Patient histories regarding frequency and severity of urinary symptoms are often inaccurate. A more reliable indicator of symptoms is a fluid intake/voiding diary, which should be distributed to patients.
They would be instructed to document in it the amount and type of fluid consumed and the volume and time of voiding and leakage and to note events associated with each incontinence episode.
Physical Examination
A complete physical examination is essential, and special emphasis should be given to the abdominal, pelvic, genital, and neurological examinations.
- Abdomen: Inspect the abdomen for surgical scars and obesity and palpate for any abdominal or retroperitoneal masses or bladder distension.
- Genitals: Inspect the external genitalia for any abnormalities (e.g., Bartholin’s cyst, condyloma, adhesion, and scar formation) and for atrophy of the vaginal epithelium, specifically shiny cell wall or loss of rugae. In addition, inspect for periurethral and urethral lesions (e.g., mucosal prolapse, carbuncle, condyloma, Skein’s abscess, or stenosis). Palpate for scarring, fibrosis, or tenderness, suggesting urethritis or urethral diverticulum. And, with the patient placed in the lithotomy position, measure urethral hypermobility by placing a Q-tip in the urethra to the level of the bladder neck. The patient should be asked to cough and strain. A deflection of the Q-tip greater than 30° suggests significant urethral hypermobility. Conversely, the absence of a hypermobile urethra based on the Q-tip test suggests intrinsic sphincteric deficiency. Determine postvoid residual urine by bladder ultrasound or straight catheterization. Inspect the anterior, posterior, and apical aspects of the vaginal vault with the posterior blade of a Grave’s speculum. With the patient at rest and after she strains, palpate the pelvic floor muscles. Finally, ascertain the various components of prolapse (e.g., cystocele, rectocele, enterocele, or uterine prolapse).
- Neurological examination: Examine the general neurological status, perineum, and lower extremities for the presence of tremor, loss of cognitive function, weakness, or gait abnormality. Examine the back for asymmetry of bone contours, for skin dimples or scar. Evaluate the S2-S4 nerve roots by the bulbocavernosus reflex (contraction of the external anal sphincter when pressure is applied to the clitoris). Evaluate lower extremities by testing typical sensory patterns and evaluate deep-tendon and primitive reflexes that may bear anatomic and etiologic significance. A stocking pattern of sensory loss may be indicative of metabolic neuropathies such as diabetes or alcoholism. The Babinski sign (primitive reflex) and ankle clonus suggest suprasacral cord lesions. Deep tendon reflexes of the quadriceps (L4) and Achilles tendon (S1) can demonstrate segmental spinal cord function as well as suprasegmental function.
- Provocation test/simple cystometrogram: A sterile catheter is inserted in the patient’s bladder, residual urine is collected, and then a 50-cc syringe without its piston is attached to the catheter and held above the bladder level. The patient is then asked to sit or stand, and the bladder is filled with 50-cc aliquots of sterile water from the syringe. Patient’s first sensation and maximum capacity are noted. The column of water in the syringe is observed for any rise that can be caused detrusor overactivity.
The catheter is then removed and the patient is asked to cough in various positions (supine, sitting, or standing). Loss of urine in spurts associated with the coughs suggests the diagnosis of SUI.
Laboratory Tests
- Urinalysis is performed to exclude hematuria, pyuria, bacteriuria, glycosuria, and proteinuria.
- A urine culture is obtained for evidence of bacteriuria or pyuria.
- Urine cytology is indicated to screen for bladder cancer if there is evidence of hematuria (2-5 red blood cells per high-power field) and frequency or urgency.
- Serum urea nitrogen (BUN) and serum creatinine level determinations are indicated in patients with a history or findings of severe voiding dysfunction. Furthermore, excess fluid intake may be reflected in an abnormally low serum urea nitrogen level.
- Vaginal swabs are used for culturing ureaplasma and chlamydia.
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Adonis Hijaz, MD and Firouz Daneshgari, MD
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REFERENCES
- Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. Second International Consultation on Incontinence, 2nd ed., Plymbridge Distributors, Plymouth, UK, 2002.
- Agency for Health Care Policy and Research. Urinary Incontinence Clinical Practice Guidelines, US Department of Health and Human Services, Agency for Health Care Policy and Research, Washington, DC, 1996.
- Weidner AC, Myers ER, Visco AG, Cundiff GW, Bump RC. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol 2001;184:20-26.
- Weber AM, Taylor RJ, Wei JT, Lemack G, Piedmonte MR, Walters MD. The cost-effectiveness of preoperative testing (basic office assessment vs urodynamics) for stress urinary incontinence in women. BJU Int 2002;89:356-363.
