The primary purpose of physical examination is to exclude confounding or contributing factors to the incontinence or its management. A complete physical examination should be performed, with emphasis on neurologic assessment and on abdominal, pelvic, and rectal examinations. The general examination should include height and weight, which will allow for objective assessment of body mass index, as obesity is an established risk factor of UI [5]. Assessment of the gait and mobility of the patient can help to rule out a functional etiology for the UI.

The abdominal examination will allow evaluation of scars and palpation for possible distended bladder and pelvic mass. The neurologic examination concentrates on the sacral segments predominantly along with lower lumbar segments. This includes, but not limited to, testing of lower limb tone, sensation, reflexes, perineal sensation, and reflexes such as bulbocavernosus or anal reflex.

Local examination concentrates on demonstration of urinary leak, presence of prolapse, atrophic vaginal changes and pelvic mass. Evidence of pelvic organ prolapse (POP) beyond the hymen is consistent with complicated SUI because the prolapse can produce a relative obstruction of urethra that can impair bladder emptying. Therefore, it is recommended that all pelvic compartments (anterior, posterior, and apical) be assessed individually. When POP is reduced with a nonobstructing pessary or large cotton swabs, SUI may become apparent or worsen [6].

Stress urinary incontinence should be objectively demonstrated before any anti-incontinence surgery is performed. Visualization of fluid loss from the urethra simultaneous with a cough is diagnostic of SUI. Delayed fluid loss is considered a negative cough stress test result and suggests cough-induced detrusor overactivity [5]. The cough stress test can be performed with the patient in the supine position during the physical examination. However, if urine leakage is not observed, the cough stress test needs to be repeated with the patient standing and with a full bladder (or a minimum bladder volume of 300 mL) to maximize test sensitivity [7].

Support to the bladder neck is assessed by evaluating the mobility of the urethrovesical junction. Urethral hypermobility is defined as a 30° or greater displacement of urethra from the horizontal (measured with a cotton tip swab in urethra) with the patient in supine lithotomy position and straining – referred to as the “Q-tip test.” This test is not recommended in the routine evaluation of patients with UI. Other methods of evaluating urethral mobility include measurement of point Aa of the POP Quantification system, visualization (inaccurate method), ultrasonography, and lateral cystourethrogram. Women with stress incontinence who have good urethral mobility have a lesser chance for failure of mid-urethral sling procedures. In women with SUI without urethral hypermobility, where leak can be due to intrinsic sphincter deficiency (ISD), bulking agents were considered to be a more appropriate surgical option [8]. This notion is however being increasingly questioned with use of mid-urethral slings, where cure rate of 78 % is quoted with tension-free vaginal tape (TVT) in patients with ISD [9].

Digital assessment of the pelvic floor muscle contraction and grading it using modified Oxford grading scale (Table 4.2) can be helpful in discussing management options such as pelvic floor exercises for SUI.