Editing AUA: Female SUI (2023) (section)

== Diagnosis and Evaluation of Patients Wanting Surgery for SUI ==

=== Recommended Investigations ===

==== Mandatory (4): ====
# '''<span style="color:#ff0000">History (including assessment of bother) and Physical Exam</span>'''
# '''<span style="color:#ff0000">Objective demonstration of stress urinary incontinence</span>'''
# '''<span style="color:#ff0000">Urinalysis</span>'''
# '''<span style="color:#ff0000">PVR</span>'''

=== History and Physical Exam ===

==== History ====
* '''<span style="color:#ff0000">Characterize incontinence</span>''' (stress, urgency, mixed, continuous, without sensory awareness).
** Presence of coughing, sneezing, lifting, walking, or running as initiators of incontinence increases the likelihood of SUI as the cause of urinary leakage
** '''<span style="color:#ff0000">Chronicity of symptoms</span>'''
** '''<span style="color:#ff0000">Frequency, bother, and severity</span>''' of incontinence episodes. Pad or protection use.
*** '''<span style="color:#ff0000">An assessment of bother is paramount to the decision to operate in the index patient.</span>'''
* '''<span style="color:#ff0000">Associated</span>''' 
**'''<span style="color:#ff0000">Urinary tract symptoms</span>''' (e.g., urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying)
** '''<span style="color:#ff0000">Pelvic symptoms</span>''' (e.g., pelvic pain, pressure, bulging, dyspareunia)
**'''<span style="color:#ff0000">GI symptoms</span>''' (e.g., constipation, diarrhea, splinting to defecate)
* '''<span style="color:#ff0000">Menopausal status</span>'''
* '''<span style="color:#ff0000">Obstetric history</span>''' (e.g., gravity, parity, method of delivery)
* '''<span style="color:#ff0000">Previous pelvic surgeries</span>'''
* '''<span style="color:#ff0000">Past medical history</span>''' (e.g., hypertension, diabetes, history of pelvic radiation)
* '''<span style="color:#ff0000">Current and past medications</span>'''
* '''<span style="color:#ff0000">Fluid, alcohol, and caffeine intake</span>'''
* '''<span style="color:#ff0000">Previous treatments for incontinence</span>''' (e.g., behavioral therapy, Kegel exercises/pelvic floor muscle training, pharmacotherapy, surgery)
* '''<span style="color:#ff0000">Patient’s expectations of treatment</span>''' (patient-centered goals)
* '''<span style="color:#ff0000">History alone, while helpful, does not definitively diagnose SUI in women</span>'''

==== Physical exam (6): ====
# '''<span style="color:#ff0000">Stress test (supine and/or standing) with comfortably full bladder</span>'''
# '''<span style="color:#ff0000">Focused abdominal examination</span>'''
# '''<span style="color:#ff0000">Urethral mobility</span>''' (Q-tip test or other method)
# '''<span style="color:#ff0000">Pelvic prolapse</span>''' (any method)
# '''<span style="color:#ff0000">Vaginal atrophy/estrogenization status</span>'''
# '''<span style="color:#ff0000">Focused neurologic examination</span>'''

==== Objective demonstration of SUI ====
* '''<span style="color:#ff0000">Stress test (supine and/or standing) with comfortably full bladder</span>'''
** Considered positive if involuntary urine loss from the urethral meatus is witnessed coincident with increased abdominal pressure
*** A positive stress test had a high sensitivity and specificity for detecting SUI
** '''If leakage is not witnessed in the supine position, the test may be repeated in the standing position to facilitate the diagnosis'''

==== Urinalysis ====
* Screen for abnormalities (microscopic hematuria, pyuria, etc.), which may prompt further investigations and reveal underlying cause (bladder tumour, for example) of incontinence

==== Post-void Residual (PVR) ====
* May prompt further investigations and reveal underlying cause (overflow, for example) of incontinence

=== Other Tests ===

===== Questionnaires =====
* Overall, low strength of evidence due to limited number of studies for each questionnaire

===== Q-tip test =====
* '''Positive test is unlikely to aid in the diagnosis of SUI; SUI may exist without urethral hypermobility and vice versa.'''
* Can provide potentially useful information regarding the degree of urethral mobility

===== Pad test =====
* May confirm the presence of incontinence but does not distinguish the specific type

=== Additional Evaluations ===
* '''<span style="color:#ff0000">Should be considered for patients with the following conditions (8)</span>''':
*# '''<span style="color:#ff0000">Neurogenic lower urinary tract dysfunction</span>''' (known or suspected)
*# '''<span style="color:#ff0000">Inability to demonstrate stress urinary incontinence</span>'''
*# '''<span style="color:#ff0000">Inability to make definitive diagnosis based on symptoms and initial evaluation</span>'''
*# '''<span style="color:#ff0000">Elevated post-void residual</span>''' per clinician judgment
*# '''<span style="color:#ff0000">Evidence of significant voiding dysfunction</span>'''
*# '''<span style="color:#ff0000">Urgency-predominant mixed urinary incontinence</span>'''
*# '''<span style="color:#ff0000">Abnormal urinalysis,</span>''' such as unexplained hematuria or pyuria
*# '''<span style="color:#ff0000">High grade pelvic organ prolapse</span>''' (POP-Q stage 3 or higher) '''if SUI not demonstrated by pelvic organ prolapse reduction'''
* '''May be performed in patients with:'''
** Concomitant overactive bladder symptoms
** Failure of prior anti-incontinence surgery
** Prior pelvic prolapse surgery

==== Cystoscopy ====
* '''<span style="color:#ff0000">Should not be performed in index patients for the evaluation of SUI</span>''' 
*'''<span style="color:#ff0000">Indications (3):</span>'''
*#'''<span style="color:#ff0000">Suspected bladder pathology</span>''' based on history or concerning findings on physical exam or urinalysis (e.g. microhematuria)
*#'''<span style="color:#ff0000">Structural lower urinary tract abnormality</span>'''
*#'''<span style="color:#ff0000">Patients undergoing certain surgical procedures (e.g., midurethral (MUS) or pubovaginal fascial (PVS) slings)</span> to confirm the integrity of the lower urinary tract and the absence of foreign body'''
*#'''<span style="color:#ff0000">History of prior anti-incontinence surgery or pelvic floor reconstruction, particularly if mesh or suture perforation is suspected</span>'''
*#*'''Perforation should be suspected with new onset of lower urinary tract symptoms, hematuria, or recurrent UTI'''

==== UDS ====
* '''<span style="color:#ff0000">May be omitted for the index patient desiring treatment when SUI is clearly demonstrated'''
**'''<span style="color:#ff00ff">VALUE (NEJM 2012)</span>'''
***Population: 630 females with uncomplicated SUI
***Randomized to preoperative office evaluation and urodynamic tests vs. evaluation only
***Primary outcome: Treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of “much better” or “very much better” on the Patient Global Impression of Improvement
***Results: preoperative office evaluation alone was not inferior to evaluation with urodynamic testing
***[https://pubmed.ncbi.nlm.nih.gov/22551104/ Nager, Charles W., et al. "A randomized trial of urodynamic testing before stress-incontinence surgery." ''New England Journal of Medicine'' 366.21 (2012): 1987-1997.]
* '''<span style="color:#ff0000">May be performed at the urologist’s discretion in certain non-index patients, including but not limited to (8):'''
*# '''<span style="color:#ff0000">Neurogenic lower urinary tract dysfunction</span>'''
*# '''<span style="color:#ff0000">Unconfirmed SUI</span>'''
*# '''<span style="color:#ff0000">Mismatch between subjective and objective measures</span>'''
*# '''<span style="color:#ff0000">Elevated PVR per clinician judgment</span>'''
*# '''<span style="color:#ff0000">Significant voiding dysfunction</span>'''
*# '''<span style="color:#ff0000">Significant urgency, UUI, overactive bladder (OAB)</span>'''
*# '''<span style="color:#ff0000">History of prior pelvic organ prolapse surgery</span>'''
*# '''<span style="color:#ff0000">History of prior anti-incontinence surgery</span>'''