The basics - Diagnosing incontinence

An understanding of the types of incontinence and how they differ is essential, says Joanne Townsend.

Full bladder: consider the main symptom before treating
Full bladder: consider the main symptom before treating

The definitions of stress urinary incontinence (SUI), overactive bladder (OAB) or mixed urinary incontinence (MUI), and the differences between these conditions should be understood before undertaking a urinary assessment.

SUI is the complaint of involuntary leakage on effort or exertion. The pelvic floor muscles are unable to maintain adequate closure pressure around the urethra when abdominal pressure is exerted upon them, causing urine to leak from the bladder, usually during activities such as coughing, lifting, bending and jumping.

Urgency, with or without urge incontinence, usually with frequency and nocturia, defines OAB syndrome. Symptoms are caused by the detrusor muscle of the bladder overriding the pelvic floor muscles and expelling the contents of the bladder with little or no warning.

The unpredictable nature of this condition is distressing for patients. MUI is a combination of both SUI and OAB.

Risk factors
An awareness of the risk factors is vital for assessment. Urinary incontinence in both men and women develops with age, but in women it can become more severe with increasing age.

Additional risk factors for women include pregnancy and childbirth, a higher BMI and the menopause, as well as smoking and family history.

Chronic conditions including Parkinson's disease, multiple sclerosis, spinal cord injury, diabetes and stroke may contribute towards incontinence, and treatments for gynaecological cancers, such as radiotherapy, and some pelvic surgery are also known to increase the risk of urinary incontinence.

In men, problems may occur after prostate surgery; but there are no studies clearly identifying the risk factors for developing urinary incontinence in men.

Ask questions
The priority must be to rule out any red flag symptoms that could indicate other pathologies.

The International Continence Society format for classifying urinary symptoms into storage, voiding and post-micturition symptoms should be employed. Assessment questions should reflect possible causes and risk factors.

In general, cover the patient's medical history and potential disorders of the neurological, metabolic, cardiorespiratory and renal systems.

The patient's drug history should be assessed, specifically for medications that may be associated with urinary symptoms such as diuretics and those that may cause CNS side-effects. Alcohol use must be considered.

Surgical history, including previous gynaecological surgery, especially for pelvic organ prolapse, and continence surgery should be noted. Sexual function should also be considered and, in women, consider future child bearing potential.

Assess bowel function and symptoms, as urinary symptoms rarely occur in isolation.

Mental health and cognitive assessment must be taken into account, as should a functional assessment with particular consideration for dexterity and functional ability to reach the toilet and use toileting aids if they are required.

Key Points
  • Catergorise the symptoms to establish a diagnosis of SUI, OAB or MUI.
  • Consider the history and risk factors of the individual patient.
  • Assess using an FVC if possible.
  • Direct treatment towards the predominant symptom.

Assessment tools and tests
Frequency volume charts (FVC) or bladder diaries, if the patient can complete them accurately, can be essential for assessment.

FVCs can provide data collected over a number of days on voiding volumes, times, urine output and, in some cases, the types and volumes of fluids taken orally.

The symptoms of urinary urgency, frequency and nocturia will respond to a programme of bladder retraining. A FVC will help to instigate an individualised treatment regimen to increase voiding intervals.

Pelvic examination, including vaginal and possibly rectal examination, may be indicated. A digital rectal examination is recommended in male patients to assess prostate size, shape and consistency and to check for other rectal pathologies.

An individualised regimen of pelvic floor muscle exercises cannot be undertaken without an initial accurate assessment of the pelvic floor muscles.

NICE supports routine digital assessment of pelvic floor muscle contraction before the use of pelvic floor muscle training for the treatment of urinary incontinence.

Assessment must include urinalysis to rule out underlying UTI. Assessment of post-micturition urine in women with possible voiding dysfunction (using a bladder ultrasound or urethral catheter) is recommended.

Urodynamics
The role of urodynamics is controversial; a lack of correlation between history taking and urodynamics has been established, and whether urodynamic findings assist future treatment is yet to be proven.

There is no guarantee that the patient's symptoms will be reproduced at the time of urodynamic investigation, and the tests can be undignified and have the potential to cause UTI, but it may prevent surgery where conservative and pharmacological options have failed.

Treatment decisions
NICE recommends treatment options based on the initial clinical assessment categorising the woman's symptoms as SUI, OAB or MUI. In women complaining of mixed symptoms, treatment should be directed towards the predominant one.

Ongoing monitoring will be enhanced by repeating aspects of the assessment, such as quality of life questionnaires, FVC or pelvic floor muscle assessment. This helps evaluate the existing interventions and guide future treatment.

The importance of a full assessment cannot be underestimated. Guidelines and pathways based on symptoms do not take into account individual and holistic assessment findings.

Treatments for urinary symptoms will only be effective if they are employed correctly and follow an accurate assessment.

  • Joanne Townsend is an urogynaecology nurse specialist at the University Hospitals of Leicester NHS Trust
Treatment options depending on assessment findings

Stress urinary incontinence:

  • Advise weight loss if BMI >30.
  • Supervised pelvic floor muscle training for a minimum of three months.
  • Consider electrical stimulation and/or biofeedback if patient cannot actively contract pelvic floor muscles.
  • Surgical intervention.
  • Duloxetine 40mg twice daily if pharmacotherapy preferred to surgery.

Overactive bladder:

  • Advise weight loss if BMI >30.
  • A trial of caffeine reduction.
  • Modification of high/low fluid intake.
  • Bladder retraining for a minimum of six weeks.
  • Anticholinergic drugs (if no contraindication).
  • Consider propiverine for frequency in OAB (but not urinary incontinence).
  • A trial of electrical stimulation (do not use routinely).
  • Intravaginal estrogen for postmenopausal women with OAB and vaginal atrophy.
  • Sacral nerve stimulation if no response to conservative treatments.

Mixed urinary incontinence:

  • Treat predominant symptom first.
  • Absorbent products, hand-held urinals and toileting aids should be used as a coping strategy pending definitive treatment, as an adjunct to other ongoing therapy, or for long-term management of incontinence only after treatment options have been explored.

 

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