Editing Functional: Urinary Incontinence (section)

== Diagnosis and Evaluation of Urinary Incontinence ==

=== History and Physical Exam ===
* '''History'''
** Characterize incontinence (subjectively, quantify leakage, duration of symptoms, any inciting events that contributed to the onset of leakage, impact on daily life and activities)
** Voiding pattern should be defined
** Treatment expectations and an understanding of the balance between benefits and risks/burden of available treatment options.
** '''Females'''
*** Regarding pelvic prolapse specifically, focus on whether the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing.
*** Gynecologic and obstetric history, including gravity, parity, and hormonal status.
*** Determination of whether the patient is premenopausal, perimenopausal, or post-menopausal and whether she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy
* '''Physical examination'''
** '''Body habitus (BMI)'''
** '''Females'''
*** '''External genitalia:''' general appearance, estrogen status, lesions, and labial size, and adhesions.
**** Attention to the overall tissue appearance and color is important. Hormonally deficient vaginal tissue has a pale, flat, dry appearance with no rugae, as opposed to the healthy, pink rugated tissue of well-estrogenized tissue
**** '''Findings that may indicate estrogen deficiency (3):''' 
****#'''Urethral caruncle'''
****#'''Urethral prolapse'''
****#'''Labial adhesions'''
*** '''Urethral position''' '''and mobility'''
**** '''Should be assessed at rest and with straining and coughing.'''
**** The Q-tip test was developed to objectify the evaluation of urethral mobility.
***** With the patient in the lithotomy position, a Q-tip is inserted into bladder through the urethra and the angle that the Q-tip moves from horizontal to its final position with straining is measured.
***** '''Hypermobility is defined as a Q-tip angle of > 30° from horizontal.'''
*** '''Assessment of prolapse'''
**** '''Ideally, should be performed in both the lithotomy and standing position'''.
** Anal sphincter tone
***A reflection of the function at S2-4
***Particularly important in neurologic patients with pelvic floor dysfunction

=== Laboratory ===
* Urinalysis
* Optional: PSA, blood tests (eg. urea and electrolytes)

=== Imaging ===
* Standard imaging studies are not necessary in the initial evaluation of uncomplicated incontinence.
** Upper and lower urinary tract imaging in patients in whom renal damage or pelvic pathologic conditions are suspected should be performed.
* Voiding cystourethrogram (VCUG)
** Optional in patients with recurrent UTIs, but can be helpful in the diagnosis of a urethral diverticulum or VUR.
* MRI
** Has been proposed as an ideal method by which to evaluate the anatomy of the bladder neck and urethra with good correlation with functional studies.
** Has also been advocated for evaluation of pelvic floor relaxation and pelvic organ prolapse.

=== Other ===
* Circumstances that warrant consideration of supplemental evaluation:
*# Inability to establish a diagnosis based on the patient’s symptoms and initial evaluation
*# Concomitant overactive bladder symptoms
*# Prior lower urinary tract surgery including anti-incontinence surgery
*# Known or suspected neurogenic bladder
*# Negative stress test
*# Abnormal urinalysis (e.g. unexplained hematuria or pyruia)
*# Elevated postvoid residual
*# High-grade (stage ≥3) pelvic prolapse
*# Evidence of dysfunctional voiding

==== Symptom quantification instruments ====
* Voiding diaries can provide both diagnostic and therapeutic advantages.
** The use of diaries often helps patients realized their pattern of urination and is more accurate than recall. Furthermore, the diary can provide patients with insights into those behaviors that can be altered to decrease urinary frequency.
* '''3-day voiding diary offers the same information as a 7-day one without being too exhaustive for patients'''

==== Questionnaires ====
* Several validated questionnaires exist, including the International Consultation on Incontinence questionnaire short form (ICIQ-SF).
* Both the voiding diary and the quality of life questionnaire not only help in the assessment of patients but also help in looking at treatment effects if repeated after the same patient has been treated

==== Postvoid residual ====
* No established volumes that define normal or impaired emptying

==== Cystoscopy ====
* Routine cystoscopy is not advocated in the evaluation of uncomplicated urinary incontinence
** Cystoscopy should be considered in patients with 
***Urinary urgency
***Hematuria
***Other irritative symptoms
***History of anti-incontinence procedure, pelvic radiation, or pelvic prolapse repair.

==== Urodynamics ====
* '''Should only be performed when it is going to change the management of the patient'''
** Consider UDS in patients who are 
***Considering invasive, potentially morbid or irreversible surgery
***Have failed previous pelvic floor reconstruction
***Have mixed incontinence, urinary urgency, or obstructive symptoms
***Patients who have elevated PVRs or neurologic disease.
* Multichannel UDS offers an extensive evaluation of LUT function.
** The degree of accuracy provided by multichannel UDS is important in a variety of circumstances, including:
*** Conservative treatment methods fail
*** Diagnosis is unclear
*** Previous diagnostic procedures are inconclusive
*** Clinical pictures complicated by radiation therapy, neurologic disease, or prior failed pelvic floor reconstruction or antiincontinence surgery
*** Symptoms that cannot be confirmed by the clinician.
* One important scenario that can occur during urodynamics is cough-induced detrusor overactivity incontinence, which happens when the patient coughs and this action initiates an involuntary detrusor contraction, and the patient leaks because of the detrusor overactivity contraction rather than because of the raised intra-adominal pressure generated by the cough. Clinically, it sounds as if the patient is leaking because of SUI, whereas the urodynamics show that he has cough-induced detrusor overactivity.
* '''Occult SUI is SUI unmasked by reduction of prolapse; 11-50% of clinically continent patients will develop de novo SUI after repair of high-grade prolapse.'''
* '''Colpopexy and Urinary Reduction Efforts (CARE) trial'''
** '''Population: women with SUI undergoing sacrocolpopexy for prolapse'''
** '''Randomized to concomitant Burch colposuspension vs. no concomitant procedure'''
** '''Results'''
*** Premature termination of trial after the first interim analysis at 3 months which showed '''significant reduction in SUI in patient undergoing Burch vs. control''' (24% vs. 44%)

==== Pad tests ====
* Can be helpful in quantifying leakage
* Tedious and cumbersome; generally used for academic purposes.
** Most guidelines have not recommended the use of pad testing.
** Many investigators advocate for pad tests in clinical trials, because pad tests can provide objective, precise information for assessment of actual volume of urine lost over an established period.
** The International Continence Society recommends both a 3-day bladder diary and pad weight test as proper measures for symptom quantification in incontinence research.
* '''Urine loss >1.3g is considered a positive 24-hour pad test, whereas others consider up to 8g of urine loss in 24 hours to be normal'''
** '''Vaginal secretions should be taken into consideration, although the volume attributable to normal vaginal secretions may be as low as 0.3g in 24 hours'''.

==== Dye testing in females ====
* '''Can be helpful to verify that the leakage represents urine versus another fluid such as vaginal discharge or peritoneal fluid and to substantiate the diagnosis of urinary tract fistulae.'''
* '''Oral phenazopyridine''' (100-200mg three times per day)''', also known as pyridium, colors the urine orange, and this simple test can confirm that the leakage fluid is indeed urine.'''
* '''Diagnosis of a vesicovaginal or urethrovaginal fistula can be supported by blue or orange staining of an intravaginal tampon after intravesical instillation of methylene blue or pyridium dissolved in sterile water or saline.'''
* '''<span style="color:#ff0000">In the case of a suspected ureterovaginal fistula, intravesical methylene blue with concurrent oral phenazopyridine (pyridium) can elucidate the fistula location based on the staining pattern on the vaginal tampon</span>'''
** '''<span style="color:#ff0000">Orange staining suggests a ureteral communication</span>'''
** '''<span style="color:#ff0000">Blue staining suggests a bladder communication</span>'''
** '''<span style="color:#ff0000">Simultaneous vesicovaginal and ureterovaginal fistulae can occur.</span>'''