ASSESSMENT OF THE PATIENT WITH URINARY INCONTINENCE

Problems with urinary incontinence can be acutely embarrassing for individuals. Therefore, the clinician must adopt a holistic approach to the assessment of a patient with urinary incontinence and be cognizant of its impact on all aspects of the patient’s life.

Initial Assessment

During the initial assessment, patients are asked about:

• Onset and duration of symptoms
• Precipitating factors
• Approximate number of incontinent episodes in a 24-hour period
• Amount of urine leakage
• Fluid intake, including types of fluids, and time of day when most fluids are consumed
• Any self-imposed fluid restrictions due to incontinence
• Episodes of bowel incontinence, including onset and duration, precipitating factors, and frequency

Obtaining a complete medication profile is vital, not only of prescription medications, but also over-the-counter medications, including herbal and vitamin supplements.

The clinician obtains a full and detailed health history, beginning with existing conditions that may lead to incontinence.

One of the goals of the initial patient assessment is to determine whether urinary incontinence may be related to an underlying condition that requires further evaluation and treatment. In such instances, the patient is referred to specialty practitioners. Symptoms that indicate the need for further evaluation include:

• History of frequent or persistent urinary tract infections
• Gross or microscopic hematuria
• Uterine prolapse
• Signs of neurological conditions
• Presence of a mass in the bladder or urethral or pelvic areas
  (Abrams et al., 2017)

Major Systems Assessment

RESPIRATORY ASSESSMENT

Acute or chronic coughing causes an increase in intra-abdominal pressure that may result in stress urinary incontinence or exacerbate the symptoms in those who already have some degree of incontinence. The clinician asks about cigarette smoking, which is a factor in persistent coughing. Nicotine has also been shown to cause bladder irritation in some individuals, which adds to the risk of urinary frequency and urgency (WOCN, 2016).

CARDIOVASCULAR ASSESSMENT

Certain cardiac conditions, such as heart failure and cardiac arrhythmias, can place patients at greater risk for nocturia, difficulty getting to the toilet in time before urine leakage, and a greater risk for falls. Clinicians must consider that diuretics used in the treatment of heart failure may contribute to urinary incontinence (WOCN, 2016).

ENDOCRINE ASSESSMENT

Diabetes is a risk factor for urinary incontinence. Peripheral autonomic neuropathy can cause problems with bladder storage, and poorly controlled diabetes can lead to polyuria (the production of abnormally large amounts of urine), which can increase the risk for urge urinary incontinence. Polyuria can also potentially increase the risk for functional incontinence and make existing functional incontinence worse (WOCN, 2016).

Neurological Assessment

A neurologic assessment is critical for a patient with urinary incontinence. Urination is regulated by spinal cord reflex centers, the micturition center in the pons, and cortical and subcortical areas in the brain. The sacral spinal cord segments 2–4 (S2–4) play a pivotal role in the voiding process, providing for relaxation of the internal and external sphincters and facilitating the flow of urine (Lehman, 2015).

Several neurologic conditions can affect voiding. Stroke and Parkinson’s disease are associated with urinary incontinence, in particular urge urinary incontinence. Multiple sclerosis and spinal cord injury are associated with neurogenic bladder and impaired bladder contraction (Abrams et al., 2017).

Genitourinary Assessment

VOIDING SYMPTOMS

Voiding symptoms associated with urinary incontinence in all genders include:

• Hesitancy: a delay in starting urination
• Slow urine stream: the person’s observation of diminished urine flow compared to their longstanding pattern
• Intermittent stream: flow of urine during voiding that stops and starts and reoccurs frequently
• Straining to void: increase in muscle contraction required to begin micturition
• Spraying of urine: described by the individual as urine spraying out rather than streaming
• Dribbling: a prolonged trickle of urine at the end stage of voiding
• Sensation of incomplete bladder emptying: the sensation of the bladder not being empty after completion of voiding
• Need to instantly urinate again: needing to void a second time immediately after voiding the first time
• Postvoiding leakage: uncontrolled leakage of more urine as soon as urination is complete
• Dysuria: discomfort or pain with urination
  (Abrams et al., 2017)

MALE ANATOMY

Since urinary incontinence is less common among those with a male anatomy, it is an area that may be overlooked by clinicians during assessment of such patients. Physical assessment includes abdominal palpation for a distended bladder as well as examination of the external genitalia. The location of the urethral meatus is determined, along with the ease of retraction of the foreskin and any indication of congenital deformity (Abrams et al., 2017).

FEMALE ANATOMY

The medical history and physical assessment of patients with female anatomy address a number of genitourinary issues:

• Pregnancy and the type and circumstances of delivery can significantly increase a woman’s risk for incontinence. During pregnancy the increased pressure of the enlarging uterus on the bladder can lead to episodes of transient incontinence.
• Pelvic surgeries and pelvic pain can be related to problems with pelvic muscle support.
• Vaginitis can lead to the development of urge incontinence, so the clinician must inquire about symptoms such as pruritis, vaginal discharge, and malodor.
• Endometriosis (the growth of uterine lining tissue outside of the uterus) can result in urge urinary incontinence.
• Pelvic organ prolapse, which the patient may experience as a sensation of a vaginal “bulge,” increases the risk for urinary incontinence.
  (WOCN, 2016)

During the physical examination, the clinician pays close attention to the abdominal region. The presence of scars may indicate past surgeries. Abdominal palpitation can help to detect bladder fullness or retention. Any vaginal pain is recorded, as well as any atrophic changes to the vulva. In postmenopausal patients, findings related to incontinence may include vaginal dryness, pain, itching, or irritation, and vaginal atrophy related to estrogen depletion (Abrams et al., 2017; WOCN, 2016).

Pelvic Floor Muscle Strength Assessment

An examination may be indicated to determine pelvic floor muscle strength. A vaginal examination of the female anatomy or a rectal examination of the male anatomy is a critical part of a continence assessment to determine pelvic floor muscle strength. These exams are carried out by professionals, including RNs, APRNs, OTs, and PTs, who have the appropriate training and qualifications.

The clinician begins by explaining to the patient the reason for the examination and how it will be performed, including obtaining verbal and/or written consent per facility policy. It is vital that the clinician preserves the patient’s dignity and comfort at all times while performing these procedures.

VAGINAL EXAMINATION

Prior to carrying out a digital assessment of pelvic floor muscle strength, it is advisable for the clinician to evaluate for the existence of intravaginal pain. The clinician does this by gently palpating the vaginal walls with a gloved index finger beginning at the 6 o’clock location at the level of the hymnal remnants (a stretch of tissue in the vagina where the hymen used to be) and gradually moving the gloved index finger to the 9, 12 , 3 o’clock locations, and back to the 6 o’clock location at the same level to complete the full assessment. Moving the gloved index finger a little deeper into the vaginal vault each time, the clinician performs several more rounds of the above assessment to determine if the patient will be able to tolerate a full digital examination of the pelvic muscle floor strength (Berghmans et al., 2020).

The clinician then carefully inserts one or two gloved fingers into the vagina and inquires if the patient is aware of the fingers in the vaginal vault. The patient is asked to contract the vaginal muscles around the clinician’s finger as if trying to prevent urinating or passing gas. This effort permits the clinician to assess the patient’s capacity to:

• Identify and isolate the pelvic floor muscles
• Contract the pelvic floor muscles
• Relax the pelvic floor muscles
  (WOCN, 2016)

The pelvic floor muscle strength evaluation is graded using the Modified Oxford Scale (see table).

MODIFIED OXFORD SCALE

Patient Capacity	Grade	Description
Absent	0	No palpable muscle contraction noted
Slight trace	1/5	A slight, quick contraction with insubstantial compression of the clinician’s finger
Feeble	2/5	Feeble contraction with faint pressure felt on the clinician’s finger; may or may not result in lifting of clinician’s finger; sustained >1 second but <3 seconds
Moderate	3/5	Moderate contraction and compression noted on the clinician’s finger; may or may not result in lifting of the clinician’s finger; sustained for a minimum of 4–6 seconds and can be replicated 3 times
Steady	4/5	A solid contraction with effective compression of the clinician’s finger and lifting of the clinician’s finger near the pelvic bone; sustained for a minimum of 7–9 seconds and can be replicated 4–5 times
Robust	5/5	Distinct strong contraction and compression of the clinician’s finger along with posterior lifting of the clinician’s finger; sustained for a minimum of 10 seconds and can be replicated 4–5 times

While performing the pelvic muscle strength assessment, the clinician maintains eye contact with the patient as much as possible and is aware of the patient’s nonverbal communication that may indicate discomfort or pain with the procedure, such as the patient holding their breath or guarding. The clinician also assesses for any irregularities such as anterior or posterior vaginal wall defects or uterine prolapse.

The clinician keeps in mind that the above measurement of pelvic floor muscle strength performed with the patient in a semisupine position may not be an accurate indication of pelvic muscle functionality during normal daily activities. Based on the results of the above assessment, the clinician discusses an individualized treatment plan with the patient (see “Pelvic Floor Exercises” later in this course) (Berghmans et al., 2020).

RECTAL EXAMINATION

A digital rectal examination is used to assess pelvic muscle strength in males and in females who cannot endure a vaginal examination. The Oxford scale listed above is also used to determine pelvic muscle tone with rectal examinations.

The clinician inserts a gloved finger into the patient’s rectum, and then the patient is instructed to contract their rectal muscles around the clinician’s finger (WOCN, 2016). For both male and female patients, a rectal exam also allows the clinician to assess for rectal impaction. Rectal examination for male patients is a means for assessing the prostate gland; an enlarged prostate gland can be palpated through the rectum wall.

Evaluation of perineal reaction to different stimuli is important in assessing neurological involvement. The clinician assesses the patient’s response to light touch, and their ability to distinguish between sharp and dull stimuli are noted. Saddle anesthesia (diminished or loss of sensation to the buttocks, perineum, and inner aspects of the thighs) is found in the presence of a spinal cord lesion that affects S2–4 (Abrams et al., 2017; WOCN, 2016).

Skin Assessment

Maintaining skin integrity can be challenging for patients with urinary incontinence (and for their caretakers, among patients who need assistance). Incontinence-associated dermatitis (IAD), also called perineal dermatitis, can be caused by urine and stool coming in sustained contact with the skin surface. It is found on the perineal area, buttocks, and upper thighs.

Both urine and stool are caustic to the skin and lead to maceration and breakdown of the acid mantle that protects the skin integrity. The most common presentation of IAD is reddened skin. In people with darker skin, IAD may present as areas of hypo- or hyperpigmentation. When left untreated, it can progress to a partial-thickness skin injury. A serious concern for patients with IAD is their greater risk for developing pressure injury.

Another important concern for patients with incontinence is malodor of their skin and clothing. This is another factor that leads to isolation and decreased participation in activities (Baranoski & Ayello, 2016; Wound Care Resource, 2015).

Functional Assessment

Patients who have limitations in functional ability, such as difficulties with ambulation and sitting balance, are at high risk for functional incontinence. A functional assessment of the patient includes a comprehensive review of the patient’s ability to maintain independence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

A functional assessment can be performed by a physical therapist or occupational therapist. The clinician first assesses for balance. Is the patient able to maintain a safe sitting position without losing their balance? Are they safe when standing independently and ambulating? If assistance is needed for any of these activities, how much assistance is required? Range of motion, transfer ability, ambulation, coordination and proprioception will also be evaluated (Lehman, 2015).

A home evaluation is particularly valuable because it provides insight into environmental issues that can lead to or increase the risk for incontinence, e.g., poor lighting, inadequate toileting facilities, and placement of furniture or rugs that hinder quick access to bathrooms.

Several musculoskeletal conditions can impede a patient’s ability to maintain continence, including osteo- and rheumatoid arthritis and back problems, to name a few. These conditions affect ambulation and the person’s ability to reach a bathroom as well as dexterity and the ability to manipulate clothing to successfully achieve toileting. Chronic pain and fatigue can also impair motivation to attain continence. Other mobility impediments include braces, splints, and immobilizers (Lehman, 2015).

The clinician also inquires about the patient’s living situation and occupations, such as:

• Do they live in the community or a care facility?
• If in the community, with family or others?
• Are they still in the workforce?
• What are their activities and hobbies?
• Do they require assistance from others to perform activities of daily living, such as toileting?
• Is their bathroom easily accessible?
• Does the patient use a bedside commode or urinal at night?
  (WOCN, 2016)

Cognitive/Mental Status Assessment

Cognitive conditions can impact an individual’s ability to maintain continence. For instance, depression and dementia may lessen the motivation for toileting. Persons with cognitive decline may not recognize the need for toileting or they may not remember the location of the toilet or how to prepare for toileting (WOCN, 2016). The Mini-Mental State Exam (MMSE) is a short, structured test that can be used as an initial assessment of a patient’s cognitive status (Rosenzweig, 2020).

• Delirium (an abrupt change in mental function resulting in confusion and decreased awareness of the environment) is associated with an acute onset of urinary incontinence. Delirium is reversible and can be caused by dehydration and/or a urinary tract infection, especially in those over 65 years.
• Dementia is a progressive condition and results in worsening episodes of incontinence. Those with advanced dementia may not be able to make known their need for toileting, may respond to toileting help with distress, and may be unable to respond to toileting cues from caretakers (WOCN, 2016).
• Depression is a frequently occurring and underdiagnosed condition in older patients and in those with cognitive loss. It may lessen the motivation for toileting and heighten the risk for urinary incontinence. Conversely, many persons with urinary incontinence are too embarrassed to seek professional help and may instead withdraw from society as a means of dealing with their condition, which may increase the risk for depression (WOCN, 2016).

Laboratory and Diagnostic Studies

Laboratory and diagnostic studies play a critical role in diagnosing urinary incontinence. Some of the more common tests performed are discussed below.

URINALYSIS

For all patients with urinary incontinence, a urinalysis is ordered to assess for the presence of urinary tract infection and hematuria. Results from a urinalysis may require a follow-up urine culture and sensitivity testing.

POSTVOIDING RESIDUAL

Measurement of postvoiding residual determines the amount of urine in the bladder after the patient voids. There are two methods of measuring postvoiding residual:

• A catheter is inserted into the bladder (using sterile technique) immediately after the patient has voided to drain and measure the amount of any residual urine left in the bladder.
• A noninvasive ultrasonic examination of the patient’s abdomen measures the amount of urine remaining in the bladder. Ultrasound has proven to be as accurate as catheterization at measuring postvoiding residual and is the preferred method (Abrams et al., 2017).

Postvoiding residuals greater than 250 cc of urine are regarded as abnormally high and increase the risk for renal damage (WOCN, 2016).

BLOOD TESTS

Blood tests include a prostate-specific antigen test (PSA) for men. This test checks the amount of PSA present in the blood, with a result of ≥4 nanograms/ml considered abnormal and requiring further investigation. Elevated levels can indicate an enlarged prostate, prostatitis, or prostate cancer.

Other blood tests to assess the status of renal and endocrine functioning include:

• Blood urea nitrogen (BUN)
• Serum creatinine
• Complete blood count (CBC)
• Estimated glomerular filtration rate (which maybe done as part of a blood chemistry panel)
• Fasting blood sugar
• Hemoglobin A1C
  (Abrams et al., 2017; WOCN, 2016)

PAD TEST

A pad test is a noninvasive method used to measure the amount of urine lost in each incontinent episode and to determine the severity of urine incontinence. Pad tests can be done at home by having the patient wear pads continuously for 24–48 hours. The pad is weighed before and after an episode of incontinence. A one-hour pad test can be done in the clinical setting by inserting a predetermined amount of saline into the patient’s bladder before they are asked to perform a series of exercises. A pad test, however, will not distinguish between the different types of incontinence (Abrams et al., 2017).

BLADDER DIARY

The patient (or their caretaker) may be requested to keep a 24-hour record of:

• Fluid intake
• Frequency and amount of voiding
• Number of incontinent episodes
• Activities the patient was engaged in when an episode of incontinence occurred
• Any patient-reported sensation of urgency, discomfort, or pain

URODYNAMIC TESTING

Urodynamic testing is used to gain a clear picture of how well the lower urinary tract is functioning, the bladder’s urine storage capabilities, and how well the bladder can empty. Types of urodynamic testing include:

• Uroflowmetry. This is a noninvasive test that can be used for male and female patients. It measures the flow rate of urine and the patient’s ability to empty the bladder. The patient is asked to arrive for the test with a full bladder. The patient is provided with privacy and asked to void into a commode fitted with a flow meter funnel. The flow of urine is continuously measured and the findings displayed on a graph. A normal uroflowmetry test produces a bell-shaped curve (Abrams et al., 2017; WOCN, 2016).
• Filling cystometry. This test measures the pressure within the bladder to determine its storage capacity and intra-activity abdominal pressures. It is an invasive test and requires the placement of two pressure-sensitive catheters, one in the patient’s bladder and the other in the rectum, which gauge the abdominal pressure range. The bladder is then filled with normal saline via the catheter placed in the bladder. Pressure is monitored while the bladder is being filled and before the patient is allowed to void. The abdominal pressure readings are subtracted from the bladder pressure readings, and the resulting value indicates the pressure wielded by the bladder (Abrams et al., 2017; WOCN, 2016).
• Electromyography (EMG). Electrode patches are placed in the groin area to monitor the functioning of the pelvic muscles during the different stages of voiding, with the electrical output from the pelvic floor muscles displayed graphically. During the bladder-filling phase, a slight increase in electrical activity should be noted, which is referred to as the guarding reflex. During voiding, the pelvic floor muscles will normally relax, indicated by minimal or no EMG activity, while abnormal pelvic floor functioning is characterized by an increase in EMG activity during voiding (WOCN, 2016).