Evaluation of urinary incontinence

History 

It’s very important to ask about the following in the history 

1. Type of incontinence (SUI, UUI, MUI)
2. LUTS (storage or voiding) 
3. Triggers (cough, sneezing, exercise, position, urgency) 
4. Frequency of incontinence episodes 
5. Severity of incontinence (usually assessed with no of pads)
6. Degree of bother 
7. Bowel function
8. Sexual dysfunction 
9. POP in women
10. Validated questionnaire (ICIQ-UI short form)
11. RED FLAG symptoms
    
    (PAIN, HAEMATURIA, RECURRENT UTI, VOIDING SYMPTOMS, HX OF PELVIC SURGERY OR RADIOTHERAPY) 
12. Risk factors: 

• Abdominal/pelvic surgery (RED FLAG)
• Rx (RED FLAG) 
• Neurological disorders
• Obsteteric and gynaecology history
• Medications (alpha blockers/agonists, diuretics, colchicine, caffeine, sedatives, antidepressants, antipsychotics, and antihistamines)

Physical examination: 

Women

• Pelvic examination (Supine, Standing, LL position w Sim’s speculum)
• Ask to cough and inspect for 
• Anterior and posterior vaginal wall prolapse
• Uterine or vaginal vault descent
• Urinary leakage (stress test)
• Internal pelvic examination to assess 
• Strenght of pelvic floor muscle 
• Bladder neck mobility
• Inspect vulva for oestrogen deficiency
• Calculate BMI

Both sexes 

• Examine abdomen (palpable bladder)
• Neurological examination (gait, anal reflex, perineal sensation, lower limb funciton)
• DRE to exclude 
• Constipation
• Rectal mass
• Test anal tone 
• RED FLAG SIGNS
  
  (NEW NEUROLOGICAL DEFICIT, HAEMATURIA, URETHRAL, BLADDER OR PELVIC MASSES, AND SUSPECTED FISTULA).  

Basic investigations

• Bladder diaries 
• Fluid intake 
• Frequency and volume of urine voided 
• Incontinent episodes
• Pad usage
• Degree of urgency 
• Urinalysis and culture 
• Flow rate and post-void residual (PVR) volume
• 150 ml for accurate result
• PVR Less than 50 normal more than 200 abnormal, 50-200 requires clinical correlation)  
• Pad testing 
• Performed with a full bladder 
• Pad weight gain more than 1 g is + for 1h test 
• Pad weight gain more than 4 g is + for 24h test 

Further investigations

• Blood tests, imaging (USS) and cystoscopy: indicated for
• Complicated cases with persistent or severe symptoms
• Haematuria 
• Bladder pain
• Voiding difficulties
• Recuurent UTIs
• Abnormal neurology
• Previous pelvic surgery
• Previous Rx 
• Suspected extraurethral incontinence 
• Urodynamics 
• In SUI distinguishes between 
• Hypermobility ALPP > 90-100 cmH2O
• ISD ALPP < 60 cmH2O
• Detects DO contractions during filling or abnormal pressure rise with position change 
• Detects poor bladder compliance 
• Ambulatory urodynamics: more physiological 
• Videourodynamics: 
• movement of proximal urethra and bladder neck with filling or provocation, also DSD, VUR) 
• Sphincter EMG: 
• provides information on synchronization between the detrusor and EUS.