Evaluating Urinary Incontinence
Many people never tell a physician that they are incontinent, and that leads to prolonged and largely needless suffering. In 70% of cases, incontinence can be cured or significantly improved. The treatment of incontinence has advanced greatly and is changing all the time, so don’t be reluctant to seek help now, even if previous attempts brought little relief.
Depending on the complexity of your symptoms, you can choose to visit your primary care physician or go to a specialist (see “Choosing a clinician”). If you are comfortable with your primary care physician, start there. If your symptoms seem to be connected with a specific medical event, such as childbirth, surgery, or starting a new prescription, the physician involved in that treatment might be your first choice. A woman may choose to see a urogynecologist — a gynecologist with board-certified special training and an interest in incontinence. A man who has had prostate symptoms or treatment may choose to consult a urologist. Physicians vary widely in their training and interest in incontinence. If a physician seems uncomfortable or uninformed discussing the subject, presents limited options, or seems unduly pessimistic about your condition, seek another opinion.
To pinpoint and treat the underlying problem, your physician will need you to describe your symptoms in as much detail as possible. You might be asked to keep a diary of urinations and fluid intake for a few days (see “Keeping a bladder diary”). At your visit, be prepared to give a full medical history, including details on all surgeries, pregnancies, and any medications you are taking (see Table 1). You may also need to answer specific questions such as these:
- When did the incontinence start?
- How often do you have leakage?
- Is it worse during the day or night?
- What brings it on? Do you have any warning?
- What makes it worse?
- Does anything make it better?
- Do you generally leak a little (damp underwear), a moderate amount (your underwear is soaked), or a lot (your clothing gets soaked and all the urine in your bladder comes out)?
- Do you leak urine during intercourse or with orgasm?
- What is your typical fluid intake (including caffeinated and alcoholic beverages)?
- How often do you go to the toilet to empty your bladder during the daytime? How often when you are trying to sleep?
- Do you have other problems urinating? After you urinate, does your bladder still feel full? Do you have trouble starting the urine flow? Is the stream weak or strong? Is urination ever painful?
- Have you also had trouble controlling your bowel movements?
- Are you using pads or other means to manage your incontinence? How is it working? Have you altered your activities because of incontinence?
Table 1: Medications that can cause urinary incontinence
|Diuretics, such as hydrochlorothiazide (Esidrix, Hydrodiuril, Oretic), furosemide (Lasix), bumetanide (Bumex), triamterene with hydrochlorothiazide (Maxzide)||Increase urine production by the kidney.||Frequent urination, overactive bladder, stress incontinence.|
|Muscle relaxants and sedatives, such as diazepam (Valium), chlordiazepoxide (Librium), lorazepam (Ativan)||Cause sedation or drowsiness, relax urethra.||Frequent urination, stress incontinence, lack of concern or desire to use the toilet.|
|Narcotics, such as oxycodone (Percocet), meperidine (Demerol), morphine||Cause sedation or drowsiness; relax bladder, causing retention of urine.||Lack of concern or desire to use the toilet, difficulty in starting urinary stream, straining to void, voiding with a weak stream, leaking between urinations, frequency incontinence.|
|Antihistamines, such as diphenhydramine (Benadryl)
Anticholinergics and calcium-channel blockers, such as verapamil (Calan), nifedipine (Procardia), diltiazem (Cardizem)
|Relax bladder, causing retention of urine; in some cases, increase urine production.||Difficulty in starting the urinary stream, straining to void, voiding with a weak stream, leaking between urinations.|
|Alpha-adrenergic antagonists, such as terazosin (Hytrin), doxazosin (Cardura)||Relax the bladder outlet muscle.||Leaking when coughing, sneezing, laughing, exercising, etc.|
The physical exam
For this exam, your clinician places more focus on your nervous system, abdomen, and genital area than during a standard physical. The clinician checks your reflexes, assesses your muscle strength, and observes whether you can distinguish the touch of something sharp from something dull. To test nerves in the genital area, the doctor may stroke the skin near your anus and watch for a normal muscle contraction. In women, the doctor gently taps the clitoris and looks for a subtle muscle contraction of the anus, which is a normal reflex.
None of these tests is painful or uncomfortable. If the doctor observes problems with any functions that rely on the same nerves as those that control urinary continence, it can mean that these nerves are involved in your bladder symptoms.
During the abdominal exam, the doctor presses on your abdomen to feel your bladder and check other areas for hernias, tenderness, or any signs of tumor, infection, scarring from previous surgeries, or an impacted bowel.
Both men and women provide a urine sample, which is checked immediately for blood, sugar, or large amounts of bacteria (normal urine is sterile). Blood can indicate irritation of the urinary tract. If there is such irritation, the cause must be determined. If sugar is detected, your physician might suspect diabetes, which can increase your urine volume and make incontinence more likely. Bacteria indicate possible infection. As a more specific test, a urine sample may be sent to a laboratory to be cultured; if harmful bacteria are detected, a sensitivity test can identify the appropriate antibiotic to treat the infection.
For women. During a thorough pelvic exam, the clinician inserts a gloved finger into the vagina to help assess the strength of the pelvic floor muscles and to see whether the bladder or uterus has prolapsed (dropped out of normal position). If you hear the word “POP” it may mean your clinician is using the Pelvic Organ Prolapse Quantification system, also called the “POP-Q” system, as a way of measuring and grading the degree of prolapse of the pelvic organs to help guide decisions about treatment.
The clinician might ask you to contract your muscles as if you were trying to avoid urinating or passing gas, or to cough during the exam to see if urine spurts out of the urethra. The clinician might repeat the exam while you are in a standing position.
With a speculum in place, the clinician observes whether the tissue lining your vagina shows atrophy or other signs that it lacks estrogen. That would indicate that your urethral lining (not visible during the exam) is likely to show a similar lack of this hormone. The clinician may insert a Q-tip coated with numbing jelly (such as Xylocaine) into your urethra just up into the bladder to observe how the angle of the Q-tip changes when you bear down as if trying to have a bowel movement. A large change indicates poor support of the urethra and points toward a diagnosis of stress incontinence.
The clinician might also look for direct evidence of stress incontinence. You may be asked to stand with one leg up on a stool, holding a paper towel over your crotch; if urine appears on the paper towel after you cough, that’s a positive stress test. This test is usually performed at the beginning of your physical, when you have a full bladder. Afterward, you can urinate to increase your comfort during the rest of the exam.
Occasionally, if stress incontinence is suspected but is not observed during the exam, the clinician may give you a pre-weighed pad to wear while doing a series of exercises. The pad is then weighed again to determine how much leakage has occurred. You might go home with a package of pads to wear and save in sealed plastic bags over a 24-hour period, so that total leakage can be estimated.
For men. The doctor examines the penis for signs of constriction of the foreskin or an abnormal narrowing, or stenosis, of the urethra, which can result from scarring or infection. The doctor conducts a digital rectal exam, which involves inserting a gloved finger into the rectum to feel the size and texture of the prostate gland and assess the strength of the pelvic muscles. You may be asked to contract your muscles as if you were trying to avoid urinating or passing gas.