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Clinical investigations in female urinary incontinence
By Hogne Sandvik

Female urinary incontinence (UI) is a condition with severe economic and psychosocial impact. I have studied the epidemiology of UI in the general female population and the prevailing management of UI by Norwegian general practitioners (GPs). Those who are interested in more details, may take a look at this synopsis. The main conclusions that may be drawn from these studies are that UI is very prevalent among adult women, mostly in the form of stress incontinence. At least 6% may be regarded as potential patients. Although complicated by methodological difficulties, studies of GPs' management indicate that available therapeutic tools are not used to their full potential. A literature review demonstrates that the history is the most important diagnostic tool in general practice, and that the value of clinical investigations (described below) is poorly documented.

TOC Gynaecological examination

Review papers and guidelines agree that a gynaecological examination should be included in the basic evaluation of incontinent women.(1-6) Accordingly, all authors who have actually evaluated management programmes for UI have included a gynaecological examination in their programme.(7-10) However, in a British survey only 25% of incontinent women reported that their GP had actually done a gynaecological examination.(11)

There are several reasons why a vaginal examination should be undertaken, only some will be discussed in this section. The stress provocation test is discussed in the next section, and the therapeutic implications of evaluating the pelvic floor muscles will be described in the chapter about therapeutic tools.

Hørding et al. examined 509 women (aged 45) of whom 22% were incontinent. Cystocele and uterine prolapse were significantly more common in the incontinent women than in the continent ones. In women presenting with one or more abnormal findings at the pelvic examination, 35% were incontinent. In contrast, 15% of those with normal gynaecological examination were incontinent. They found no correlation between an enlarged uterus and incontinence.(12)

Several studies have failed to demonstrate that cystocele/prolapse is of any use in discriminating between stress and urge incontinence.(13-15) However, the lack of significant results may be due to small materials. In a larger study Fischer-Rasmussen et al. found that genital prolapse was significantly more frequent in stress incontinence than in other types (72% v. 54%, p<0.01).(16)

Practice guidelines usually stress the importance of recognizing signs of vaginal atrophy.(15) However, it may not be obvious what these signs are. By using cytological smears as gold standard it has been shown that "classical" signs such as vaginal pallor, petechiae, purpura, or reduced introital size are not associated with vaginal atrophy. The most helpful features in predicting vaginal atrophy are thinness of the patient, vaginal dryness, and low parity.(17)

The Q-tip cotton swab test has been used as a simple means of identifying patients with hypermobility of the urethrovesical junction. A sterile Q-tip is placed in the urethra and the patient is asked to bear down. If the Q-tip moves more than 30°, the test is considered positive, and the patient may benefit from surgery. However, the validity of this test has been questioned. Compared with ultrasound scanning the Q-tip test has a sensitivity of only 25% and a specificity of 78%.(18) Walters & Shields conclude that the Q-tip test contributes no additional information to that found by history taking and clinical examination.(15)

TOC Stress provocation test

If stress incontinence is suspected, a provocative stress test may be performed by asking the patient to cough vigorously while the examiner observes for urine loss from the urethra.(16) However, if the bladder is empty the test will of course be negative. Thus, a negative test does not rule out stress incontinence.

Several authors have investigated the validity of the stress provocation test. Fischer-Rasmussen et al. reported a positive predictive value of 89% (pretest 61%) and a negative predictive value of 89% (pretest 39%).(16) Slightly lower values were reported by Scotti & Myers.(19) Both studies included women aged 30-90. Summit et al. found the stress provocation test positive in about 90% of patients with genuine stress incontinence or mixed incontinence, and in only 18% of those with detrusor instability.(14) However, a weak point of these studies is the use of a gold standard which is partly based on the result of the test itself.(16) All tests were performed with a full bladder, and thus may have attained higher sensitivity than what can be expected in general practice.

The Bonney test has been advocated as an adjunct to the stress provocation test. After a positive stress test the index and middle finger of the examiner's hand are pressed against the anterior vaginal wall, without pressing on the urethra. The stress test is repeated, and if no leakage occurs this time, the Bonney test is said to be positive. A positive Bonney test has been taken as an indication that the patient will benefit from surgery. However, careful studies have shown that this test works by obstructing the urethra, and that it will be positive irrespective of incontinence type.(20,21)

While the Bonney test should be discarded, a pessary test has been shown to be a reliable tool that works without compressing the urethra. When a positive stress provocation test becomes negative with a vaginal pessary, the patient is likely to benefit from surgery.(22)

TOC Neurological examination

Most primary care guidelines recommend that a neurological examination should be part of the basic clinical examination of incontinent patients.(1,3-6) Some recommendations are very unspecific,(4,6) others concentrate on lower extremity and perineal nerves.(5)

Urinary incontinence is frequently associated with neurological disorders. Thomas et al. interviewed 305 community dwelling men and women (aged 15-59) with chronic neurological disease and found that 54% were incontinent. The most frequent neurological disorder was multiple sclerosis, accounting for 71% of all female patients.(23) Other studies have shown that UI is frequent among patients suffering from stroke and dementia.(24-26) A survey among women visiting a Swedish health centre revealed that incontinence was significantly more frequent among patients with neurological disorders than among patients without such disorders.(27) In a British general practice 343 incontinent women were identified and offered an appointment. One of the 67 who attended had a neurological disorder (multiple sclerosis).(7,28)

Very little research has been published about the actual benefit of routine neurological examination of incontinent women. Walters & Shields evaluated 106 consecutive women complaining of UI and found abnormalities of the lower neurological examination in six of them. All six women had histories suggestive of neurological disease (stroke, diabetes, or back trauma).(15) Molander et al. invited a random sample of incontinent women aged 65-85 to a geriatric outpatient clinic and performed a detailed neurological examination of the first 150 who attended. The same detailed neurological examination was performed of an age-matched control group (n=150). As it turned out, the two groups did not differ significantly regarding the frequency of pathological neurological signs. Thus, providing the medical history does not indicate a possible neurological background, a neurological examination is not mandatory in unselected incontinent women.(29)

TOC The frequency/volume chart

The urinary diary may be used for diagnostic purposes, as an adjunct to treatment (bladder training), and for the evaluation of treatment. In this section only the diagnostic possibilities of the diary will be discussed, more specifically to what extent the diary may be helpful in predicting detrusor instability.

The self reported urinary diary is a way of documenting the time and volume of all voidings during a certain period of time. The diary gives information about the number of voidings, their distribution in time, single volumes, average single volume, variation of diuresis, and total urine volume per 24 hours.(30) Sometimes drinking volumes are also recorded.(30,31) Most incontinent women will easily understand how to use a simple urinary diary,(32) but the addition of "extra items" may reduce compliance.(31)

Although the frequency/volume chart has been in clinical use for a long time, only recently have investigators examined the normal micturition pattern in a healthy, continent female population. Larsson & Victor investigated 151 women aged 19 to 81 years,(33) and Boedker et al. investigated 123 women aged 14 to 69 years.(34) Both studies showed that the recorded parameters were not correlated to age. Mean total volume per 24 hours was 1430 ml,(33) median 1350 ml.(34) Mean frequency of micturition per 24 hours was 5.8,(33) median 5.7.(34) Thus, the average single volume was found to be slightly less than 250 ml. This is the most important parameter, since it takes into account both 24 hours volume and frequency.(30,33)

The reliability (reproducibility) of the frequency/volume chart has been measured in terms of correlation between test and retest, with correlation coefficients from 0.80 to 0.93.(33,35) Larsson & Victor found that the reliability increased with observation time, and that best reproducibility was found for average single volume.(33) Larsson et al. also investigated reliability in the more precise terms of limits of agreement,(36) and found that the reproducibility was somewhat better in urge than in stress incontinence.(37,38)

In their test-retest study of the urinary diary, Wyman et al. also compared frequency and number of incontinent episodes in women with stress incontinence and urge/mixed incontinence. No significant difference was found between the groups.(35) Diokno et al. were unable to find any correlation between the frequency of urination and presence or absence of detrusor contractions.(39)

Larsson et al. compared a group of women with detrusor instability with a group of healthy volunteers. Although statistically significant differences were found for frequency, mean voided volume, and largest single voided volume, the overlap between the groups was considerable. No correlation was found between the data of the frequency/volume chart and cystometry. Larsson et al. concluded that although the urinary diary may not be a tool with differential diagnostic capabilities, it offers a quantitative measure of the symptomatic degree of motor urgency.(37)

Since no single parameter in the frequency/volume chart can be used to predict detrusor instability, attempts have been made to construct weighted mathematical models, taking into account several parameters at the same time. The most successful of these attempts is probably the Bladder Instability Discriminant Index (BIDI) by Ortiz et al.(40,41) The BIDI index was first developed by comparing a seven-day urinary diary with the urodynamic diagnosis of bladder instability in 89 incontinent women.(40) By multiple discriminant analysis a rather complex weighted score (BIDI) was obtained, taking into account six parameters from the urinary diary. A cut-off point of best discriminatory power was also defined. Afterwards, the BIDI was validated in a prospective study of 217 incontinent women (of whom 26 had bladder instability), achieving 88% sensitivity, 83% specificity, 41% positive predictive value (pretest 12%), and 98% negative predictive value (pretest 88%).(41)

The BIDI index is suggested as a tool for the non-invasive diagnosis of bladder instability in primary health care.(41) However, considering the complexity of its calculaton, confirmatory studies of validity (and feasibility) should be undertaken, preferably in general practice.

TOC Measurement of residual urine

Residual urine may increase due to outlet obstruction or reduced bladder contractility, resulting in overflow incontinence. A residual volume less than 50 ml is considered normal, over 200 ml is considered inadequate emptying.(1) Overflow incontinence is most common among institutionalized elderly women. Resnick et al. found that outlet obstruction was responsible for 4% of the incontinent cases in such a population, underactive detrusor for 8%.(42) In a large survey of women referred for urodynamic investigation only 0.5% were given a diagnosis of overflow incontinence.(43) In a survey of community dwelling women 1.9% complained of constant hesitancy, 0.5% complained of constant weak stream.(44)

Estimation of residual urine can be made by abdominal palpation/percussion, by bimanual examination, or by catheterization. Hilton & Stanton investigated 100 women who were referred to a urodynamic unit. Thirteen patients had residual urine exceeding 100 ml. In ten this was evident on abdominal palpation (300-1250 ml), and in the remainder the residual volume was not considered important.(45)

Diokno et al. compared residual urine in 69 continent and 92 incontinent women and found no significant difference.(39) In another study Summit et al. showed that a residual urine volume of >50 ml was not associated with any particular type of UI.(14)

The US Clinical Practice Guideline on urinary incontinence in adults recommends that an estimation of residual urine is made for all patients. However, the panel members disagreed as to whether an accurate measurement (catheterization or ultrasound) is necessary.(1) Review papers on UI management in primary care tend to recommend accurate measurement of residual urine.(2,3,5) However, most authors who have reported their actual experiences with such management programmes, have not included catheterization.(7,9,46) Unless history indicates otherwise, present scientific evidence is not in favour of recommending catheterization for residual urine as a standard procedure in general practice.

TOC Urinalysis

All guidelines and review papers recommend that a urinalysis is performed in incontinent females.(16) Usually, a urine culture is also recommended.(25) Jolleys took a culture of all patients included in her original study,(7) but in a later paper she only recommended dipstick testing as standard procedure.(6) The US Clinical Practice Guideline on urinary incontinence in adults also recommends only a dipstick testing of urine as a screening.(1)

What enzymatic analyses should be included on the dipstick are either not specified,(1,5) or only briefly suggested in the guidelines. Specifically recommended are tests for blood,(2-4) glucose,(2,6) or indicators of possible infection.(2) However, the recommendations are not based on scientific research, the predictive value of dipstick testing in urinary incontinence is unknown. In a British survey 53% of incontinent women reported that their GP had taken a urine sample.(11)

Symptomatic urinary tract infection is more common in incontinent than continent women,(27,47,48) but is of no use in differentiating between different types of incontinence.(14,15,49) However, while symptomatic infections will be treated irrespective of continence status, the question is what to do with nondysuric bacteriuria.

In a well designed study Boscia et al. investigated old patients (aged 69-101) with and without bacteriuria, none was dysuric. They were followed for six months. During this time bacteriuria developed, resolved, or was treated with antibiotics. No differences in incontinence symptoms were found when bacteriuric subjects were compared with themselves when they were nonbacteriuric.(50)

In another study Bergman & Bhatia investigated 20 bacteriuric women (aged 29-63) who had been referred to a urodynamic laboratory, none had acute symptoms indicating urinary tract infection. Urodynamic evaluation was undertaken before and after eradication of the bacteria. Before antibacterial treatment nine patients had unstable bladder, but only three remained unstable after treatment. Likewise, four of 12 cases of stress incontinence resolved after antibacterial therapy.(51)

Possibly, the different age groups investigated may explain the seemingly contradicting results of these two studies. It may be an indication that one should take a more liberal attitude towards screening for bacteriuria in young incontinent patients than in the old ones.

TOC References

1. Urinary Incontinence Guideline Panel. Urinary Incontinence in Adults: Clinical Practice Guideline. AHCPR Pub. No. 920038. Rockville, MD. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. March 1992.

2. Smith N, Clamp M. Continence promotion in general practice. Oxford: Oxford University Press, 1991.

3. Walters MD, Realini JP. The evaluation and treatment of urinary incontinence in women: a primary care approach. J Am Board Fam Pract 1992; 5: 289301.

4. Brocklehurst JC. Urinary incontinence in old age: helping the general practitioner to make a diagnosis. Gerontology 1990; 36: 37.

5. Pannill FC. Urinary incontinence for the primary care physician. Conn Med 1993; 57: 299308.

6. Jolleys J. Urinary incontinence. Practitioner 1993; 237: 6303.

7. Jolleys JV. Diagnosis and management of female urinary incontinence in general practice. J R Coll Gen Pract 1989; 39: 2779.

8. LagroJanssen ALM, Debruyne FMJ, Smits AJA, van Weel C. The effects of treatment of urinary incontinence in general practice. Fam Pract 1992; 9: 2849.

9. Harrison GL, Memel DS. Urinary incontinence in women: its prevalence and its management in a health promotion clinic. Br J Gen Pract 1994; 44: 14952.

10. Molander U, Milsom I, Ekelund P, Arvidsson L, Eriksson O. A health care program for the investigation and treatment of elderly women with urinary incontinence and related urogenital symptoms. Acta Obstet Gynecol Scand 1991; 70: 13742.

11. Brocklehurst JC. Urinary incontinence in the community analysis of a MORI poll. BMJ 1993; 306: 8324.

12. Hørding U, Pedersen KH, Sidenius K, Hedegaard L. Urinary incontinence in 45yearold women. An epidemiological survey. Scand J Urol Nephrol 1986; 20: 1836.

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18. Caputo RM, Benson JT. The Qtip test and urethrovesical junction mobility. Obstet Gynecol 1993; 82: 8926.

19. Scotti RJ, Myers DL. A comparison of the cough stress test and singlechannel cystometry with multichannel urodynamic evaluation in genuine stress incontinence. Obstet Gynecol 1993; 81: 4303.

20. Migliorini GD, Glenning PP. Bonney's test fact or fiction? Br J Obstet Gynaecol 1987; 94: 1579.

21. Bhatia NN, Bergman A. Urodynamic appraisal of the Bonney test in women with stress urinary incontinence. Obstet Gynecol 1983; 62: 6969.

22. Bhatia NN, Bergman A. Pessary test in women with urinary incontinence. Obstet Gynecol 1985; 65: 2206.

23. Thomas TM, Gibson M, George M, Parikshak N, Meade TW. The prevalence of urinary symptoms in patients with chronic neurological disease. Community Med 1988; 10: 1249.

24. Henriksen T. Urininkontinens som følge af apopleksi. Ugeskr Læger 1993; 155: 11079.

25. McGrother CW, Jagger C, Clarke M, Castleden CM. Handicaps associated with incontinence: implications for management. J Epidemiol Community Health 1990; 44: 2468.

26. Campbell AJ, Reinken J, McCosh L. Incontinence in the elderly: prevalence and prognosis. Age Ageing 1985; 14: 6570.

27. Simeonova Z, Bengtsson C. Prevalence of urinary incontinence among women at a Swedish primary health care centre. Scand J Prim Health Care 1990; 8: 2036.

28. Jolleys J. Prevalence of urinary symptoms in women and their management in general practice, with particular reference to incontinence. Thesis. Leicester: University of Leicester, 1992.

29. Molander U, Ekelund P, Mellström D, Milsom I, Norlén L, Fogelberg M. Neurological examination of elderly women under investigation for urinary incontinence. Arch Gerontol Geriatr 1989; 9: 7785.

30. Klevmark B. Miksjonslistens parametre, diagnostiske prototyper og bruk for kontroll av behandling. Nord Med 1987; 102: 3402.

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32. Robinson D, McClish DK, Wyman JF, Bump RC, Fantl JA. A comparison between urinary diaries completed with minimal instruction and after personalized patient instruction. Abstract 158. ICS 24th Annual Meeting, Prague, Czech Republic, 31.8 2.9 1994.

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46. Simeonova Z, Bengtsson C, Ekelund P, Milsom I. Kontinensmottagning på en vårdsentral. Abstract nr. 33. Nordisk kongress i allmennmedisin, Oslo 26. 29. juni 1991.

47. Rekers H, Drogendijk AC, Valkenburg HA, Riphagen F. The menopause, urinary incontinence and other symptoms of the genitourinary tract. Maturitas 1992; 15: 10111.

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50. Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med 1986; 81: 97982.

51. Bergman A, Bhatia NN. Urodynamics: effect of urinary tract infection on urethral and bladder function. Obstet Gynecol 1985; 66: 36671.

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