Basic Evaluation of Urinary Incontinence - BINASSS
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CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 64, Number 2, 276–286
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Basic Evaluation of
Urinary Incontinence
FAREESA RAZA-KHAN, MD
Female Pelvic Medicine and Reconstructive Surgery,
Rush University Medical Center, Chicago, Illinois
Abstract: Urinary incontinence is a significant, quality varies widely by study with rates in older
of life health condition affecting millions of women. women ranging from 17% to 55%. Wom-
Incontinence is increasingly common as the popula-
tion ages, and women present with varying degrees of en are twice as likely as men to experience
bother. With basic in-office evaluation, most subtypes UI.2 Population based studies estimate
of urinary incontinence can be defined, evaluated, and the prevalence of UI to be 25% and
treated. Basic in-office evaluation involves a detailed increases with age.3 Within the US, the
history with a review of current medical problems and prevalence of moderate to severe UI was
medications, a physical examination, and selective in-
office testing. found to be 15.7%.4
Key words: urinary incontinence, quality of life, in- While the reported prevalence of UI is
office basic evaluation, overactive bladder, stress high, it is often misperceived as a normal
incontinence, mixed incontinence and inevitable consequence of childbirth
and aging. This common misconception
Urinary incontinence (UI) is a common, leads to underreporting and failure to
expensive, and highly bothersome medi- seek treatment. In addition, health care
cal condition. Proper understanding, providers with increasing time constraints
evaluation, and management of inconti- may not fully explore the subject with
nence is necessary as prevalence increases their patients. As women age and self-care
with the aging population. It is estimated becomes more difficult, many resort to
that the number of people aged 65 and management methods which can be em-
over will increase from 39 million in 2010 barrassing, costly and socially isolating.
to 69 million by 2030. Furthermore, the Direct costs alone for UI were already
age group over 85 will be the fastest estimated at 16.3 billion dollars per year
growing with a projected 18.2 million by over 20 years ago. Not surprisingly, the
2050. And finally, census reports estimate cost of UI is estimated to have increased
that by 2030, 1/5 of all women will be over 250% from 1984 to 1995.5 A 2010 review
the age of 65.1 The prevalence of UI of the economic impact of this growth
projected the direct annual cost of iso-
Correspondence: Fareesa Raza-Khan, MD, Female lated urge UI for adults over the age of 25
Pelvic Medicine and Reconstructive Surgery, Rush to reach $82.6 billion (about $250 per
University Medical Center, 1653 West Congress Park-
way, Kellogg 230A, Chicago, IL. E-mail: fareesa_khan person in the United States) by 2020.6
@rush.edu UI as defined by the Internati-
F.R.-K.: Guidepoint Global LLC. onal Continence Society-International
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 64 / NUMBER 2 / JUNE 2021
276 | www.clinicalobgyn.com
Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.Basic Evaluation of Urinary Incontinence 277
Urogynecological Association is the com- leakage, is the least common subtype of
plaint of any involuntary loss of urine and UI. In a national telephone survey with
is subclassified into 3 main groups: stress follow up, nested controls, the NOBLE
urinary incontinence (SUI), urgency uri- study found that nearly 17% of women
nary incontinence (UUI), and mixed experienced symptoms of urgency, fre-
urinary incontinence (MUI). SUI is the quency, urge leakage, and nocturia. This
complaint of involuntary leakage on study highlights that while not all women
effort or exertion or on sneezing or will leak urine, there are other bother-
coughing. UUI is the complaint of invol- some symptoms of overactive bladder
untary leakage accompanied by or imme- (OAB) that should be addressed as they
diately preceded by urgency. Finally, can still affect quality of life. Symptoms of
MUI, a combination of SUI and UUI, OAB increased with age with a 9-fold
is the complaint of involuntary leakage increase in symptoms between the ages of
associated with urgency and with effort, 18 to 24 and 65 to 74 years.10
exertion, sneezing and coughing.7 Other As physicians increasingly encounter
less common types of UI include contin- patients with UI in their office practices,
uous incontinence because of anatomic the basic evaluation of UI becomes para-
variants such as an ectopic ureter or mount in obtaining a correct diagnosis to
genitourinary (GU) fistulas, postural in- be able to create a safe and effective
continence, insensible incontinence, and treatment plan. The evaluation needs to
overflow incontinence. In the absence of be accurate, cost effective, efficient, and
anatomic problems, a vast majority of evidence based, and in most cases, this
cases can ultimately be classified as SUI, can be accomplished within the first 1 to 2
UUI, or MUI. patient encounters. For example, low-risk
In the Norwegian EPINCONT study, empiric treatment such as behavioral
nearly 28,000 women between 1995 and modifications can be initiated immedi-
1997 responded to a survey regarding the ately, even before the full evaluation is
prevalence of urinary tract infection completed, minimizing time to symptoms
(UTI). This large epidemiologic study improvement. This approach is particu-
sampled community-dwelling women larly well suited for virtual visits. In some
and obtained subjective outcome meas- cases, multiple treatments can be offered
ures only. Stress incontinence was found concurrently to achieve patient goals in
to be the most common urinary subtype, efficiently. Practicing value-based medi-
affecting 50% of respondants.3 Risk fac- cine is increasingly important as payors
tors for SUI include Caucasian race and will be less likely to agree to costly,
obesity.8 Stress incontinence commonly unnecessary work ups. Close follow up
affects women between the ages of 25 and of patients that have initiated treatment
49 and then decreases with age. Mixed UI allows the clinician to evaluate efficacy,
is the second most common subtype compliance, side effects, and ultimate
occurring in 20% to 36% of women.3 success of treatment. Response to initial
Mixed UI poses the greatest challenge to treatment can inform next steps in the
classification and treatment. Likely be- management of symptoms.
cause they are affected by both SUI and In this review, we address the basic
UUI, women with mixed symptoms re- evidence based, in-office evaluation of
port more severe UI, more bother and UI. It is organized into history, physical
worsened quality of life because of the exam, basic and advanced testing
UI.9 The mechanism for this is unclear. and details the different components
Urgency incontinence, with urgency, fre- essential to the diagnosis and treatment
quency, nocturia, and urgency-related of UI.
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.278 Raza-Khan
History degree of bother related to leakage during
Taking a thorough history can begin even different day-to-day activities (ie, shop-
before the patient’s first office visit. Using ping, entertainment) and the effect of UI
symptom-based questionnaires, patients on feelings (ie, fear, anger, frustration).
can consider their symptoms in depth The IIQ uses a Likert scale from 0 (no
before presentation. The in-office history impact at all) to 3 (exerts a great impact).
further explores symptoms, so the diag- The instruments have been shown to be
nosis of UI and subtype classification reliable, valid, and sensitive to change.12
takes shape. This initial impression is These questionnaires are commonly ad-
further refined by analyzing past medical, ministered in short forms, which have
surgical history, medications, allergies, been validated against their full-length
and social history. The diagnosis of UI versions, and are available online without
begins with a thorough understanding of a fee. Several other validated question-
the patient’s symptoms, which may naires including the Medical, Epidemio-
be difficult to obtain as the topic can be logical and Social Aspects of Aging
embarrassing for patients to describe. (MESA) questionnaire are commonly
Younger women of childbearing age utilized in research and clinical practice
may not be forthcoming with symptoms as well.
of UI, believing them to be a normal While questionnaires have been found
consequence of childbirth. Similarly, the useful in identifying symptomatic patients
older woman may consider it a normal and degree of bother, the actual correla-
part of aging and have other competing tion with the subtype of UI is not exact.
medical issues that concern her. The goal In a study looking at the sensitivity and
of the history is not be limited to eliciting specificity of a basic instrument, the 3
the symptoms of UI but also, if present, incontinence questions, a tool for primary
the severity, degree of bother, and type care providers, the sensitivity for finding
of UI. UUI was 75% and SUI 86% meaning that
Symptom questionnaires are a simple, 14% to 25% of women with a particular
comprehensive, and time-saving method subtype of UI were missed. The specificity
to determine the presence of UI and delve for UUI was 77% and 60% for SUI
into the specifics of degree, bother, and meaning that between 23% and 40% of
subtype. Many validated symptom ques- women could be inappropriately treated
tionnaires are available and can be com- for the wrong condition.13 This illustrates
pleted by patients before their visits that the utility of questionnaires lies
through online portals allowing patients mostly in determining if the symptoms
to consider their symptoms thoughtfully of UI are present and the degree to which
and private, without feeling rushed. One patients are bothered by their symptoms.
widely accepted instrument is the urogen- Questionnaires are not exhaustive, and
ital distress inventory, often administered further evaluation as described below are
in conjunction with the Incontinence necessary to diagnose UI subtypes accu-
Impact Questionnaire (IIQ). It is designed rately.
to identify the presence and degree of The patient interview provides details
bother from UI.11 Using a scale of 0 (no of the history of present illness such as
bother) to 4 (greatly bothered), the uro- onset, timing, duration of symptoms,
genital distress inventory originally con- severity, precipitating or alleviating fac-
tained 28 questions and assessed urgency, tors, associated pelvic floor symptoms,
frequency, leakage, pain, obstructive, and contributions of medical and sur-
irritative symptoms. The IIQ, originally gical events as well as medications, and
consisting of 30 items, addressed the prior treatments attempted. Furthermore,
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.Basic Evaluation of Urinary Incontinence 279
information on pad use, impact of UI on sphincteric deficiency. Careful assessment
sexual function, and lifestyle limitations of symptoms will help differentiate
around UI can further indicate degree of between these diagnoses.
bother. Inquiry about an inciting event Duration of symptoms and symptom
that may have prompted the patient to severity also help in determining the cause
come in can further determine motivation of UI and the length of time likely needed
for intervention. to address and manage the UI. If the
The presentation of patient symptoms duration of symptoms is short, that is,
themselves often guide the workup of UI. < 1 month, consideration of recent life-
For example, acute symptom onset, that style changes, increase in fluid intake, or
is, over a period of days to weeks, is infection are helpful. If the duration of
commonly seen in women after acute symptoms is longer term, then prior treat-
UTI. If UTI has been ruled out, the ments and the progression of disease
presence of acute onset of OAB symp- becomes important. If symptoms are not
toms in younger women should cause severe or bothersome, then no further
suspicion for neurological conditions, evaluation or workup may be needed.
some of which require immediate evalua- Often, simple reassurance is enough in
tion such as cauda equina syndrome, and these instances. Evaluating for fluid
some which may require a more involved intake, bladder irritants, new exercise
workup, such as multiple sclerosis. In routines, loss of mobility, and cognitive
both cases, urological symptoms can be decline are all important in determin-
presenting symptoms for previously un- ing the etiology of a patient’s urinary
diagnosed neurological conditions. Two incontinence.
to 2.5% of women with multiple sclerosis While UI can be bothersome in and of
present initially with bladder symptoms.14 itself, it is well known that pelvic floor
Characterizing the timing of UI can disorders will co-exist in women. In a
distinguish between incontinence because cross-sectional analysis of 196, nonpreg-
of bladder versus nonbladder pathology. nant women ( ≥ 20 y) who participated in
For example, nocturnal leakage can rep- the 2005 to 2006 National Health and
resent a primary sleep disorder. Nocturia Nutrition Examination Survey, Nygaard
is the sudden strong urge to urinate that et al4 estimated that 23.7% of women had
awakens a person from sleep. It is often one or more pelvic floor disorders. Eighty
accompanied by leakage with the inability percent of women with stress or urge UI
to make it to the bathroom on time. This also report another pelvic floor symptom
should be distinguished from patients such as pelvic organ prolapse (POP),
who wake because of poor sleep and then voiding dysfunction, abdominal/pelvic
decide to use the bathroom before falling pain, or bowel dysfunction.15 An assess-
back to sleep, which is not a primary ment of concomitant pelvic floor disor-
bladder problem but a sleep-related ders is imperative in the UI workup as a
disorder. Sleep apnea can also cause comprehensive history can improve the
disruptive nighttime voiding and exces- provider’s understanding of the etiology
sive nighttime urine production. Release and treatment options for UI. For exam-
of atrial natriuretic peptide with obstruc- ple, constipation can worsen UI, so man-
tive sleep apnea leads to nocturnal polyu- aging constipation may be an effective
ria. Other common nighttime bladder initial step in managing UI in women with
disturbances include nocturnal enuresis, constipation. Women who present with
urinary dysfunction related to substance progressively worsening vaginal prolapse
use, nocturnal polyuria related to may report that urination becomes pro-
metabolic disturbances, and intrinsic gressively more difficult as the day goes
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.280 Raza-Khan
on, coinciding with descent of prolapse, SUI symptoms but may not completely
or a history of splinting the prolapse to ameliorate all incontinence symptoms.
release residual urine or even initiate urine Despite many patients undergoing SUI
flow. Others may reports a history of procedures reporting improvement in
stress incontinence which improved as urge symptoms, some report no improve-
the prolapse worsened because of pro- ment or worsening of urgency inconti-
gressively worsening obstruction. In these nence. Some of these women feel that
cases, while the patient may not report their surgical procedures failed and re-
current stress incontinence at the time of quire counseling that their stress incon-
evaluation, treatment of the prolapse tinence has been successfully treated, but
without addressing urinary function can their urgency incontinence remains un-
(much to the dismay of the patient and treated. Prior prolapse surgery without a
her provider) unmask occult SUI. concomitant stress incontinence proce-
A careful review of the patient’s past dure may lead to occult SUI postoper-
medical history also can be revealing. For atively. Also, prior prolapse surgery in the
example, in women with allergies or anterior compartment can cause disrup-
asthma, the worsening of a patient’s SUI tion of the nerve supply to the bladder
symptoms may correlated with exacerba- leading to both stress and urge inconti-
tions of these problems during certain nence. Finally, dissection or use of
times of the year. Women with chronic exogenous materials in the anterior com-
obstructive pulmonary disease may devel- partment for prolapse repair may affect
op a persistent cough, which can lead to the surgical approach for subsequent in-
SUI symptoms. Congestive heart failure continence surgeries.
can alter fluid return to the heart and Review of a patient’s medications will
kidneys, increasing fluid excretion at commonly reveal agents that affect lower
night, when the patient is recumbent,
causing nocturnal polyuria. A history of TABLE 1. Risk Factors for Urinary
Parkinson disease, multiple sclerosis, Incontinence
stroke or other neurological conditions Endocrine/increased Diabetes
could lead to neurologically mediated fluid production Obesity
bladder dysfunction. Risk factors for the Fluid overload
development of UI are listed in Table 1. Excessive fluid intake
Pregnancy/delivery
Past surgical history of both GU and Congestive heart failure
non-GU procedures also can shed light on Infection Urethritis
the workup of UI. Orthopedic surgery Urinary tract infection
such as lower extremity joint replacement Neurological Multiple sclerosis
can lead to pelvic floor muscle dysfunc- Cerebro-vascular accident
Parkinson
tion, which can worsen UI. Neurosurgical Delirium
interventions also can improve or worsen Gastrointestinal Constipation
symptoms of UI and urinary retention. Stool impaction
Prior GU surgical interventions that re- Iatrogenic Medications
quire may impact the success of future Prior pelvic surgeries
Prior radiation therapy
SUI procedures. For example, in women Gynecological Atrophic vaginitis
with recurrent SUI after synthetic mesh Pelvic organ prolapse
midurethral slings, prior mesh procedures Urologic Urethral diverticulum
may affect the success rates of future Ectopic ureter
procedures or impact the selection of a Urinary retention
Musculoskeletal Impaired or restricted
specific sling device in the future.16 In mobility
addition, treatment of SUI may resolve
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.Basic Evaluation of Urinary Incontinence 281
urinary tract function. Diuretics and al- bladder diary (https://journals.lww.com/
pha-adrenergic drugs can cause or worsen fpmrs/Fulltext/2015/11000/Urinary_
urinary urgency, frequency, and inconti- Incontinence_in_Women.3.aspx) (Fig. 1).
nence. Anticholinergics, antihistamines, If the patient cannot complete the diary
psychotropic drugs, alpha-adrenergic ago- herself, a caregiver may be able to pro-
nists, and calcium channel blockers can duce a log of intake and pad counts.
cause a variety of symptoms including Bladder diaries can be requested before
retention, sedation, and constipation, the initial visit or after the initial visit
which can worsen UI. Some of these when insufficient or inconclusive infor-
medications can be eliminated, or their mation has been obtained. Voiding or
doses or scheduling can be modified to bladder diaries provide a longer-term
minimize urinary effects. Diuretics and snapshot of symptoms. Typical diaries
other medications affecting the cardiovas- span 3 to 5 days, and their accuracy tends
cular system require consultation with the to diminish with duration. Information
patient’s prescribing providers before al- gathered includes frequency and quantity
terations are made. of voids, frequency and severity of leak-
Several patient factors can cause barriers age and urgency episodes, events sur-
to the patient-provider interaction and af- rounding leakage episodes, and timing
fect diagnosis and treatment of UI. Cogni- and amount of fluid intake. With a simple
tive decline is particularly common in the diary, various bladder measures can be
aging patient with UI, who may be con- quantified and analyzed such as average
fused about the events surrounding her bladder capacity, maximum functional
leakage, prior treatments for UI, or even bladder capacity, approximate daily fluid
current medications. Polypharmacy, com- intake and output, nocturnal urine out-
mon in the elderly, often causes confusion put, nocturia, stress incontinence episodes
regarding prior and current treatments for and urgency incontinence episodes. Noc-
UI or side effects of other medications on turnal polyuria is defined by a nightly
the bladder. Patients who are not function- output that is ≥ 33% of the patient’s total
ing independently may come to their visits 24-hour output. Diaries can also help
with caregivers, who can provide varying distinguish between wet and dry OAB.
degrees of detail about the patient’s UI
based on their exposure to and understand-
ing of the patient’s condition. While care- Physical Exam
givers can be integral to obtaining a history After a thorough history is obtained, the
from again and disabled patients, their next portion of the evaluation will be
input must be balanced by a respect for the physical exam, which can confirm or
patient autonomy. Finally, cultural and exclude many etiologies for UI. Mobility,
language barriers can prevent open discus- cognitive status, and general health can be
sion of UI symptoms. A literature review of assessed in the first few minutes of consulta-
the health care disparities in the LatinX tion. Abdominal exam can reveal masses
population in 2002 found evidence that and surgical scars indicating prior abdomi-
those “with limited proficiency in English nal/pelvic surgeries as well as masses. After a
are at risk for experiencing decreased access brief general exam, the clinician will proceed
to care and decreased quality of care.”17 with a targeted pelvic exam.
If the clinician finds the history to be Pelvic exams in this population start
of limited utility, bladder diaries are with a gross initial overview of the area
commonly obtained. The National for lesions, support defects and other
Institute of Diabetes and Digestive and abnormalities. Obliterative vulvar dis-
Kidney Diseases has developed a daily ease, such as lichen planus or lichen
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.282 Raza-Khan
FIGURE 1. Bladder diary.18
sclerosis can be obstructive and are ob- apical, and posterior can be examined
vious on visual inspection. In addition, separately and documented using the
excessive vaginal discharge can be mis- POP quantification system or POP-Q.19
taken for urine loss and will be seen on If POP is identified, its role in UI
exam. POP should be evaluated is in symptoms can be assessed. Mild vaginal
standing and lithotomy positions. Each prolapse (stage 1 or 2) is common in
compartment of the pelvic floor; anterior, the general population. In fact, 73% of
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women presenting for annual gynecologic unusual cause of UI, but some women
examination will present with stage 1 or with diverticular experience postvoid
stage 2 prolapse.20 Because the urethra dribbling, with or without UTIs and pain.
runs along the anterior vaginal wall, POP Other atypical causes of UI including
can have implications for urethral sup- urinary fistula or ectopic ureter can be
port. Assessment of urethral mobility is of demonstrated by urine in the vaginal
debatable clinical significance, but this is vault and patient history.
assessed by visualization or using the A brief neurological exam typically
Q-Tip test. In the Q-Tip test, a lubricated involves sensory and motor assessment
thin cotton swab is placed gently into the of lumbosacral nerve roots in addition to
urethra into the bladder and then pulled general mental status. Neurological
distally until mild resistance is met, in- abnormalities that can cause bladder dys-
dicating that the head of the swab is function include Parkinson Disease, mul-
resting at the bladder neck. The angle of tiple sclerosis, cerebrovascular disorders,
rotation of the swab from rest to max- infections, and tumors. The sacral seg-
imum Valsalva is measured, and angles ments contain the neuronal pathways to
> 30 degrees indicate urethral hypermo- the end organs which control micturition.
bility, suggesting diminished support of Sensory function can be assessed by re-
the urethra from the vaginal wall. sponse to light touch, pin prick, and
An approximation of the Q-Tip test can temperature. Specific areas of interest
be performed more easily and without include the perineum and perianal skin
discomfort to the patient by visually supplied by the pudendal nerve (S2-4),
observing the anterior vaginal wall during mons pubis and upper labia majora sup-
cough or Valsalva. plied by the ilioinguinal nerve (L1-2),
While urethral mobility is seen com- front of knees (L3-4), and soles of feet
monly in women complaining of mild to (S1). On pelvic exam, the bulbocaverno-
moderate SUI, some women, particularly sus and anal reflex can be used to assess
those with severe SUI may not display the integrity of the S2-4 sacral segments as
any mobility at all. This finding is more well as the afferent and efferent pathways
concerning for intrinsic sphincteric defi- of the pudendal nerve. The bulbocaver-
ciency or prior surgery. The presence of nosus reflex is elicited by squeezing or
hypermobility may impact a surgeon’s tapping the clitoris and observing move-
counseling about the expected efficacy of ment at the anal sphincter. The anal reflex
a specific SUI procedure.21 is elicited by provoking the anal sphincter
In women with significant (stage 3 or 4) with a pin prick and observing contrac-
anterior vaginal prolapse, an assessment tion of the external anal sphincter known
for occult SUI can be performed by as an anal wink. Motor function is
reducing the prolapse while the patient assessed by observing extension and flex-
bears down or coughs. This exam also ion of the hips, knees, ankle, and foot.
may be a good opportunity to reassure Pelvic floor muscle examination involves
women about the safety of reducing her palpation of the levator ani complex with
prolapse to urinate and instruct them how determination of strength, tone, tender-
to do it. ness, and ability of the pelvic floor mus-
The physical exam should also include culature to relax. Clinicians can also
palpation of the urethra for urethral assess the patient’s ability to perform a
diverticulum. Typically, a diverticulum pelvic floor muscle contraction and coach
appears as a suburethral bulge which her as needed. Rectal examination pro-
can express a urethral discharge with vides information regarding resting anal
palpation. Urethral diverticulum is an sphincter tone, contraction strength, and
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anatomy of the anal sphincter. Finally, upper urinary tract imaging and cysto-
impaction of stool, palpated in the poste- scopy for lower urinary tract evaluation.
rior vagina and in the anal canal can help
diagnose constipation or obstipation
which is a common, treatable cause of UI. Postvoid Residual
Postvoid residual (PVR) volume is ob-
tained to assess voiding function. Resid-
Cough Stress Test uals can be obtained with ultrasonic
bladder scanners or straight catheriza-
The gold standard for diagnosis of SUI a
tion, usually obtained within ten minutes
positive cough stress test (CST). The
of voiding. Residuals obtained by bladder
immediate visualization of urine from
scanner are more comfortable for patients
the urethral meatus with increased ab-
and may reduce the risk of UTI.23 Vari-
dominal pressures, either with cough or
ous cutoffs have been proposed for defin-
bearing down, is diagnostic of SUI.
ing an elevated residual with the United
Delayed release of urine after a increasing
States Department of Health and Human
intra-abdominal pressure, leakage with
Services Agency for Health Care Policy
urge, or complete bladder emptying is
and Research recommending that a PVR
not diagnostic of SUI and warrants
> 200 mL be considered inadequate
further investigation of possible stress
emptying.24 In the Value of Urodynamic
induced detrusor overactivity. The CST
Evaluation (VALUE) Trial, a PVRBasic Evaluation of Urinary Incontinence 285
risk factors for urothelial cancers such as detrusor, and abdominal pressures during
smoking. Cystoscopy is most routinely filling and storage. Uroflow and pressure
done as an in-office procedure with min- flow studies provides data on flow time,
imal to no local anesthesia. flow pattern, urethral function, and de-
Urodynamic testing is an available test- trusor activity during voiding. Data ob-
ing modality that can further elucidate the tained in pressure flow studies can help
specific type of UI. While most straight- determine causes of urinary retention or
forward cases of UI do not require urody- voiding dysfunction. Measurements of
namic testing, it is helpful in complicated urethral pressures and leak point pres-
patients with recurrence, co-existing pelvic sures have been used to guide surgical
floor disorders, neurological conditions, decisions; however, data is variable on the
or failed prior treatment. Urodynamics utility of measurements in predicting sur-
previously had been used a confirmatory gical outcomes.26 Needle electromyogra-
test before SUI surgery. However, the phy was used in the past to identify and
VALUE study, a randomized control trial study the motor unit potentials within the
of 630 women undergoing preoperative striated urethral sphincter as part of
urodynamic testing versus in-office evalu- urodynamic testing. Equipment and ex-
ation found no difference in treatment pertise in this technique is no longer
outcomes 1 year after surgery. In office widely available. Patch electrodes placed
evaluation in the VALUE trial included a on the skin have been used with the hope
positive result on the MESA questionnaire of obtaining similar information, but they
for SUI, a PVR under 150 ml, negative lack the specificity to provide clinically
urinalysis or culture, clinical assessment of useful information as they are unable to
urethral mobility, positive provocative detect urethral sphincter activity.
stress test.25 The prevalence of UI will mirror the
Urodynamic testing consists of multiple rising population of aging women. Incon-
test including simple or multichannel cyst- tinence has the potential to significantly
ometry. Simple urodynamic studies in- limit a woman’s quality of life, affecting
volves instilling sterile saline or water by not only her but her family, friends, and
aliquots into the bladder through a Foley caregivers. In addition, the economic
attached to a 50 ml Tumi syringe. Data impact of UI has a substantial effect on
such as volume of first sensation, first society. Simple in-office evaluation of UI
desire, strong desire and maximum ca- can help lessen the effects of UI. History,
pacity is recorded. Detrusor contractions physical exam, and urine testing available
are noted when a rise in the water meniscus to most clinicians allows for the classifi-
is seen in the Tumi syringe during filling. cation of UI type in most women. After
At the end of filling, the catheter is gaining a better understanding into the
removed, and the patient asked to perform severity and type of UI experienced by the
a provocative maneuver, such as coughing woman, treatments can be initiated as
or jumping, for evaluation of SUI. soon as the first patient encounter.
Multichannel urodynamic testing, with Follow-up evaluation and readdressing
or without a video component, is typically the history and evolution of symptoms
performed only in subspecialty offices. A during treatment is equally important in
water or air charged catheter is placed maintaining improvements. Future devel-
transurethrally to measure bladder and opments in the evaluation of UI will likely
urethral pressures, and another is placed involve the use of web-based technology
rectally or vaginally to approximate to document, quantify, and possibly test
abdominal pressures. Cystometry pro- for UI, making it easier for women to
vides a visual depiction of bladder, obtain treatments sooner.
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References 14. Litwiller SE, Frohman EM, Zimmern PE. Multi-
1. Current Population Reports. Population projec- ple sclerosis and the urologist. J Urol. 1999;161:
tions of the united states by age, sex, race, and 743–757.
hispanic origin: 1995 to 2050… 1996. 15. Lawrence JM, Lukacz ES, Nager CW, et al.
2. Thom D. Variation in estimates of urinary incon- Prevalence and co-occurrence of pelvic floor
tinence prevalence in the community: effects of disorders in community-dwelling women. Obstet
differences in definition, population character- Gynecol. 2008;111:678–685.
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