Approach to urinary incontinence (GYN): Clinical sciences

Urinary incontinence refers to the involuntary leakage of urine. This is a common problem that impacts both physical and psychological well-being. Often, patients do not disclose symptoms of urinary incontinence due to feelings of embarrassment, but these symptoms can adversely impact daily activities and diminish quality of life. Underlying causes of incontinence include pregnancy, childbirth, urinary tract infections, changes to the pelvic floor, or bladder dysfunction. It’s also associated with medical conditions such as diabetes or certain neurologic disorders, as well as physical immobility, or cognitive impairment. There are several categories of urinary incontinence including stress, urgency, mixed, overflow, and functional urinary incontinence.

When a patient presents with a chief concern suggesting urinary incontinence, the first step is to perform a focused history and physical examination and obtain an hCG to assess for pregnancy. If the hCG is positive you have a diagnosis. Urinary incontinence is common in pregnancy, mostly during the second and third trimesters due to increased pressure on the bladder and pelvic floor. Also, pregnant patients are at increased risk for asymptomatic bacteriuria and urinary tract infections, which can cause urinary leakage.

After assessing for pregnancy, the next step is to assess for a urinary tract infection by obtaining a urinalysis. Now, it might come back positive for nitrites and leukocyte esterase, and possibly heme or blood. In this case, the patient will likely report an acute onset of incontinence. They may also report associated symptoms of dysuria, urinary frequency or urgency, and gross hematuria. The physical examination might reveal suprapubic tenderness. So, consider a lower urinary tract infection and send the urine for culture. If the culture is positive, you have made your diagnosis of a lower urinary tract infection.

Here is a clinical pearl! If urinary leakage persists after successful treatment of a urinary tract infection, evaluate the patient for other types of urinary incontinence.

On the other hand, if the urinalysis is negative for nitrites, leukocyte esterase, and heme or blood; assess for common causes of urinary incontinence.

Let’s start with stress urinary incontinence. The patient will report loss of urine with physical exertion, sneezing, or coughing. They may have risk factors for stress incontinence including previous pregnancy, constipation, or obesity. The physical examination may demonstrate pelvic organ prolapse, such as a cystocele; or pelvic muscle weakness. In this case, consider stress urinary incontinence and perform a cough stress test, post void residual or PVR, and test for urethral hypermobility.

Let’s take a moment to discuss these tests. A cough stress test is simply the observation of the leaking of urine from the urethra when the patient coughs. It can be performed while the patient is supine or standing and may require a full bladder. A PVR involves the measurement of residual urine in the bladder after the patient voids. This can be done with bladder ultrasonography or catheterization. A normal PVR is generally considered to be less than 150 milliliters. Finally, a test for urethral hypermobility is performed by measuring the displacement of the angle of the urethra-bladder neck from the horizontal position when the patient performs a Valsalva maneuver. In the past, this was done by placing a cotton-tipped swab into the urethra, known as a Q-tip test; but actually the cotton-tipped swab is not necessary, and it may also be uncomfortable for the patient. Instead, the measurement can be made by direct visualization or palpation.

Urethral hypermobility is present if the angle is greater than 30 degrees from the horizontal.

Now, if there is leaking of urine with the cough stress test, a normal PVR, and possible evidence of urethral hypermobility, the testing supports the diagnosis of stress urinary incontinence.

Here’s another clinical pearl! Often, a simple office evaluation is sufficient to make the diagnosis of urinary incontinence. A voiding diary or a validated urinary incontinence questionnaire are useful tools to confirm your findings. Additionally, complex urodynamic testing and cystourethroscopy are helpful if the diagnosis is unclear, a treatment plan is not successful, or a preoperative evaluation is needed.