme Urinary incontinence assessment in women: stress, urge or both?
conditions causing polyuria (eg. diabetes mellitus or insipidus, t o document severity/type of incontinence urodynamically
hypercalcaemia) need to be excluded (which can guide type of incontinence surgery offered)
frequent small volume voids with low urine output usually due to document voiding function
to deliberate patient restriction of fluid intake to try and control failed conservative management of urinary incontinence
urinary symptoms in complex patients who have:
nocturnal polyuria may be associated with aging, obstructive an unclear diagnosis
sleep apnoea, cardiac failure, excess evening fluid intake. mixed stress and urge symptoms
a history of previous urological or gynaecological surgery (for
Limitations of clinical assessment incontinence or prolapse)
Unfortunately despite strenuous efforts by both the clinician and failed surgery
patient, it may not be possible to come to a clinical diagnosis of neurological disorders.
the type of incontinence. This may be due to a combination of
Steps in a urodynamic study
factors including mixed symptoms, extremely severe incontinence,
reduced patient awareness of bladder symptoms and vague A urodynamic study is performed without sedation or the need for
history telling. fasting. The patient either stands, tilted upright on a tilt table or sits to
There is also significant overlap in the various symptoms and help reproduce urinary symptoms. Specialised computerised urodynamic
underlying conditions such that the same symptom can be produced equipment is required. Steps in the urodynamic procedure include:
by different mechanisms. It is for this reason that the bladder free flow rate patient passes urine into a commode which
is known as an unreliable witness. For example: a patient may measures urine flow and volume
describe urine loss with activity (suggestive of SUI) but the cause urodynamic catheters inserted into bladder and rectum to
of the leakage may actually be an uninhibited bladder contraction measure various pressures
(detrusor overactivity); a patient may lose urine from detrusor the bladder is filled at a fixed rate by the urethral catheter and
overactivity with minimal sensation of urgency of urination. bladder pressures are recorded simultaneously with patient reporting
Urodynamic studies are useful in patients such as these to better symptoms, eg. first sensation of filling (~150 mL), sensation of bladder
define bladder dysfunction, but are not required in all patients with fullness (~300 mL), urgent desire to urinate (~400600 mL)2,11
urinary incontinence. the patient coughs and strains during the procedure at fixed
bladder volumes to check for SUI
Urodynamic study
pressure flow studies while the patient urinates assess voiding
Urodynamic study is the gold standard test of bladder function. It gives function
information about bladder function in the same
way that an echocardiogram gives information Figure 2. Fluoroscopic urodynamic study showing measurement of voiding pressures and flow
about cardiac function. Urodynamic study can with simultaneous imaging of voiding
vary from simple cystometry (where bladder
pressures alone are measured) to complex
cystometry (performed by urologists and
urogynaecologists) where multiple pressures
within the urinary tract are recorded with
specialised electronic equipment, computer
analysis and imaging. Patient complexity
determines the degree of study complexity
required.
116 Reprinted from Australian Family Physician Vol. 37, No. 3, March 2008
Urinary incontinence assessment in women: stress, urge or both? THEME
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Figure 3. Patient undergoing fluroscopic urodynamic study on a tilt table
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The urodynamic study can be combined with an imaging modality
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The aim of the urodynamic study is to reproduce the patients urinary 15. Chapple CR, Wein AJ, Artibani W, et al. A critical review of diagnostic criteria
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bladder compliance the elasticity of the bladder wall
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bladder emptying. A clinical diagnosis of stress, urge or mixed
urinary incontinence can then usually be made and conservative
management instituted. Atypical features on history, examination or
investigation as well as failure to respond to conservative measures
or medical management should prompt specialist referral.
References
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correspondence afp@racgp.org.au
Reprinted from Australian Family Physician Vol. 37, No. 3, March 2008 117