Basic Assessment of Urinary Incontinence Presented by: Jonas Jaco P. Talamo & Noe Villahermosa Introduction Incontinence is a common problem worldwide, with perhaps 200 million or more sufferers around the globe and a prevalence of 15% to 30% in the United States. In the past decade, great advances have been made in understanding the causes of urinary incontinence and in the the ability to diagnose and treat it. This is of limited usefulness, however, if the majority of sufferers remain too embarrassed to seek professional help, or if those who provide primary care service are unaware of the need for active detection of incontinence and of recent advances in the field. Failure to treat patients or to refer them for investigation and treatment, therefore, can occur. Regardless of age, sex, race, functional status, cognition, or institutionalization, urinary incontinence is never normal. Although incontinence is not life-threatening, it predisposes the person to perineal rashes, pressure ulcers, urinary tract infections, falls, and bone fractures. It is associated with embarrassment, stigmatization, isolation, depression, loss of patient morale and dignity, and risk of unnecessary institutionalization, as well as caregiver burden. Basic Clinical Assessment The basic assessment has three purposes: to determine the cause of the incontinence, to detect related urinary tract and nervous system pathology, and to evaluate the patient comprehensively with regard to mental and physical status, comorbidity, medications, environment, quality of life, and availability of resources. The basic assessment should be tempered by the realization that even without an established diagnosis, simple measures are often effective and some conditions may not be curable (Table1). The first step is to characterize the voiding pattern and to determine whether symptoms of abnormal voiding, such as urgency, frequency, straining to void, dribbling, or a sense of incomplete emptying, are present. A complete urinary history should be taken (Table 2) and should include information regarding neurologic and congenital abnormalities, as well as information about previous urinary tract infections and relevant surgeries. Irrespective of the presenting problem, reversible conditions need to be identified when assessing a patient with urinary incontinence. Transient causes account for one third of incontinence cases among community-dwelling patients, up to half of the cases among patients hospitalized for acute care, and a significantly higher percentage of cases among nursing home residents. The most common reversible conditions are outside the lower urinary tract. Transient causes of incontinence are shown in Table 3, and can be recalled using the mnemonic DIAPPERS. "D" is for delirium, a confusional state with fluctuating attention and disorientation. It can result from almost any medication and from virtually any acute illness. "I" is for infection, especially from the urinary tract. Asymptomatic urinary tract infection, however, is not a cause of incontinence. "A" is for atrophic urethritis and/or vaginitis. It is a frequent source of urinary tract symptoms, including incontinence. The importance of recognizing atrophic vaginitis is that it responds to low doses of topical or systemic estrogen. "P" is for pharmaceuticals, the most common cause of incontinence in the elderly. Seven different categories of drugs are commonly implicated: major tranquilizers, antidepressants, anti-Parkinson's-disease drugs, antihistaminics, antiarrhythmics, antispasmodics, and diuretics (Table4). The second "P" is for psychiatric disorders, primarily depression, in which patients lack motivation to perform daily activities. "E" is for excess urinary output. Common causes include excess fluid intake, the use of diuretics (including caffeine and alcohol), metabolic abnormalities (hyperglycemia, hypercalcemia), congestive heart failure, peripheral venous insufficiency, hypoalbuminemia, and drug-induced peripheral edema associated with non-steroidal anti-inflammatory drugs or some calcium channel blockers (nifedipine, nicardipine). "R" is for restricted mobility. In addition to obvious causes, restricted mobility may also be associated with orthostatic or postprandial hypotension, poorly fitting shoes, physical deconditioning, or fear of falling. Finally, "S" is for stool impaction, a common cause of incontinence in the acute-care setting and in geriatric facilities. Another helpful component of the basic assessment is the micturition protocol kept by the patient or the caregiver. Recorded over a 72-hour period, this chart shows the time of each void or incontinent episode. To record the volume voided at home, a patient can use a measuring cup. Information about the volume voided provides an index of functional bladder capacity, and the pattern of voiding and leakage can be helpful in pointing to the cause of incontinence. Like the history, the physical examination is essential for ruling out transient causes of urinary incontinence and the evaluation of complicating conditions and factors, as well as functional ability. The examination should include: (1) assessment for neurologic diseases (stroke, dementia, Parkinson's disease, hydrocephalus, multiple sclerosis, spinal cord injury, peripheral neuropathies, and tumors) and mental evaluation; (2) identification of general medical illnesses (heart failure, orthostatic hypotension, arthritis, peripheral vascular insufficiency, constipation, diabetes); and (3) pelvic examination to assess atrophic vaginitis, pelvic mass, pelvic-floor muscle strength, pelvic organ prolapse; palpation of the anterior vaginal wall and urethra to elicit urethral discharge or tenderness; and rectal examination for skin irritation, symmetry of gluteal creases, perineal sensation, tone and voluntary control of the anal sphincter, rectal masses, and prostatic enlargement. The provocative stress test for suspected stress incontinence should be included as part of the physical examination. To be diagnostically meaningful, leakage should replicate the patient's symptoms. Performed correctly, the test is reasonably sensitive and specific. Optimally, the bladder should be full, and the patient should relax the perineal muscles and assume a position as close to upright as possible; the patient should cough or strain vigorously once while the examiner observes for urine loss from the urethra. If the test is initially done with the patient recumbent and no leakage is observed, it should be repeated with the patient in the upright position. The post-void residual urine measurement (PVR) is essential for basic clinical assessment. There is no standard maximal PVR volume that is considered normal, nor is there a standard minimum that is considered normal. The exact measurement of PVR requires that bladder catheterization or bladder ultrasound be done. A volume less than 50 mL is considered normal, whereas more than 200 mL is considered abnormal and justifies specialized evaluation. Optimally, the PVR is measured within a few minutes of voiding. The variability of the PVR in a patient can be reduced substantially by elimination of abdominal straining during voiding and by repetitive testing. Practical algorithms for the basic assessment of urinary incontinence in men and women are presented in Figures 1, 2, and 3. Figure 1 Figure 1 Figure 2 Figure 3 Conservative Treatment of Urinary Incontinence Therapeutic options for urinary incontinence include behavioral, pharmacologic, surgical, and lifestyle interventions, used either alone or in combination. Behavioral techniques are now the accepted frontline therapy in the treatment of all forms of urinary incontinence. Various lifestyle factors may play a role in either the pathogenesis or the resolution of incontinence. While published literature about life-style factors and incontinence is sparse, health care professionals frequently recommend alterations in life-style. Obesity is an independent risk factor for urinary incontinence, and weight loss would appear to be an acceptable treatment option. Chronic straining due to chronic constipation may also be a risk factor for the development of urinary incontinence. Caffeine and fluid intake play a minor role, if any, in the pathogenesis of incontinence, and there is no evidence that strenuous exercise or smoking are associated with incontinence. Pelvic floor muscle training (PFMT), also known as Kegel exercise, is designed to strengthen the voluntary periurethral and perivaginal muscles, which contribute to the closing force of the urethra and to the support of the pelvic visceral structures. Strengthening these muscles gives the patient more control of micturition and lowers the incidence of urinary incontinence episodes. The PFMT protocols should include 3 sets of 8 to 12 slow-velocity maximal contractions sustained for 6 to 8 seconds each, performed 3 to 4 times a week for at least 15 weeks. Evidence-based data suggest that PFMT is better than no treatment for patients with stress incontinence, urge incontinence, and mixed incontinence. The expected shortterm rates of cure/improvement for PFMT may be in the range of 70%. The bladder and urethra form an anatomic functional unit that has two functional phases: the filling or collecting phase, and the emptying or micturition phase. The normal physiology of this unit is in accordance with social and hygienic norms. To achieve this, a process of behavioral learning is needed. Behavioral interventions may reproduce and/or reinforce such a learning process. Bladder retraining, first described by Jeffcoate and Francis in 1966, has been applied to a variety of scheduled voiding regimens. Recent evidence indicates that bladder retraining is an effective treatment for patients with urge incontinence, stress incontinence, and mixed urinary incontinence. Its benefits appear similar to drug therapy and it may have greater long-term benefits. Specific goals of bladder retraining include correcting faulty habits of frequent urination, improving ability to control bladder urgency, prolonging voiding intervals, increasing bladder capacity, reducing episodes of incontinence, and building patient confidence in bladderfunction control. The underlying mechanism of how bladder retraining achieves its effects is poorly understood. Bladder retraining programs typically involve patient education regarding the mechanisms underlying continence and incontinence, a scheduled voiding regimen with gradually increasing voiding intervals, urgency-control strategies using distraction and relaxation techniques, self-monitoring of voiding behavior, and positive reinforcement provided by a clinician. Bladder retraining requires a cognitively intact and motivated patient who is capable of independent toileting and can adhere to the scheduled voiding regimen.