Urinalysis (UA) is a useful screening and diagnostic tool that provides rapid results in the office setting. A simple UA can be used to rule out urinary tract infection, screen for microscopic hematuria, and identify causes of secondary incontinence such as glucosuria, pyuria, and proteinuria. Urine culture is also helpful in the diagnosis of urinary tract infection. Microscopic hematuria should not be ignored in this patient population, as urinary tract malignancy may present as new onset urinary urgency/frequency or urge incontinence—a full urologic hematuria workup may be appropriate. At times, it can be difficult in some female patients to provide a specimen that does not exhibit vaginal contamination (as evidenced by the presence of vaginal squamous epithelial cells). This can be encountered in patients with pelvic organ prolapse, obesity, and in patients who may have limited coordination. In this circumstance, it is often helpful to obtain a sample via catheterization.

The basic metabolic panel (BMP) is often used as a surrogate for renal function assessment. Although not necessary in all patients, biochemical tests for renal function are recommended in patients with urinary incontinence and known or high probability renal impairment. Some of the neurogenic bladder population is at risk for renal deterioration, and routine BMP is useful for ongoing surveillance of the upper urinary tract.

Patients should complete a voiding diary to objectively assess fluid intake, voided volume, episodes of incontinence, and voiding frequency as well as functional capacity avoiding, maximal bladder capacity, and nocturia. These diaries may document intake and voiding behavior which may be useful for patient education and for documenting both baseline symptoms and treatment efficacy. Table 2 is an example of the voiding diary used at our institution. The voiding diary has multiple advantages. It is an inexpensive test that involves the patient in their treatment program. It is also a reasonable substitute for cystometry—the largest voided volume on the voiding diary has been demonstrated to correlate with the patient’s cystometric capacity [2]. The diary objectively determines a reasonable voiding interval to begin a program of bladder training and establishes a way to measure change with therapy [3]. In addition to the above advantages, clinicians may use the diary to guide the conduct of urodynamics by using information such as the average voided volume to establish more physiologic bladder capacities at which certain tests such as leak point pressures are evaluated.

Pad weight testing helps to objectively quantify the amount of urine lost during incontinent episodes. Several methods of performing this test have been documented. Traditionally, gynecological literature describes instilling 250 mL of saline into the bladder, followed by asking the patient to complete a series of activities over 60 min (walking, climbing stairs, coughing, etc.) while wearing a pad. If the weight of the pad increases by 2–3 g over the hour, the test is considered positive.

Alternatively, patients are asked to wear pads over varying intervals of time (ranging from 1 to 72 h) and to collect and return the used pads to the physician. These pads are then weighed by the clinic and total urine volume lost is calculated, using a dry pad as baseline. Greater than 8 g of urine loss over 24 h with this method is considered a positive test.

Current research shows that the 1-h pad test has poor predictive value in the diagnosis of female urinary incontinence when compared to stress test and urine leakage [4–6]. Simply asking a woman if she is continent was as effective as performing the pad test and correlated more strongly with the patient quality of life. While useful for academic purposes and clinical trials, the 1 h pad test is tedious and inconvenient for the patient and often has poor compliance [7]. The Fourth International Consultation on Incontinence (ICI) Committee did not recommend pad tests as part of the initial evaluation in the incontinent patient [8].

Although not indicated in all patients, direct visualization of the lower urinary tract may be of some benefit to rule out urethral and bladder pathology. If justified by the history and physical, cystoscopy can help diagnose a number of conditions that may influence or cause the patients symptoms. Specific examples include urethral stricture, inflammation, urethral or bladder diverticula, anatomic defects, and foreign bodies. In patients with microscopic or macroscopic hematuria and irritative symptoms, one must rule out malignancy as a cause prior to treatment. Cystoscopy is an essential component of the hematuria workup [9].

In men with incontinence after radical prostatectomy (both before and after treatment), cystoscopy is vital to evaluation of the urethra when considering surgical intervention. Cystoscopy provides valuable information about urethral sphincter function, can evaluate coaptation of the urethral mucosa with a previously placed artificial urinary sphincter, and can demonstrate urethral tissue atrophy if present.

The volume of urine left in the bladder following voiding is termed the postvoid residual (PVR ) and should be evaluated in all incontinent patients [10]. The PVR evaluates the bladder’s ability to empty. Knowing the patient has an elevated PVR can be helpful in diagnosing overflow incontinence. It also establishes a baseline for the patient, as both medical and surgical therapy may cause this to worsen. PVR measurement may not be necessary for uncomplicated patients if treatment is limited only to behavioral therapy.

Imaging studies are not required for most patients. However, in patients with hematuria, upper tract imaging is required to ensure the clinician does not miss a potentially harmful cause such as urothelial cancer or calculus disease [9]. In male patients in whom there is a high suspicion of urethral stricture, the clinician should obtain a retrograde urethrogram to both diagnose and define the severity of disease.

Although urodynamic testing is a useful diagnostic tool for evaluating patients with lower urinary tract dysfunction, some patients may not need the full spectrum of tests available. In fact, some patients may not require urodynamic testing at all after the clinical evaluation is complete. Multiple societies have published recommendations regarding the use of urodynamics. The following recommendations are a synthesis of the published guidelines from the American Urological Association, the National Institute for Health and Clinical Excellence, the International Continence Society, the American Urogynecologic Society, and the Urinary Incontinence Treatment Network [11–16].

Urodynamics not necessary—Urodynamic studies are optional in uncomplicated patients with stress incontinence. In addition, they are not necessary when starting a conservative treatment program. Patients with neurogenic bladder who are at low risk of renal complications (such as most patients with multiple sclerosis), do not need to be routinely offered urodynamic testing.