Expert Commentary

Q Can a questionnaire differentiate urge and stress incontinence?

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A Yes, but not completely. The “3 Incontinence Questions” (3IQ) had sensitivity and specificity of 0.75 and 0.77, respectively, for identifying urge incontinence, and 0.86 and 0.60, respectively, for stress incontinence. Positive likelihood ratios were 3.29 for urge and 2.13 for stress incontinence.

The 3IQ is therefore acceptable for use by primary care physicians, especially when treatment will be noninvasive.

Expert Commentary

When a woman complains of urinary incontinence, the clinician’s first objective is determining which type of incontinence she has so therapy can be appropriately targeted. This is not as straightforward as might be expected. The symptoms of urge and stress incontinence overlap significantly, necessitating simple or complex urodynamics.

Simple conservative treatments such as timed voiding and Kegel exercises may benefit all incontinent women. However, other treatments, such as anticholinergic drugs for urge incontinence or the new transobturator sling procedures for stress incontinence, require a more precise diagnosis. Thus was born the 3IQ.

The 3 Incontinence Questions

1. During the last 3 months, have you leaked urine?

□ Yes

□ No

If no, no need to proceed

2. During the last 3 months, did you leak urine: (Check all that apply)

□ a. When you were performing a physical activity such as coughing, sneezing, lifting, or exercise?

□ b. When you had the urge or need to empty your bladder, but could not get to the toilet fast enough?

□ c. Without physical activity and without a sense of urgency?

3. During the last 3 months, did you leak urine most often: (Check only one)

□ a. When you were performing a physical activity?

□ b. When you had the urge or the feeling that you needed to empty your bladder?

□ c. Without physical activity and without a sense of urgency?

□ d. About equally as often with physical activity as with a sense of urgency?

Score by response to question 3:

a=stress or stress-dominant

b=urge or urge-dominant

c=other causes


Adapted from Brown JS, et al

How the 3IQ assesses symptoms

The 3IQ was completed by 301 women with untreated incontinence and was compared with a “gold standard” evaluation that included a history, physical examination (including neurologic evaluation), pelvic exam, cough stress test, measurement of postvoid residual, and review of a 3-day voiding diary.

Investigators did not evaluate each question individually, which is unfortunate, as it would be interesting to know whether a single question has similar value in distinguishing stress and urge incontinence.

All the women attended tertiary continence centers. It would be helpful to repeat this study in a primary care setting where women may have less severe symptoms and be less likely to undergo further evaluation.

Despite limited utility to ObGyns, the study is good news

The 3IQ appears to be particularly useful for selecting noninvasive therapy for women with urge incontinence. For surgeons who perform minimally invasive sling procedures for stress incontinence, the low specificity of this test renders it inappropriate. Thus, the 3IQ may be more useful for a family practitioner or internist than for the ObGyn who is also a surgeon.

The fact that this study was published in Annals of Internal Medicine makes it clear that primary care physicians are interested in the care of women with urinary incontinence. ObGyns should be happy about this, as studies like this one will increase awareness of the frequency of urinary incontinence and lead to further referrals to ObGyns for more extensive management.

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