Urinary incontinence (UI) is a common condition that affects physical, mental and psychosocial well-being. An estimated 25 million Americans experience UI.1,2 Although UI is not a life-threatening condition, its effects are profound: embarrassment, isolation, decreased self-esteem, shame and depression.3
UI is two to three times more common in women than in men.4 One in 4 women older than 18 experiences involuntary UI.5 Despite its prevalence, UI is frequently underdiagnosed and undertreated.6 Only about half of women with UI receive treatment.7 It is an underreported problem, often hidden or not disclosed due to embarrassment, beliefs that UI is a normal part of aging, and that symptoms are not severe enough to warrant treatment.8
Primary care NPs and PAs are in an optimal position to diagnose, evaluate and treat UI. According to the Agency for Healthcare Research and Quality, uncomplicated UI is best managed in the primary care setting.9 Unfortunately, UI is often missed or not prioritized in this setting.4
Many patients with UI do not specify the problem as a chief complaint. When providers do not ask UI screening questions, women may not disclose UI issues. Primary care NPs and PAs should therefore learn to identify women at risk for UI and perform routine screening for it.
The patient presentation associated with UI can vary widely. It is not unusual for women to describe UI symptoms secondary to other issues. Patients may voice complaints ranging from dysuria to skin irritation to other lower urinary tract symptoms. Women may attribute their symptomology to a urinary tract infection.
No matter what the patient presentation, incontinence is a symptom that can be successfully evaluated and treated in the primary care setting.
Types of UI
UI is characterized by the involuntary leakage of urine in any amount. Whether one drop or a large volume of urine, UI is a symptom, not a disease.3 Stress urinary incontinence (SUI) is the involuntary loss of urine with coughing, sneezing, lifting or straining. SUI is caused by increasing intra-abdominal pressure that exceeds urethral pressure. Urge urinary incontinence (UUI) is the strong, sudden need to urinate resulting from abnormal bladder spasms or detrusor instability, resulting in the loss of urine. UUI is often referred to as overactive bladder or detrusor hyperreflexia.10 Mixed urinary incontinence (MUI) is a combination of stress and urge incontinence. For women with MUI, assessment and treatment of the most bothersome symptom are warranted.10
Overlap between male and female risk factors exists, but some UI risk factors are unique to women. Risk factors for urinary incontinence in women are listed in Table 1. Consider including UI screening questions for any patient presenting with multiple UI risk factors, with or without a chief complaint of UI.
The initial evaluation of UI should include a health history focused on UI. This involves having an in-depth conversation about the quality and characteristics of the incontinence, as well as the overall impact on quality of life (Table 2). The initial questions should focus on the presence of lower urinary tract symptoms, including urgency, intensity, dysuria and nocturia. Questions about the severity, duration and frequency of the incontinence are also necessary. Conduct a full review of systems, including co-morbid conditions associated with UI. These include frequent UTIs, constipation, diabetes, obesity, chronic bronchitis, asthma, heart failure, multiple sclerosis and/or nerve injuries.11
A gynecologic history, including questions specific to pregnancies, deliveries and any history of pelvic surgery, should be collected. Ask about fluid intake, bowel habits, consumption of bladder irritants and use of specific medications, particularly diuretics, anticholinergics, angiotensin-converting enzyme inhibitors, psychotropics, and narcotics.
Quality-of-life and symptom severity scales may assist in evaluation. Two common survey instruments are the Urogenital Distress Inventory (UDI-6; http://www.mrptny.com/f/Incontinence_Questionnaire.pdf) and the Incontinence Impact Questionnaire (IIQ-7; http://www.gericareonline.net/tools/). These tools are brief and can be self-administered. They are frequently used to assess quality of life, symptom severity and UI type.11 Both are readily accessible, cost effective and have demonstrated significant validity and reliability for assessment of UI. These tools are often used in urologic specialty clinics, and they can provide a wealth of information in primary care settings.
An additional piece of the UI history is a voiding diary covering 24 to 72 hours. Components of the voiding diary include time and amount of all voids, incontinence episodes, leakage amount, activity during leakage, symptoms before urination (including urgency), fluid intake, and use of bladder irritants.12 The voiding diary allows the provider to cluster information specific to bladder habits and to determine the extent and precipitating factors of the UI.12 The diary can be revealing, since many women may not pay attention to exact quantities of urine output or fluid intake. Women may not realize the extent or severity of their UI or how much they have changed their habits as a result of it.
Focused Physical Examination
A focused physical examination is essential in the evaluation of UI. To determine secondary causes and pinpoint specific UI issues, the physical exam must include assessment of multiple systems, not just the genitourinary system. Table 3 provides a description of the complete focused physical examination. The exam may reveal underlying issues and may help identify whether the cause of the UI is stress or urge incontinence.
Click to view larger graphic.
Click to view larger graphic.
The patient should empty her bladder immediately before the physical exam. This enables assessment of postvoid residual (PVR). The PVR test can be conducted easily in the primary care setting, and it should be performed within 10 minutes of voluntary bladder emptying.10 The PVR test involves insertion of a straight "in and out" catheter and measurement of the residual content of urine after urination. The advantage of the PVR test is that it can assess all types of UI. A PVR measuring less than 25 mL is considered normal.10 A PVR measuring more than 100 mL is considered abnormal and may warrant surveillance and/or treatment when symptoms are reported.10
An additional advantage to conducting the sterile catheterization is the ability to obtain a sterile specimen for urinalysis and culture. Urinalysis findings are an essential piece of the evaluation for UI, especially when symptoms of urgency and frequency are reported. The results of the urinalysis assist in ruling out or identifying acute UTI or diabetes-induced glycosuria, both of which are reversible with appropriate treatment.
Screening procedures that can be implemented in the primary care setting include a 24-hour pad test, cough stress test, phenazopyridine pad test, and a cotton swab test.
The 24-hour pad test measures the quantity of leaked urine in SUI. Over 24 hours, the patient saves all wet pads in an airtight container. At the clinic, the pads are weighed to measure the quantity of urine leakage. A quantity of 1.3 g to 20 g is mild, a quantity of 21 g to 74 g is moderate and a quantity of 75 g or greater is severe.13 The 24-hour pad test objectively measures fluid loss. Limitations include user error and false positive results for UUI and/or MUI.
The urinary cough stress test is also used for SUI screening. It is conducted through direct observation of the urethra. Ask the patient to come to the exam with a full bladder. While she is in the lithotomy position, ask her to perform the Valsalva maneuver or to cough forcefully, enough to produce urine loss. Observation of urine loss is a positive result.
The phenazopyridine pad test10 is a good screening technique for the woman who is unsure whether she is producing urine or vaginal discharge. The test is performed after administering a one-time dose of phenazopyridine and asking the woman to wear a pad. Then she coughs or performs the Valsalva maneuver. Since the phenazopyridine turns urine orange, any sign of orange staining on the pad confirms that the leakage is urine. The phenazopyridine pad test may yield a false positive result due to staining of the perineum from an earlier void or loss of urine that is clinically insignificant.
The cotton swab test assesses for SUI by evaluating urethral hypermobility, which is indicative of poor pelvic floor support. To conduct the cotton swab test, place the patient in the lithotomy position and insert a small lubricated sterile cotton swab through the urethra into the bladder. Once the cotton portion of the swab is completely inserted into the bladder, the angle of the projecting stem should be noted at rest. With the swab still in place, ask the woman to perform Valsalva or cough. A change in angle greater than 30 degrees indicates hypermobility indicative of SUI.15
When to Refer
Most community-dwelling women with UI can be thoroughly assessed and managed in the primary care setting without referral to a urology specialist.5 After the focused history and physical, synthesize the findings, giving consideration to the goals of the patient. UI treatment is largely determined by the outcomes desired.
A referral should be considered for any women with complicated UI. This includes, but is not limited to, women with PVR > 200, women with sudden onset of UI with unknown etiology, women with underlying medical conditions contributing to UI, and any patient with recurrent UI refractory to initial treatment. UI associated with concomitant complaints of pain and/or hematuria may also need further evaluation.
1. Society for Urology. Urinary incontinence: Patient fact sheet. http://www.suna.org/download/members/urinaryIncontinence.pdf
2. Agency for Healthcare Research and Quality. Urinary incontinence. New hope. http://www.ahrq.gov/research/jul12/0712RA3.htm
3. National Association for Continence. What is incontinence? http://www.nafc.org/bladder-bowel-health/
4. Gibbs CF, et al. Office management of geriatric urinary incontinence. Am J Med. 2007;120(3):211-220.
5. Ward-Smith P. The cost of urinary incontinence. Urol Nurs. 2009;29(3):188-194.
6. Keilman LJ, Dunn KS. Knowledge, attitudes, and perceptions of advanced practice nurses regarding urinary incontinence in older adult women. Red Theory Nurs Pract. 2010;24(4):260-279.
7. Wallner LP, et al. Prevalence and severity of undiagnosed urinary incontinence in women. Am J Med. 2009;122(11):1037-1042.
8. Visser E, et al. Systematic screening for urinary incontinence in older women: who could benefit from it? Scand J Prim Health Care. 2012;30(1):21-28.
9. Agency for Health Care Research and Quality. Incontinence in women. http://guidelines.gov/content.aspx?id=16386
10. Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. American Family Physician. 2000; 62(11): 2433-2444.
11. van Gerwen M, et al. Comorbidities associated with urinary incontinence: a case control study from the second Dutch national survey of general practice. J Am Board Fam Med. 2007; 20(6): 608-610.
12. Dowling-Castronovo A. Urinary incontinence assessment in older adults. http://consultgerirn.org/uploads/File/trythis/try_this_11_1.pdf
13. Miller JM, et al. Cluster analysis of intake, output, and voiding habits collected from diary data. Nurs Res. 2011;60(2):115-123.
14. O'Sullivan R, et al. Definition of mild, moderate and severe incontinence on the 24-hour pad test. BJOG. 2004;111(8):859-862.
15. Swift S, et al. Test-retest reliability of the cotton swab (Q-tip) test in the evaluation of the incontinent female. Int Urogynecol J. 2010;21(8):963-967.
Amy Hamlin is a family nurse practitioner who is an associate professor at Austin Peay State University in Clarksville, Tenn. Tamara M. Robertson is a family nurse practitioner who is an associate professor at the same university. The authors have completed disclosure statements and report no relationships related to this article.