Ob.Gyns. Key in Identifying Urinary Incontinence
Keep the Initial Workup Simple
Step one is to ask women whether they're experiencing urinary incontinence symptoms. Dr. Fenner recommends including a focused question on your intake questionnaire and in person during routine office visits such as, “Are you having difficulty holding your urine?” Or, “Is urinary incontinence a bother?”
Dr. Brubaker offered the following phrase to use during visits with patients: “Women experience urinary incontinence commonly. If you do, let me know, because there are things we can do to help.” This approach creates “a safety net so the woman can talk about this without feeling humiliated, or embarrassed, or alone.”
If a patient informs you of urinary incontinence symptoms at the end of an office visit, Dr. Brubaker recommends ordering a urine culture to rule out a urinary tract infection. Then ask her to schedule a follow-up visit by saying something like, “I'm so glad you raised this. I'd like to order some basic urine tests today, but I'd like to set up a dedicated time in the near future so that we can investigate what's going on.”
Experts interviewed for this story emphasized that most women do not require a complex evaluation such as a multichannel urodynamic study to make a diagnosis of stress, urge, or mixed urinary incontinence. “A lot of what we recommend is based on her symptoms: when she leaks, what promotes her incontinence,” said Dr. Fenner, who is also director of gynecology for the University of Michigan Health System. “That can help direct your therapy. In addition, we recommend looking for prolapse and testing to see how well she can squeeze and perform a Kegel contraction. That gives you an idea of whether physical therapy may be of benefit or not.”
Dr. Fenner recommends post-void residual testing in symptomatic patients, “to make sure that women are emptying their bladder completely, that they don't have a more complex neurologic etiology. You can do that with a catheter or with an ultrasound.” Full bladder stress testing also can be helpful. For this test, have the woman lie down with a full bladder. “If she doesn't leak lying down, we have her do three strong coughs,” she said. “Have her stand up and see if that makes her leak.”
Workups should include consideration of potentially reversible factors. In 1985, geriatrician Dr. Neil M Resnick, chief of the division of geriatrics at the University of Pittsburgh, proposed the mnemonic DIAPPERS for the following treatable causes of urinary incontinence: delirium, infection, atrophic urethritis and vaginitis, pharmaceuticals, psychologic disorders, excessive urine output (such as from heart failure of hyperglycemia), restricted mobility, and stool impaction (N. Engl. J. Med. 1985;313:800–5).
“Defining etiology directs therapy,” Dr. Fenner said. “There are things that can go wrong with the bladder. There are things that can go wrong with the urethra. There are things that can irritate the bladder. There can be systemic problems like diabetes, Parkinson's or multiple sclerosis that can impact urinary incontinence.”
If you'd like to get a more detailed sense of how symptoms are impacting your patients, Dr. Iglesia recommends two validated questionnaires. One is called the Medical, Epidemiological, and Social aspects of Aging, “which tells you more about stress and urge incontinence symptoms,” she said. Another is the Incontinence Impact Questionnaire, which measures the impact of urinary incontinence on activities, roles, and emotional states (Neurourol. Urodyn. 1995;14:131–9). Other questionnaires to consider using, she said, include the Incontinence Severity Index (ISI) and the six-item Urogenital Distress Inventory—6 (UDI-6).
Support and Education Efforts
Consumer groups such as The Accidental Sisterhood (
Progress is being made on that front. In April of 2011, the American Board of Medical Specialties accredited the new subspecialty of female pelvic medicine and reconstructive surgery. According to Dr. Fenner, the American Board of Obstetrics and Gynecology and the American Board of Urology are working together to develop board testing and certification, which is expected to be available in 2013. “The purpose is to have subspecialists for complex surgical procedures and for the complex patients who have failed initial treatment,” Dr. Fenner said. “With the increase in the population and the growing number of healthy women who want to live very active lives, urinary incontinence is only going to be increasing. There won't be enough providers to care for this population. It will be very important that general ob.gyns. and other primary health care providers ask patients if they're having issues with urinary incontinence. They certainly can care for many of these women.”
Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate. Dr. Brubaker and Dr. Iglesia said that they had no relevant financial conflicts to disclose.
