Assessment of Urinary Incontinence

TAKING THE HISTORY
EXAMINATION
INVESTIGATIONS


Taking the history

Incontinence is a symptom of an underlying disorder and a continence assessment is essential to identify possible causes and to plan treatment or referral for specialist advice. Therefore high quality continence services should be based on the principles of proactive detection of any problem and early treatment of incontinence. This requires assessment of the whole patient rather than just his or her continence problems. People with bladder and / or bowel problems, but without incontinence, will also benefit from assessment – as it may be possible to identify risk factors and prevent incontinence occurring.

The aim of taking the history is to build up a complete picture of the bladder or bowel dysfunction and why the individual is failing to cope with it. Most people find talking about their incontinence embarrassing, so taking a full history needs time and a sympathetic approach.

Assessment takes time and it is important not to rush the patient. Maintain their privacy and dignity at all times. Remember to use words the patient understands. To many people incontinence means total loss of control and they will deny suffering from it, while admitting to 'leaking', 'damp pants', or 'occasional wetness'.

Here is a list of the key points that the history should cover, together with trigger questions designed to draw out that information. Further probing will probably be necessary to clarify some of the points. Note should be taken of any exacerbating conditions e.g. chronic cough.

Key Points and Trigger Questions


Stress incontinence
Do you get wet when you cough or exercise?

Day and night frequency
How often do you pass water each day? (up to 8 times is normal)
How many times are you woken by the need to pass water at night? (up to twice is normal)

Urgency/urge incontinence
Do you have to rush to passs water?
Do you always make it to the toilet in time?

Voiding difficulties
Do you have to wait for the stream to start? (hesitancy)
Does your urine come out reasonably fast? (poor stream)
Do you feel as if you empty your bladder? (incomplete voiding)
Do you have to strain or push? (straining)
Do you ever get wet unexpectedly when you think you have finished passing water? (Post-micturition dribbling)

Symptoms of urinary tract infection
Does it ever hurt or burn when you pass water?
Does your urine smell unpleasant?
Have you started to pass water very frequently?

Haematuria
Do you ever see blood in your water?

Do you always make it to the toilet on time?

Symptoms of incontinence
When did this leakage start? (onset)
How often are you getting wet? (frequency)
How much leaks out - a few drops, enough to wet your clothes or a whole bladder full? (extent)
How do you cope with this leakage? (self-management)

Bowel habit
How many times a day do you open your bowels? (1 to 9 times in 3 days is normal)
Is the motion hard?
Do you have to strain?

Faecal incontinence
Do you ever get leakage from the back passage? (an affirmative answer needs following up)

Fluid intake
How many cups of liquid do you drink in a day?
What type of drinks?

How much do you drink in the evenings?

Do you ever drink overnight, if you wake to pass water?

Medication, caffeine, alcohol
Ask about over-the-counter as well as prescribed drugs

Mobility and dexterity
Do you have any difficulties getting to the toilet?
Do you have any difficulties adjusting your clothes?

Environment
Where is your toilet?- Upstairs, downstairs?

Mental state
Note confusion, anxiety, depression and the patient's attitude to their problem

Past medical history
Gynaecological, neurological, diabetes, back operations

Desire for treatment
Motivation and expectations of the patient.

RETURN TO TOP OF PAGE
CAUSES OF URINARY INCONTINENCE
ASSESSMENT OF URINARY INCONTINENCE
TREATMENT OF URINARY INCONTINENCE
FAECAL INCONTINENCE
LIVING WITH INCONTINENCE
MANAGING INCONTINENCE
FURTHER READING

NOTE: THE EXAMINATION AS DESCRIBED SHOULD OF COURSE BE UNDERTAKEN ONLY SUBJECT TO APPROPRIATE QUALIFICATIONS AND EXERIENCE.

Treatment of stress incontinence

General treatment

Treat chronic cough and constipation and encourage weight loss if appropriate.

Pelvic floor exercises should be undertaken for at least six months before surgery is considered. They will cure more than 70% of mild-to-moderate cases in 3 to 6 months but must be performed correctly (check by vaginal examination) and regularly, with frequent supervision and boosting of motivation.Weighted vaginal cones may add biofeedback and enhance motivation.

Electrotherapy and biofeedback therapy administered by a physiotherapist or suitably trained continence nurse specialist may be helpful if the patient cannot locate the correct muscle or if progress is slow.

Post-prostatectomy stress incontinence in men will often respond to pelvic floor exercise.

Drug therapy

Oral or topical oestrogen replacement may help women with post-menopausal atrophic changes.

Surgery

Several well established operations are in use to cure stress incontinence. They are thought to enhance pelvic floor muscle support of the bladder neck and urethra by elevating the bladder neck and preventing it from opening or by supporting the urethra or in some cases by partially obstructing outflow. Until the late 1990s, the most popular operation was the Burch Colposuspension, a retro-pubic (abdominal) operation with a success rate of approximately 85% at five years. It can be performed as an open or laparoscopic procedure, but to date there have been no long term studies assessing the cure rate of the laparoscopic procedure.

Needle suspensions such as the Stamey have a comparatively poor long term cure rate and anterior repair of the vaginal wall is appropriate only when the primary objective is to cure prolapse of the anterior vaginal wall (cystocele) and curing stress incontinence is of less importance. When previous operations have failed and the vagina is restricted or immobile or just scarred from previous surgery, it may be useful to perform a sling procedure. This can be done either abdominally or vaginally or as a combined procedure.

The most recent type of sling is the "tension free vaginal tape" (TVT) which is a knitted prolene mesh passed under the mid-urethra using two insertion needles. This is an attractive procedure as it can be carried out under local anaesthetic as a day case operation, but there are no long term results available as yet.

Another less invasive treatment for stress incontinence is the use of bulking agents which are injected around the bladder neck. The most commonly used are collagen or microparticulate silicone. This procedure also can be performed on a day case basis and can be repeated but unfortunately the long term results are not particularly good, making it more suitable for those who are unable to undergo conventional surgery.

As the first operation is the one that is most likely to cure stress incontinence and subsequent procedures become progressively less effective, it is important that the best operation is performed on the first occasion following adequate pre-operative assessment.

For men whose condition does not repond to pelvic floor exercises, surgical repair is indicated (e.g. artificial sphincter).

Conservative treatment

If female patients refuse treatment, or treatment fails, various proprietary devices are available that may enable them to attain social continence.


Treatment of urge incontinence (overactive bladder)

General treatment

Decreasing caffeine and alcohol intake may help. Pelvic floor exercises may improve the ability to hold on.

Bladder retraining in conjunction with drug treatment

Encourage the patient to keep a bladder record chart. There are two examples on this site: a simple one is shown in the section on Symptoms and Treatments. A more sophisticated chart will allow for recording also of fluid intake - patients can be asked to measure or estimate the volume of intake and of voids - but there are different views about the usefulness and practicality of such detail. The aim is to increase the time between visits or the volume passed each time. Regular review and encouragement is crucial to the success of this approach.

The most effective drugs are anticholinergics. Among the available options are the following:

oxybutynin (usual dose 2.5mg - 5 mg b.d. or t.d.s., or daily in slow release format: or as a transdermal patch, twice per week)

tolterodine (2 mg b.d. or slow release daily)

propiverine (15 mg t.d.s.)

trospium (20mg b.d)

solifenacin (5mg - 10mg daily)

darifenacin (7.5mg or 15mg daily)

These drugs should be closely monitored for signs of retention and side effects (dry mouth, constipation, heartburn, blurred vision, headache and abdominal pain). Many patients benefit from starting with a low dose, to facilitate tolerance, and gradually increasing until maximum effect is achieved.

Alarms and hormone treatment

For nocturnal enuresis in adults or children, modern body-worn enuresis alarms are discreet and comfortable and particularly effective for children. Anticholinergics may help but relapse is common. Synthetic antidiuretic hormone, desmopressin (e.g. as a nasal spray - 20 µg nocte - or tablet - 200 µg nocte), is safe and effective in adults and children but should be used with caution in older people and those with a renal or cardiac problem. It is useful for short-term relief such as on holiday.

Neurotrophic electrical stimulation

This is found helpful by some patients with neurogenic incontinence including those with spinal cord injury.

Surgery

This is seldom indicated, though severe intractable cases can be managed by clam ileocystoplasty - bladder augmentation with a patch of small bowel. Intermittent self-catheterisation is often needed for complete bladder emptying after this operation.

Complementary therapies

There are anecdotal reports of successful treatment of detrusor instability by various complementary approaches, including hypnotherapy, homeopathy, psychotherapy and acupuncture.