Evaluating Urinary Incontinence - Urinary Incontinence: Bladder Conditions

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Evaluating urinary incontinence

Many people never tell a physician that they are incontinent, and that results in prolonged and largely needless suffering. In 70% of cases, incontinence can be cured or significantly improved — often by taking simple, inexpensive steps that do not involve medication or surgery. The treatment of incontinence has improved greatly and is changing all the time, so don't be reluctant to seek help now, even if previous attempts brought little relief.

Depending on the complexity of your symptoms, you may see your primary care physician or go to a specialist (see "Choosing a clinician"). If you are comfortable with your primary care physician, start there. If your symptoms seem to be connected with a specific medical event, such as childbirth, surgery, or starting a new prescription, the physician involved in that treatment might be your first choice. A woman might choose to see a urogynecologist — a gynecologist with special training and interest in incontinence. A man who has had prostate symptoms or treatment might choose to consult a urologist. Physicians vary widely in their training and interest in incontinence. If a physician seems uncomfortable or uninformed discussing the subject, presents limited options, or seems unduly pessimistic about your condition, seek another opinion.

To pinpoint and treat the underlying problem, your physician will need you to describe your symptoms in as much detail as possible. You may be asked to keep a diary of urinations and fluid intake for a few days (see "Keeping a bladder diary"). At your visit, be prepared to give a full medical history, including details on all surgeries, births, and any prescriptions you may be taking (see Table 1). You may also need to answer specific questions such as these:

• When did the incontinence start?

• How often do you have leakage?

• Is it worse during the day or night?

• What brings it on? Do you have any warning?

• What makes it worse?

• Does anything make it better?

• Do you generally leak a little (damp underwear), a moderate amount (your underwear is soaked), or a lot (your clothing gets soaked and all the urine in your bladder comes out)?

• Do you leak urine during intercourse or with orgasm?

• What is your typical fluid intake (including caffeinated and alcoholic beverages)?

• How often do you go to the toilet to empty your bladder during the daytime? How often when you are trying to sleep?

• Do you have other problems urinating? After you urinate, does your bladder still feel full? Do you have trouble starting the urine flow? Is the stream weak or strong? Is urination ever painful?

• Have you also had trouble controlling your bowel movements?

• What medications are you taking?

• Are you using pads or other means to manage your incontinence? How is it working? Have you altered your activities because of incontinence?

The physical exam

For this exam, your clinician places more focus on your nervous system, abdomen, and genital area than during a standard physical. The clinician uses a reflex hammer to check your reflexes, assesses your muscle strength, and observes whether you can distinguish the touch of something sharp from something dull. To test nerves in the genital area, the doctor may stroke the skin near your anus and watch for a normal muscle contraction. In women, the doctor gently taps the clitoris and looks for a subtle muscle contraction of the anus, which is a normal reflex.

None of these tests are painful or uncomfortable. If the doctor observes problems with any functions that rely on the same nerves controlling urinary continence, it may mean that these nerves are related to your bladder symptoms.

During the abdominal exam, the doctor presses on your abdomen to feel your bladder and check other areas for hernias, tenderness, or any signs of tumor, infection, scarring from previous surgeries, or an impacted bowel.

Both men and women provide a urine sample, which is checked immediately with a dipstick to detect blood, sugar, or large amounts of bacteria (normal urine is sterile). Blood may indicate irritation of the urinary tract. If there is such irritation, the cause must be determined. If sugar is detected, your physician may suspect diabetes, which can increase your urine volume and make incontinence more likely. Bacteria indicate possible infection. As a more specific test, a urine sample may be sent to a laboratory to be cultured; if harmful bacteria are detected, a sensitivity test can identify the appropriate antibiotic to treat the infection.

For women. During a thorough pelvic exam, the clinician inserts a gloved finger into the vagina to help assess the strength of the pelvic floor muscles and to see whether the bladder or uterus is prolapsed (dropped out of normal position). The clinician may ask you to contract your muscles as if you were trying to avoid urinating or passing gas or to cough during the exam to see if urine spurts out the urethra. The exam may be repeated while you are in a standing position.

With a speculum in place, the clinician observes whether the tissue lining your vagina shows atrophy or other signs that it lacks estrogen. That would indicate that your urethral lining (not visible during the exam) is likely to show a similar lack of this hormone. The doctor may insert a Q-tip coated with numbing jelly (such as Xylocaine) into your urethra just up into the bladder to observe how the angle of the Q-tip changes when you bear down as if trying to have a bowel movement. A large change indicates poor support of the urethra and points toward a diagnosis of stress incontinence.

The doctor may also look for direct evidence of stress incontinence. You may be asked to stand with one leg up on a stool, holding a paper towel over your crotch; if urine appears on the paper towel after you cough, that's a positive stress test. This test is usually performed at the beginning of your physical, when you have a full bladder. Afterward, you can urinate to increase your comfort during the rest of the exam.

Occasionally, if stress incontinence is suspected but is not observed during the exam, the clinician may give you a pre-weighed pad to wear while doing a series of exercises. The pad is then weighed again to determine how much leakage has occurred. You may also be sent home with a package of pads to wear and save in sealed plastic bags over a 24-hour period, so that total leakage can be estimated.

For men. The doctor examines your penis for signs of constriction of the foreskin or an abnormal narrowing, or stenosis, of the urethra, which can result from scarring or infection. The doctor conducts a digital rectal exam, which involves inserting a gloved finger into your rectum to feel the size and texture of the prostate gland and assess the strength of your pelvic muscles. You may be asked to contract your muscles as if you were trying to avoid urinating or passing gas.

Urodynamic studies

If your condition is not easily diagnosed by a physical exam and a discussion of your symptoms, or if the strategy your doctor recommends does not improve your incontinence, your doctor may suggest urodynamic testing. Urodynamic testing is the general name given for a series of specialized tests that allows the physician to evaluate your urinary system in action. It is available for both men and women.

The usefulness of urodynamic testing depends on the experience of the tester, the choice of tests, and the type of incontinence. For example, urodynamic tests are very sensitive in detecting stress incontinence, but asking a woman about her symptoms is almost as good, and is even more effective when supplemented with a bladder diary.

Urodynamic studies are costly, and for years, clinicians have debated when to use them. Some physicians routinely include them in the initial assessment of all patients. Most physicians suggest urodynamic testing when evaluating men and older women.

If you are a woman under age 60, your doctor may not recommend urodynamic testing if your symptoms, physical exam, and tests clearly indicate stress incontinence and no other type. Women in this group generally can be treated successfully without urodynamic testing. Urodynamic testing will likely be recommended if your symptoms point toward more than one type of incontinence, if you have had previous surgery on your bladder or sphincters, or if you do not improve after standard treatments.

Your urodynamic test may include one or more of the following:

Uroflowmetry. For this test, you start with a full bladder and urinate into a funnel at a special urinal or commode that automatically measures the amount you produce and the rate of the flow. A slow flow might indicate an obstruction in the urethra or a weak bladder muscle. This test is quick and noninvasive.

Post-void residual volume. This test measures the amount of urine left in your bladder after you urinate. Two techniques are used to measure this. The physician may insert a soft tube (called a catheter) through your urethra into the bladder to draw off the remaining fluid (which also provides an uncontaminated sample for urine culture and prepares you for further tests). Alternatively, the amount of urine in your bladder may be visualized using a specialized ultrasound machine called a bladder scanner. This is quicker and more comfortable, and it avoids the possibility that inserting a catheter could cause an infection or traumatize the lining of the urethra. However, it may be less accurate.

Measuring residual urine volume is particularly valuable if you are troubled by repeated urinary tract infections, have a neurological disorder, or if your doctor suspects that a blockage is preventing your bladder from emptying properly.

Cystometry. This test monitors how the pressure builds up in your bladder as it fills with urine, how much urine your bladder can hold, and at what point you feel the urge to urinate (see Figure 3).

Figure 3: Pressure test (Cystometry) For men or women, a cystometry test measures the pressure in the bladder, urethra, and the abdominal area. A catheter in the bladder fills the bladder with fluid and measures pressure in millimeters of mercury (mm Hg). A gauge monitors pressure in the vagina for women or the rectum for men. Cystometry can reveal urge incontinence due to detrusor instability, stress incontinence due to sphincter weakness, or damaged pelvic floor muscles and nerves.

After your bladder is emptied, a very narrow catheter is placed in your bladder to measure pressure. Through the catheter, the technician slowly refills your bladder with sterile water. The catheter measures the pressure inside your bladder; an additional small pressure monitor may also be inserted into your rectum (for men) or vaginal canal (for women). You tell the physician when you first feel the urge to urinate, when the urge becomes strong, and other sensations (pain, temperature changes, and the symptoms that brought you to the doctor).

This test detects abnormal contractions or spasms of your detrusor muscle during filling, indicating urge incontinence (either alone or along with stress incontinence). At several points during the filling, you may be asked to cough or bear down so the doctor can see whether fluid comes out the urethra. This measurement is sometimes called "leak point pressure."

A low leak point pressure is a sign of stress incontinence. If it is extremely low (you start to leak as soon as you begin bearing down), it may mean that age-related changes or scar tissue is preventing your urethra from closing well enough to prevent urine leakage, resulting in the type of stress incontinence called intrinsic sphincter deficiency.

Once your bladder is filled to the point where you have a strong urge, you can urinate, and the pressure and volume are measured. By monitoring pressure while you urinate, this test can distinguish whether a low flow is due to weak bladder contractions or something blocking the flow. Portions of the test may be repeated while you are in a standing position, which makes stress incontinence more apparent.

In women, urogynecologists often perform a "urethral pressure profile." The bladder/urethral catheter is drawn through the urethra very slowly, and the urethral pressure is measured. If your "maximum urethral closure pressure" is low, your urethral sphincter is weak, which causes stress incontinence.

Electromyography (EMG). In this test, small electrode patches are placed in the crotch area to pick up electrical current that is created when the pelvic floor muscles contract. Called a surface EMG, this test may help determine whether the activity of the bladder and urethra are coordinated with each other.

If your doctor suspects that the nerves to your urinary sphincter are seriously damaged, or that the sphincter muscle is responding inappropriately to nerve signals, he or she may insert a thin needle electrode into the muscle of the urethra to perform a more accurate EMG. Because most people find this painful, it is not done routinely and is often performed by a neurologist.

Cystography. A cystogram, or voiding cystourethrogram, is an x-ray test. The test itself is performed during cystometry or the uroflow test, or both, but a fluid visible on x-ray is substituted for the sterile water. At various points in the process, x-rays are taken as you cough or bear down and urinate. This test can pinpoint the location of a blockage or reveal an abnormally open urethra.

Video-urodynamic study. Using highly specialized equipment, this technique combines cystometry, uroflowmetry, and cystography into a single computerized test. This equipment can simultaneously measure urine flow and pressure in the bladder and rectum. The test may provide useful information about your bladder and urethral function, especially if you have problems voiding (such as being able to begin urinating only in a certain position). The equipment for video-urodynamic testing is expensive and not widely used.

Other evaluation procedures

Depending on your symptoms, other tests may be performed at the same visit as your urodynamic testing.

Cystoscopy. Using a lighted telescope at the end of a thin tube called a cystoscope, your doctor can inspect the inside of your urethra and bladder for signs of infection, abnormal growths, bladder stones, scarring, or improperly placed stitches from previous surgeries. This test is used in both men and women, but it is easier for women to undergo comfortably because the urethra is shorter.

For the test, you lie on your back. A numbing jelly is squirted into your urethra, and the cystoscope is inserted until the end is inside your bladder. Sterile water is passed through the thin tube to fill your bladder and optimize the picture. You may feel some discomfort and the need to urinate when your bladder is filled. After about three to five minutes, the cystoscope is removed, and you can use the restroom.

Ultrasound. Ultrasound uses sound waves rather than x-rays to create an image of internal organs. You may undergo an abdominal or transvaginal ultrasound exam to look at the structure and position of your kidneys, bladder, and prostate; to visualize leakage in stress incontinence; to detect abnormalities such as tumors, kidney stones, or fibroids; or to evaluate treatment with bulking agents. An ultrasound exam takes about half an hour and is painless.

Intravenous pyelogram or urogram. This test creates a picture of your kidneys and ureters. A dye is injected into your bloodstream through your arm. The dye is excreted through the kidneys and collects in urine, allowing an x-ray to reveal the structure of the kidneys and ureters and any areas where fluid may be escaping or blocked.

Last updated:	September 05, 2008