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Evaluation of Stress Urinary Incontinence

Author: William D. Po, MD

Mentor: Christopher M. Zahn, MD
Editor: Sangini Sheth, MD

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Stress urinary incontinence is an involuntary urinary loss from physical exertion related to increased abdominal pressure, resulting in a reduced quality of life.  Of the 16% of adult women with SUI, 78% report bothersome symptoms and 29% of this group have extreme symptoms. The evaluation should include history, physical exam, urinalysis, demonstration of stress incontinence, assessment of urethral mobility, and the measurement of a post-void residual (PVR) volume.  Treatments for SUI should start with conservative therapies (pelvic floor exercises, behavioral modifications, continence support devices, and urethral inserts). Surgical treatments options (retropubic urethropexies, autologous, fascial slings, urethral bulking agents, and synthetic midurethral slings) are available if conservative therapy is not successful.

Taking a history differentiates the various types of incontinence: stress, urge, postural, continuous (total), coital, spontaneous, or incontinence associated with chronic urinary retention, nocturnal enuresis, or a mix of types. Questions should elicit symptoms related to bladder storage (frequency, nocturia, urgency, incontinency) and emptying functions (hesitancy, straining, e.g.).  Other questions should include precipitating events, frequency, severity, pad use, and effects on the activities of daily living. Validated questionnaires exist and should be used to assess for prevalence of SUI symptoms and risk factors, impact on QOL, and response to non-surgical therapies.  Voiding diaries are reproducible diagnostic tools in the setting of SUI. The diaries record volume, type of fluid intake, frequency and volume of voids, and any nocturnal episodes.  Medication history (diuretics, caffeine, alcohol, anticholinergics, and more may affect bladder function), medical history (assessing the presence of conditions such as diabetes and neurologic disorders), and gynecologic, surgical, and obstetrical histories should be obtained.

Performing a physical exam ensures a thorough evaluation of other factors that may contribute to the patient’s symptoms and confound the diagnosis of incontinence such as a urethral diverticulum, fistula, and vaginal discharge. Presence of pelvic organ prolapse suggests need for thorough multi-compartment pelvic evaluation.  Reduction of the prolapse can result in complicated SUI that masks SUI symptoms. Pelvic organ prolapse that extends past the hymen may necessitate multichannel urodynamic testing. A urinalysis to identify urinary tract infection (UTI) may be the only necessary laboratory evaluation.  Any UTI must be treated before proceeding with any further evaluations and therapies.

Differentiating uncomplicated from complicated SUI is important. Uncomplicated SUI is defined as leakage on Valsalva or physical exertion with only urethral hypermobility and a postvoid residual (PVR) of less than 150 cc.  However, a complicated SU can include a history of UTI, prior pelvic surgery, voiding symptoms, contributing medical conditions, severe pelvic organ prolapse and symptoms associated with urgency or retention.

Before surgery is performed, objective measurement of stress urinary incontinence should be objectively demonstrated with visualization of urinary leakage when the patient is made to cough in the supine position If no leakage occurs, another measurement with the patient standing and coughing with a full bladder of 300 ml of fluid can be attempted. However, a delay in leakage may be due to cough-induced detrusor over-activity. If there is a delay or if leakage is not demonstrated, multichannel testing is recommended.

Surgical outcomes are more successful in patients with urethral hypermobility. The cotton swab test is positive when there is a 30 degree or greater displacement from the horizontal when the patient is in the supine lithotomy position and straining.

A post void residual volume of less than 150 ml can help exclude a bladder-emptying abnormality or chronic urinary retention (overflow incontinence). An abnormal volume may necessitate multichannel testing. Simple office cystometry with a catheter and syringe can aid in determining post void residual, basic bladder capacity, and ensuring at least 300 ml for Valsalva leakage testing. Multichannel urodynamic testing is not needed with uncomplicated SUI prior to surgery.

Further Reading:

ACOG Practice Bulletin No. 155: Urinary Incontinence in Women. Obstet Gynecol. 2015 Nov;126(5):e66-e81. doi: 10.1097/AOG.0000000000001148. PMID: 26488524.

Committee Opinion No. 603: Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. Obstet Gynecol. 2014 Jun;123(6):1403-1407. doi: 10.1097/01.AOG.0000450759.34453.31. PMID: 24848922.

Initial approval November 2015; Reaffirmed May 2017; November 2018; Reaffirmed July 2020; Revised January 2022, Revised September 2023


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