• Advise the patient to complete a 3-day voiding diary, which will help you categorize and determine the cause and severity of her incontinence. B
• Recommend Kegel exercises for stress incontinence; provide instruction in technique and/or a referral for pelvic floor physical therapy for instruction. A
• Try an anticholinergic medication with indications for urinary incontinence for women with primarily urge-type incontinence. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Voiding diary: What it’s for, how to fill it out
Visit #1: Simple steps to take right away
When a patient confides that she suffers from urinary incontinence, even if it’s near the end of her visit, there are 3 critical steps that can be taken without delay:
- Collect a urine sample for urinalysis (if the patient is capable of providing a clean-catch sample and did not already do so at the start of the visit).
- Ask her to keep a voiding diary for 3 days, using the clip-and-copy patient handout. (Tech-savvy patients may prefer to use the voiding diary app available at no charge at http://itunes.apple.com/us/app/bladder-pal/id435763473?mt=8.) Review the instructions for filling out the voiding diary with the patient, or have a nurse or medical assistant do so. Call the patient’s attention to the numerical (1-4) formula recommended for approximating the quantity of urine lost in an episode of incontinence, as this is often the component of the diary that patients have the most trouble with. 7
- Schedule a follow-up visit. If the urinalysis shows that the patient has a urinary tract infection, initiate treatment as soon as possible. Treatment should be completed by the time she arrives for visit#2 so that her incontinence can be reassessed in the absence of infection.
Tell your patient to bring the completed voiding diary to this visit and to avoid emptying her bladder before she sees you. When the patient checks in, she should be reminded again not to urinate until you have completed the examination.
What to do during Visit #2
This visit will begin with a targeted assessment to determine what type of incontinence the patient has and whether you should initiate treatment or refer her to a specialist.
Start with a targeted history and review of the voiding diary
Ask the patient about timing, quantity, and the overall circumstances of typical incontinence episodes, as well as the incidents that she finds most troubling. A medication history should be included, with information not only about what she’s taking, but also about when she takes her medications. A careful review of the voiding diary will provide additional information, including fluid intake quantity and quality (eg, caffeine or alcohol) and urinary frequency, quantity, and timing.
The initial goal is to classify her incontinence as urge (occurring simultaneously with, or right after, a strong feeling of the need to void); stress (the result of an acute increase in abdominal pressure, typically associated with a physical act such as coughing, sneezing, bending over, heavy lifting, or starting to run); or mixed, which involves some episodes of both.8 “High-yield” questions like the ones that follow are particularly helpful in pinpointing the type of incontinence and guiding treatment decisions:
- Do you worry about leakage when you cough or sneeze? (Stress incontinence.)
- When your bladder is full, do you typically have to stop what you’re doing and go right away, or can you wait until a convenient time to find a bathroom? (Urge incontinence.)
And, for patients who report both stress and urge episodes (mixed incontinence):
- Which is more upsetting to you: leakage that occurs when you cough or sneeze or the inability to wait until it’s convenient to get to a bathroom?
A pelvic exam and cough stress test
Next, perform a pelvic examination and assess the following:
External genitalia. Look for signs of chronic urine exposure (eg, erythema, skin breakdown) and urethral abnormalities.
Cystoceles or rectoceles. Ask the patient to bear down strongly to allow you to visualize cystoceles and rectoceles, which usually present as a significant bulging of the tissues of the anterior or posterior vaginal walls. Reassure her that urine leakage and flatus are completely acceptable—and expected—during this part of the exam.