Evaluation

The initial step in the clinical evaluation is the identification of patients with urinary incontinence. Many older patients do not complain about incontinence to their health care provider because they are embarrassed or believe their symptoms are just part of normal aging. Direct questioning during the review of systems can help identify urinary incontinence: Do you have trouble with your bladder? Do you lose urine when you do not want to? Do you find that you have to wear pads or adult diapers for protection? (Fantl et al., 1996; Kane et al., 2004).

A thorough history and physical examination are important in the clinical evaluation of older patients with urinary incontinence. The main objectives of the workup are to diagnose and treat reversible causes, establish the principal type of urinary incontinence to help guide treatment, identify patients who may need subspecialty referral, and improve overall quality of life for the patient. Once urinary incontinence has been identified, the evaluation should continue with a detailed incontinence history, including the type of leakage, frequency, duration, inciting factors, previous treatments, and overall treatment goals. The physical exam should include abdominal, genitopelvic, rectal, and neurologic evaluation. Health care providers need to be aware of the specific "red flags" to refer a patient for further urologic, gynecologic, or urodynamic evaluation (Table 4-17).

A urinalysis should be obtained in all patients to assess for urinary tract infections, hematuria, or other medical conditions that may be associated with urinary incontinence. Persistent hematuria should prompt additional evaluation, including upper urinary tract imaging and cystoscopy. A postvoid residual volume (with ultrasound or catheterization) helps to exclude overflow incontinence. In clinical practice, a postvoid volume of less than 50 mL is regarded as normal, and in general, residual volumes greater than 200 mL are considered abnormal (Fantl et al., 1996).

Voiding (bladder) diaries can provide valuable information for the clinician and patient. The diary includes documentation of each urination episode and any associated symptoms of incontinence for three 24-hour periods. If possible, the patient can also record the amount of fluid intake and output (Abrams and Klevmark, 1996). Several patterns of abnormality can emerge from the voiding diary. For example, frequent small volumes can occur in patients with overactive bladder syndrome, detrusor overactivity, and some painful bladder conditions (e.g., cancer). Frequent large-volume voids are associated with polyuria, as seen in patients with excessive fluid intake and conditions causing polyuria (e.g., diabetes, hypercalcemia). Obstructive sleep apnea, physiologic aging, congestive heart failure, and medications can all cause nocturnal polyuria (Bryan et al., 2004). A simple office tool that can help detect stress incontinence is the cough test. The patient is asked to produce a forceful cough with a comfortably full bladder to determine any urine leakage and potential stress incontinence.

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