Diagnostic Tests for Urinary Incontinence
Frederick R. Jelovsek MD
What can a woman who is having urinary leakage with urgency or cough or stress expect when she goes to the doctor's office? The basic diagnostic evaluation needed for urinary incontinence must determine whether or not the loss of urine falls into one of several categories:
- stress incontinence - produced by any intraabdominal straining such as coughing or straining
- urge incontinence - leakage caused by the bladder detrusor muscle contracting involuntarily or causing a very small bladder capacity
- mixed incontinence - a combination of the above two types
- overflow incontinence - in which the bladder is distended and has somewhat lost sensation of fullness so that when it just gets overfilled, the bladder muscle contracts on its own.
- other types such as a fistula (hole) in the bladder or the ureter tubes coming into the bladder, or spinal cord or brain problems affecting the bladder nerves.
There have been published guidelines for the basic work-up of this urinary loss by the Agency for Health Care Planning and Research (AHCRP) but studies have shown that work-up developed by experts may misclassify incontinence by as much as 30%. A recent quarterly report, Vol. XVIII, No 2, 1999, from the American Urogynecologic Society by Steven Swift MD, Basic evaluation of the incontinent female presents us with the answers to several questions about this subject.
Questions For Your Doctor
Can I tell from my symptoms, i.e., when and how I lose urine, what type of incontinence I have?
Symptoms can give a hint as to what type of incontinence is present but overall, symptoms are not accurate enough to make the diagnosis alone. Questions the doctor will ask are included below:
|Diagnostic category||Questions the doctor may ask|
|stress||Do you lose urine when you cough, sneeze. or laugh suddenly?|
|stress||Do you lose urine when you stand up, sit down or bend over?|
|type III stress (intrinsic urethral insufficiency)||Do you have almost continuous loss with any little movement?|
|urge/ type III stress||Is there a history of radiation treatment to pelvis?|
|urge||Do you get the urge to void and not get to the bathroom in time?|
|urge||Do you have a history of neurological diseases/trauma/strokes?|
|urge or overflow||Do you lose urine suddenly without any warning or straining?|
|obstruction/ detrusor-sphincter dyssynergia||Do you have difficulty voiding?|
|overflow||Do you wet the bed at night and are unaware of it?|
|overflow/continuous||Do you have a history of previous surgery on urethra/bladder?|
|overflow / obstruction||Do you fail to empty your bladder completely?|
|continuous||Do you stay wet all the time without any urge to void?|
|*indicates cystoscopy needed||Do you have frequent (>3 per year) urinary tract infections?|
|*indicates cystoscopy needed||Do you have blood in your urine?|
|*indicates cystoscopy needed||Do you have pain when you void?|
|*indicates cystoscopy needed||Do you urinate very frequently (>14 per 24 hours)?|
|* indicates there may be a mechanical, irritative disease in the bladder causing incontinence|
What are some of the risk factors for developing urine leakage?
Certain medications can cause incontinence such as alpha-adrenergic blockers used for hypertension. Examples would be:
- prazosin (Minipress®, Minizide®)
- terazosin (Hytrin®)
- doxazosin (Cardura®)
Diuretics do not cause incontinence but they certainly can worsen it just as too much caffeine or too many fluids each day can aggravate symptoms. Smooth muscle relaxants such as Valium®, Klonopin®, and Xanex® also can worsen urinary leakage by relaxing the external urethral sphincter.
Other risk factors for incontinence include cigarette smoking, constipation, obesity, and strenuous physical activity. Most women who have stress incontinence have undergone vaginal childbirth But childbirth does not always lead to incontinence in later life.
What does the doctor check for on examination?
The general physical exam looks for any evidence of heart failure because when excess fluid in the legs is mobilized at night or lying down, this volume of fluid can contribute to nighttime voiding and urgency. A focused exam of the nerves is done, especially if there is any history or neurological injury, trauma or stroke.
On pelvic exam, the doctor will ask you to cough with a fairly full bladder to see if leaking is observed. While this may be embarrassing for you, it is a necessary test and the doctor is used to having urine leak and spray. The pelvic exam is done to check for associated relaxation of the anterior vaginal bladder wall (cystocoele), the posterior vaginal rectal wall (rectocoele) , the sides of the vagina (paravaginal defect), and the end of the vagina (prolapse or enterocoele). After that, the doctor may put a Q-tip (cotton tipped applicator) in the urethra using a little xylocaine gel to numb it. Then you will be asked to strain down to see if the tip of it moves up by more than 30 degrees. If it does, this may indicate the bladder neck drops down with straining and this may contribute to losing urine with straining and be treatable with surgery.
Will I have to have a catheter put in my bladder?
Yes you may. There are several reasons a catheter may be used. One is to get a sample of urine for culture. This is especially needed if you have a history of frequent urinary tract infections. It is commonly done after you have been asked to void to see if you are able to completely empty the bladder. Also, at the time of your office exam or perhaps at a later visit, a catheter may be used to put fluid in the bladder and measure the bladder pressure during a cystometrogram. This is needed to make sure you are not having "bladder spasms" or uninhibited bladder detrusor contractions. If you do have them, that may explain urgency symptoms of having to void frequently. Finally a cystoscopy may need to be done if you are having any symptoms suggestive of infection, stones, or interstitial cystitis. The cystoscopy is like a catheter being put in the bladder except a cystoscope is used to look inside. The cystoscope is about the same size as a catheter.
What tests other than the physical and pelvic exam will I need to have?
The doctor may ask you to fill out a voiding calendar to record how much you drink and how often and how much urine is lost. This can tell the severity of your leakage and also if you are drinking too much or too little fluids. Finally, the doctor may want you to have complex urodynamic studies in which the bladder, the urethral muscles and the capacity and sensation of the bladder are measured using a catheter and pressure transducer placed into the bladder. These studies are sometimes done routinely, but they are especially needed if you have any history of spinal cord or neurological problems, very frequent urgency symptoms, loss of urine with just minimal movement or exertion, or a past history of bladder repair surgery that is now not successful.
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