Urine leakage in women can have different causes. First of all, it is aimed to identify the underlying or contributing causes of the type of incontinence identified in the past. Diagnosis and diagnosis methods, which start with a physical examination, are as follows;
During the physical examination, the following information is obtained from the patient;
o An assessment of the patient’s general health, particularly seeking impaired mental status (i.e. confusion, signs of dementia), obesity, and reduced mobility/dexterity
o Evaluation for the presence of systemic conditions that may contribute to incontinence, eg uncontrolled diabetes
o Abdominal examination for masses including an enlarged bladder (suggests possible urinary retention)
o Cough stress test (if you have stress incontinence)
o Pelvic examination; Perineum and external genitalia check, including bimanual pelvic and anorectal examination for tissue health, signs of estrogen deficiency, vaginal examination with speculum for pelvic organ prolapse, pelvic masses and pelvic floor muscle function and tone
Cough Test for Stress Incontinence
Stress urinary incontinence in women should ideally be confirmed by examination. To assess whether stress incontinence is present, the patient is asked to lie flat on his back and cough. The external urethral opening should be observed during the first cough. Absence of leakage does not eliminate stress urinary incontinence.
Using Bivalve and Sims speculums, a visual and digital examination of the vagina should be performed to evaluate for masses, structural abnormalities, and evidence of pelvic organ prolapse. During the digital examination, a soft, tender mass should be felt on the anterior vaginal wall, urethral discharge or tenderness that may indicate a urethral diverticulum.
The pelvic floor musculature of the patient should be evaluated as ideal. A single finger is inserted into the vagina and the patient is asked to stretch the pelvic floor muscles, so that both strength and endurance of muscle tone should be evaluated. This can provide a basis for measuring the effectiveness of treatment. If a specialist will begin pelvic floor muscle exercises while waiting for a referral to a physiotherapist or nurse, it is helpful to ensure that the patient is contracting the correct muscles.
Further investigation may be performed as indicated by the patient’s symptoms and signs. A focused neurological examination may be appropriate to assess the possibility of a neurological condition causing incontinence, eg recent stroke, multiple sclerosis.
Examinations and Assays
A dipstick urinalysis should be performed to evaluate for signs of hematuria, glycosuria, and infection. Serum creatinine is not usually necessary but may be considered if the patient has recurrent UTIs, urinary retention or renal obstruction is suspected.
The patient should be asked to keep a bladder diary.
It should cover three days per day and document the amount and type of fluids consumed, how often they emptied, any urgency events, any incontinence events, and pad/clothing changes. A bladder diary has been shown to be a reliable method for measuring frequency, incontinence, and response to treatment.
The normal volume of urine passed with each urination is between 200-400 mL, and the generally accepted average voiding frequency is four to eight times a day, including one voiding per night. Further testing (below) may be required after the bladder diary is completed at the follow-up consultation. Some of these tests may need to be performed in a secondary care setting.
Measurement of residual bladder volume after urination
Recurrent UTI with significant urinary incontinence symptoms should be evaluated in patients with symptomatic pelvic organ prolapse or bladder distension. This should be done with a bladder ultrasound without a bladder scanning device, which will require referral for these applications (bladder scans may not be routinely available in some areas). Outflow catheterization can then also be used to measure residual urine volume in the bladder, but should only be considered when bladder screening is not possible or urinary retention is recorded at the time of examination.
Urodynamic tests can be used in the second step. The urodynamic test measures how well the bladder and urethra store and release urine. The test usually records flow rate, residual urine, capacity and can identify involuntary spasm before, during, or after voiding that is causing leakage. Buffer test, Q-tip test, Bonney and Fluid-Bridge tests are not recommended to evaluate urinary incontinence.
Pelvic organ prolapse
Pelvic organ prolapse is a common cause of urinary incontinence. It usually occurs following pelvic floor injury during childbirth, but may be multifactorial; It can be caused by the loss of support from the vagina, pelvic floor muscles and connective tissue, as well as damage to the related neurological system.
Traditional terms describing pelvic organ prolapse (eg, cystocele, urethrochoel, rectocele, enterocoel) have often been replaced. This is because the older terms imply a level of certainty about the structures that cause vaginal swelling, especially in women who have had previous pelvic organ prolapse surgery. The use of current practice is the terminology that divides the anterior pelvis into posterior and middle or apical compartments. These terms mean:
o Anterior: The anterior wall of the vagina is herniated inward, usually due to the slipped position of the bladder and/or urethra and pressure on the vaginal wall. The term includes the possibility of a cystocele, urethrochoel, and cystourethrocele.
o Posterior: Weakening of the muscle and connective tissue or damage to the rectovaginal septum causes herniation of the rectum into the vagina. This term includes the possibility of a rectocoel or enterocoel.
o Apical: The tissue that supports the uterus weakens and the uterus slides down, putting pressure on the vagina; often associated with trauma at birth
o Vaginal vault prolapse: The roof of the vagina collapses, usually following a hysterectomy (an enterocoel is also present)
Any pelvic organ prolapse is then staged according to the maximum descent of prolapse seen when the patient performs a Valsalva maneuver. Sims speculum examination should be used to clarify where the sagging originates. Referral to a Gynecologist or Urologist will likely be necessary for further evaluation and treatment.
Writer: Ozlem Guvenc Agaoglu