Pelvic mass. Palpate for evidence of a pelvic mass, which can cause urinary obstruction and lead to overflow incontinence.
Kegel exercises. Ask her to perform a Kegel maneuver. If she’s doing it correctly, her perineal body should be easily seen moving upward toward her clitoris and inward toward her introitus. If you place a finger in the vagina and ask her to begin Kegel exercises, you’ll feel the tightening of the pelvic muscles if she’s doing it right. When she does this on her own, she can insert her own finger into the vagina to ensure that her technique is correct or simply practice stopping the flow of urine.
After completing the pelvic exam, perform a cough stress test. With the patient in the lithotomy position, ask her to cough while you hold the labia apart, both to observe for any leakage of urine and to approximate the volume leaked, if any ( FIGURE ). To encourage her to bear down with ample force, remind her that here, too, both leakage of urine and passing of flatus are expected.
Postvoid residual (PVr). After the pelvic exam and cough stress test, the patient should urinate and the PVR should be promptly measured. If you have doubts about her ability to provide a clean-catch urine sample (or your clinic does not have a bladder scanning ultrasound), consider obtaining the PVR via a straight catheterization. A normal PVR is 0 to 200 cc.
By now you should have the information you need to determine whether to treat the incontinence yourself or refer the patient to a urologist or urogynecologist.
FIGURE
Positive cough stress test
A physician separates the labia to observe urine leakage during a cough stress test.
Treat these conditions yourself
Dx: Uncomplicated stress incontinence. The patient has a positive cough stress test, and most urinary incontinence episodes she recorded are stress type. Urinalysis and PVR are normal, with no evidence of pelvic organ prolapse on exam.
Well-timed pelvic floor (Kegel) exercises have been shown to significantly reduce symptoms of both stress and urge incontinence when they’re done regularly, starting with 4 times a day and increased slowly to 8 times twice a day.9 Review Kegel technique and advise the patient to perform this maneuver and hold the contraction, if possible, whenever she is about to cough, laugh, sneeze, or otherwise exert herself. Tell her to practice Kegel exercises until they become second nature. If she continues to have trouble, she may need a referral to pelvic floor physical therapy to learn to do them effectively. (You can go to http://www.apta.org/apta/findapt/index.aspx?navID=10737422525 to find a therapist specializing in women’s health in your area.)
Dx: Uncomplicated urge incontinence. The patient has a normal cough stress test and most of her urinary incontinence episodes are the urge type. Her pelvic exam and PVR are within normal limits.
Prescribe an anticholinergic bladder agent. Medication with antimuscarinic properties has been shown to decrease urge incontinence and significantly improve patient-reported measures of quality of life.10
A reasonable approach is to start her on an inexpensive generic medication ( TABLE )11,12 and follow up in one month. If the medication helps and does not cause adverse effects, she can be maintained on it; if it’s effective but she has significant adverse effects (eg, constipation, dry mouth, blurred vision, urinary retention, as well as confusion and sedation in the elderly), the patient can be switched to a more expensive brand-name drug with fewer adverse effects.
Behavioral training, including timed voiding and Kegel exercises, has been shown to significantly decrease symptoms of urge incontinence.9 Timed voiding can be especially helpful for nocturnal urge incontinence; advise the patient to set an alarm for an hour before the usual time she awakens with a sense of urgency, and to empty her bladder before it is so full that she leaks.
Point out, too, that not every urinary urge requires immediately running to the toilet. A randomized, placebo-controlled trial found that patients who were taught to respond to visual cues, such as a toilet, by walking past it, then sitting down, relaxing, and contracting their pelvic muscles repeatedly had diminished urgency. Their actions also inhibited detrusor contractions, and often prevented urine loss. When the training was combined with one or 2 lessons in proper Kegel technique—reinforced at several visits—weekly incontinence episodes were reduced by 80%. The controls, who had the same number of clinic visits but did not receive specific education on urgency-reduction strategies, reduced incontinence episodes by 40%.13