DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of urinary incontinence.
Less than half of patients who have urinary incontinence report the condition to their doctor. Patients are often unaware of the nature of their condition or are too embarrassed to seek help for it. In many cases, patients simply feel that incontinence was part of the aging process and don't want to bother their physicians.
And, in spite of the commonness of this problem, two-thirds of physicians never ask their older patients if they experience incontinence. In one survey, many physicians claimed they did not have the time to treat the patient. Many also have no knowledge of treatments and did not realize that therapies are available that can help about two-thirds of people with incontinence. Some doctors are as embarrassed about incontinence as patients.
It is important, however, for both the physician and the patient to raise the issue.
The first step in the diagnosis of incontinence is a detailed history, including any medical conditions and patterns of urination. Patients should report the following information to their doctor:
Voiding Diary. In order to provide this information to the physician, the patient might find it helpful to keep a diary for three to four days before the office visit. This diary, sometimes referred to as a voiding diary or log, should be a detailed record of the following:
For each incident of incontinence, the log should also include the following:
The office visit should consist of a thorough physical examination, checking for abnormalities or enlargements in the rectal, genital, and abdominal areas that may cause or contribute to the problem.
Measuring Postvoid Residual Urine Volume
One of the important measurements for urinary incontinence is the postvoid residual urine volume (PVR). This is the amount of urine left in the bladder after urination:
Use of a Catheter. The most common method for measuring PVR is with a catheter, a soft tube, which is inserted into the urethra within a few minutes of urination. The advantage of the catheter is that it can also collect urine for analysis.
Ultrasound. Ultrasound is useful in determining the volume of urine.
Cystometry measures the bladders ability to retain urine at different capacities and pressures. It employs a catheter (a thin tube) and so can be performed at the same time as the PVR test.
Subtraction Cystometry. Although procedures vary, the following is used in some centers and referred to as subtraction cystometry.
The detrusor muscles of a normal bladder will not contract during filling. Severe contractions at low amounts of administered fluid (less than 200 mL) indicate urge incontinence. If there is no significant increase in bladder pressure or detrusor muscle contractions during the process but the patient experiences leakage if abdominal pressure increases, such as during the Valsalva movement, then stress incontinence is suspected.
Video Cystometry. Video cystometry combines a computer reading of bladder pressures and pictures of the bladder itself. It is most useful in cases where the more standard tests have not yielded satisfactory results.
To determine whether the bladder is obstructed, the speed of urine flow is measured electronically using a test called uroflowmetry. The test involves the following steps:
Many factors can affect urine flow (such as straining or holding back because of self-consciousness) so experts recommend that the test be repeated at least twice.
Q[max]. The rate of urine flow is calculated as milliliters of urine passed per second (mL/s). At its peak, the flow rate measurement is recorded and referred to as the Q[max]. The higher the Q[max], the better the patients flow rate. Men with a Q[max] of less than 12 mL/s have four times the risk for urinary retention than men with a stronger urinary flow.
The Q[max] measurement is sometimes used as the basis for determining the severity of obstruction and for judging the success of treatments. It is not very accurate, however, for a number of reasons:
The Q[max] level does not necessarily coincide with a patients perceptions of the severity of his own symptoms.
Urethrocystoscopy. Urethrocystoscopy, also called cystourethroscopy or cystoscopy, detects structural abnormalities, inflammation of the bladder wall, or masses that might not show up on x-ray.
The procedure is not without risks. Complications are uncommon, but can include allergic response to the anesthetic, urinary tract infection, bleeding, and urine retention.
Intravenous Pyelogram. Intravenous pyelogram (IVP) may be used for urge incontinence. It uses a dye that shows up on x-ray:
IVPs can detect structural abnormalities, urethral narrowing, or incomplete emptying of the bladder. This test should not be used on pregnant women or patients with kidney failure. There is a risk for an allergic reaction to standard dyes, although newer less allergenic ones are becoming available.
Ultrasound. Ultrasound plays a role in many cases of incontinence. For example, it is useful for men with prostate problems. It is helpful in measuring urine volume in the bladder. Ultrasound may also be useful in many cases of female stress incontinence, by identifying abnormalities in the bladder neck, and in assessing the urinary tract before and after surgery. It also may eventually be useful in diagnosing detrusor instability.
Chain Cystogram. In cases of stress incontinence, a chain cystogram may also be performed. With this procedure, a beaded chain is positioned in the bladder and urethra. The x-ray image of the chain reveals the angle of the bladder neck. This test should also not be performed on pregnant women.
Electrophysiologic Sphincter Testing
Electrophysiologic sphincter testing, also referred to as electromyography (EMG), evaluates two important factors:
Using a technique similar to that of an electrocardiogram, the physician places electrodes on the affected areas to observe electrical activity in the muscles.
Urethral Pressure Profile
Urethral pressure profile is used to investigate urethral blockage. A probe is placed in the urethra to determine pressure at different points along this pathway during urination and the exact location of any obstruction in the urethra.