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Urinary Incontinence Diagnosis
A complete medical history, which includes a voiding diary and incontinence questionnaire, physical examination, and one or more diagnostic procedures, helps the physician determine the type of urinary incontinence and an appropriate treatment plan.
By asking questions, a physician can better understand a patient's particular situation and type of incontinence. Questions focus on bowel habits, patterns of urination and leakage (for example, when, how often, and how severe), and whether there is pain, discomfort, or straining when voiding. The doctor will also want to know whether or not the patient has had any illnesses, pelvic surgeries, and pregnancies, as well as what medications he or she is currently taking. In certain situations (such as an elderly person with dementia), a mental status evaluation and assessment of social and environmental factors may be performed.
A physical examination includes tests of the nervous system and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing suggests a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough suggests urge incontinence. The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.
The physician may ask the patient to keep a record of his or her bladder activity. In the voiding diary, the patient records fluid intake, fluid output, and any episodes of incontinence. This contributes valuable information to help the physician understand the patient's situation.
The pad test is an objective test that determines whether the fluid loss is in fact urine. The patient may be asked to take a medication that colors the urine. As fluid leaks onto the pad, it changes color indicating that the fluid lost is urine. The pad test may be performed during a one-hour period or a 24-hour period. The pads may be weighed before and after use to assess the severity of urine loss (1 gram of increased weight = 1 mL of urine lost).
Post-void Residual Volume
The measurement of post-void residual (PVR) volume is a part of the basic evaluation for urinary incontinence. The PVR volume is the amount of fluid left in the bladder after urination. If the PVR volume is high, the bladder may not be contracting correctly or the outlet (bladder neck or urethra) may be obstructed. To determine the PVR urine volume, either a bladder ultrasound or a urethral catheter may be used. With ultrasound, a wand-like device is placed over the abdomen. The device sends sound waves through the pelvic area. A computer transforms the waves into an image so the doctor can see how full or empty it is. A catheter is a thin tube inserted through the urethra. It is used to empty any remaining urine from the bladder.
The initial attempt to urinate should be evaluated for hesitancy, straining, or interrupted flow. A PVR volume less than 50 mL indicates adequate bladder emptying. Measurements of 100 mL to 200 mL or higher, on more than one occasion, represent inadequate bladder emptying.
Cough Stress Test
A critical part of the pelvic examination is direct observation of urine loss using the cough stress test. The bladder is filled through a catheter with sterile fluid until it is at least half full (250 mL). The patient is instructed to bear down and tense the abdominal muscles while holding his or her breath (known as a Valsalva maneuver) or simply cough. Leakage of fluid during the Valsalva maneuver or cough indicates a positive test result.
This test is performed by inserting a sterile lubricated cotton swab (Q-tip) into the female urethra. The cotton swab is gently passed into the bladder and then slowly pulled back until the neck of the cotton swab is fit snugly against the outflow tract of the bladder (the bladder neck). The patient is then asked to bear down (Valsalva maneuver) or to simply contract the abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is noted as movement of the Q-tip and may correlate with stress incontinence.
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