Assessment of Urinary Incontinence

Fig. 3.1

International prostate symptom score (IPSS)

Medication history: Many medications can affect LUTS and incontinence. Beware of polypharmacy (especially in the elderly) as well as diuretics and alpha-antagonists that may exacerbate or cause incontinence.
Past medical problems: Medical problems (especially conditions such as diabetes, ischemic heart disease, hypertension) and surgical/urological history may impact on the diagnosis and treatment.
Gynecological/obstetric history: All women should be assessed as to number and type of deliveries, menopausal status, as well as any significant surgery and its relationship to her symptoms.
Social and family history: This includes the patient’s current ability to manage activities of daily living (ADLs) and level of carer support. Don’t forget to ask about how the symptoms are impacting the patient’s quality of life and sexual health.

Physical Examination

Perform a thorough examination in a warm, comfortable, and private setting. Explain the steps of the examination prior to proceeding and have a chaperone present when required.

Abdominal examination may reveal a palpable bladder, suprapubic and flank tenderness, previous abdominal surgery, or previous external beam radiotherapy tattoos. External genitalia should be examined in both sexes, with the appropriate sensitivity. Look for changes to the skin, atrophic vaginitis, as well as urethra and nonurethral incontinence.

When examining for stress incontinence, it is important to attempt to reproduce the situations in which the incontinence occurs. Examine the patient both standing and lying supine when performing a sustained Valsalva maneuver and coughing to assess for presence of stress incontinence. Patients often empty their bladder prior to seeing their health professional, and this may prevent the demonstration of incontinence. In females, reducing pelvic organ prolapse may reveal occult stress incontinence.

In females, the pelvic organ prolapse quantification (POP-Q) exam is used to quantify, describe, and stage pelvic support (Fig. 3.2). It allows for standardization and postoperative comparison. There are six points measured at the vagina with respect to the hymen. Points above the hymen are negative numbers; points below the hymen are positive numbers. All measurements except total vaginal length (tvl) are measured at maximum Valsalva.

Fig. 3.2

POP-Q quantification system (image courtesy from American Medical Systems). Aa Point on the anterior vaginal wall 3 cm from the hymen, Ba The leading point on the anterior wall at maximal Valsalva with reference to the hymen, Ap Point on the posterior vaginal wall 3 cm from the hymen, Bp The leading point on the posterior wall at maximal Valsalva with reference to the hymen, C Location of cervix or vaginal cuff with reference to the hymen, D Location of posterior fornix or pouch of Douglas with reference to the hymen, gh Genital hiatus, pb Perineal body, tvl Total vaginal length

Female pelvic examination also involves assessment of the vagina (including the degree of estrogenization) and bimanual palpation for the uterus or pelvic masses. Assess pelvic floor muscle strength (Tips 3.1). In males, rectal examination is essential to assess prostate size, consistency, and tenderness. In both sexes, rectal examination can assess perianal sensation and anal tone and check for constipation/impacted feces.

A directed neurological examination focusing on lower limb power, tone, and reflexes as well as perianal sensation and anal tone (S2–S4) should be performed especially if there is suspicion of neurologic cause for incontinence.

Tips 3.1: Pelvic Floor Muscle Testing

Digital palpation and testing of pelvic floor muscle (PFM) strength by vaginal/rectal examination is an important part of physical examination in patients with urinary incontinence. This is also performed by physiotherapists and advanced practice urology or continence nurses during initial patient assessment and subsequent visits to monitor progress during a course of pelvic floor muscle training. The Modified Oxford Scale (MOS) is often used.

Pelvic floor muscle testing is a subjective measure as the clinician interprets the quality/number of PFM squeeze and lifts during assessment. PFM testing includes the following aspects:

Power – the strength of the maximum voluntary muscle contraction based on the MOS
Endurance – the duration of a contraction measured by the number of seconds
Repetitions – the number of times of maximum voluntary contraction until the muscles fatigue
Fast – assesses the number of fast contraction (1 s) before the fast-twitch muscle fiber fatigues

Muscle Strength Grading System: Modified Oxford Scale (MOS)

Grade 0: No discernible contraction
Grade 1: Very weak contraction, a “flicker.” Slight change in tension only
Grade 2: Weak contraction
Grade 3: Moderate contraction with some squeeze and lift ability

(This is the minimum level when continence and support start to return.)
Grade 4: Good contraction, squeeze and lift against resistance
Grade 5: Strong contraction, squeeze and lift against strong resistance