Diagnostic Tests for Incontinence
Incontinence Tests: Book Excerpts
Home Diagnostic Testing
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Incontinence Diagnosis: Book Excerpts
Diagnostic Tests for Incontinence: Online Medical Books
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INCONTINENCE OF URINE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine laboratory tests include a CBC, a urinalysis, a urine culture and sensitivity, a chemistry panel, and a VDRL test. An intravenous pyelogram and a voiding cystogram may be helpful. A Q-tip test or stress test may be helpful in diagnosing stress incontinence. The bladder may be catheterized for residual urine, or abdominal ultrasonography may be employed to evaluate residual urine. Fifty milliliters or more is considered abnormal. Cystoscopy may also be necessary to determine if there is chronic bladder inflammation or bladder neck obstruction. Office cystometrography can be considered, but it is usually best to refer the patient to a urologist for cystometric studies. Prostatic size can be determined by transrectal prostatic ultrasonography.
The simplest and most cost-effective approach is to refer the patient to a neurologist if there are abnormalities on the neurologic examination, or refer the patient to a urologist if there are not. If there is stress incontinence and a cystocele is found on vaginal examination, the patient should be referred to a gynecologist. It is not cost-effective to begin ordering MRIs or CT scans of the brain and spinal cord without the assistance of these specialists.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ENURESIS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Patients who are suspected of having a urologic condition as the cause of their enuresis should have a urinalysis, intravenous pyelogram, and voiding cystogram with a urine culture and colony count. Referral to a urologist for cystometric testing may be required. If there is polyuria, a glucose tolerance test, a thyroid profile, and tests for calcium phosphorus, alkaline phosphatase, and parathyroid hormone level should be done. If epilepsy is suspected, an EEG should be ordered. If the neurologic examination is abnormal, referral to a neurologic specialist would be in order. If all the studies and examinations are within normal limits, a referral to a psychiatrist or psychologist may be in order. However, the child may have simple enuresis, in which case all that is required is to reassure the parents that the child will grow out of it by puberty.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INCONTINENCE OF FECES:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies include a CBC, sedimentation rate, chemistry panel, and VDRL test. A sigmoidoscopy and barium enema are needed to exclude malignancy. The anorectal area should be carefully inspected for lesions and the sphincter competence determined by a digital exam. If these findings are normal, it would be wise to consult a neurologist. If one is not available, further workup may be done.
If there are hyperactive reflexes with cranial nerve signs, a CT scan or MRI of the brain should be done. If there are hyperactive reflexes of all four extremities with no cranial nerve signs, MRI of the cervical spine should be done. With hyperactive reflexes of the lower extremities only, MRI of the thoracic cord should be done. If there are hypoactive reflexes in the lower extremities, MRI or CT scan of the lumbar spine should be done. If increased intracranial pressure has been excluded, a spinal tap may be done to help diagnose multiple sclerosis or tabes dorsalis. Anorectal manometry and defecography may be used to detect anal and rectal muscle dysfunction.
If the general physical examination and neurologic examination are negative, psychogenic causes should be considered, and cystometric studies might be helpful. The patient should be referred to a psychiatrist.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
STRESS INCONTINENCE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
In most cases, the diagnosis will be obvious. You can ask the patient to cough during a vaginal examination, and the urine will trickle out. If that does not establish the diagnosis, have the patient drink a lot of water and not void until he or she returns to the office. Then you can have him or her cough in the recumbent or erect position, and the urine will be released. This is called the stress test. In the Q-tip test, a Q-tip is inserted in the tip of the urethra, and the patient is asked to cough or strain. The Q-tip will move at least 30 degrees above the horizontal in cases of stress incontinence. For further discussion of incontinence, see
page 264
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Enuresis:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child's daily fluid intake. Does he drink much after supper? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur at home and away from home? Ask the parents how they've tried to manage the problem, and have them describe the child's toilet training. Observe the child's and parents' attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.
Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child's gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Urinary incontinence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection, prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Fecal incontinence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern — for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool sample. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See
Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Enuresis:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child’s daily fluid intake. Does he drink much after supper? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur both at home and away from home? Ask the parents how they have tried to manage the problem, and have them describe the child’s toilet training. Observe the child’s and parents’ attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.
Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child’s gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If can control urination occasionally, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies and childbirths she has had.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious signs of inflammation or an anatomic defect. Have female patients bear down, and note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fecal incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, at night or with diarrhea. Note the frequency, consistency, and volume of stools passed within the last 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation, page 334.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary Incontinence:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):
A. General. Is the patient physically capable of getting to the toilet?
B. Mental status. Can the patient understand and act on the urge to void?
C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.
D. Abdominal examination. Is the bladder distended?
E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?
F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.
Testing
A. Voiding journal. A voiding journal is a good way to get additional information about the patient’s problem. Have the patient record the time and approximate amount of each voiding, and whether they were wet or dry.
B. Urinalysis. Be cautious when interpreting the urine analysis: in the absence of other symptoms, bacteriuria is seldom the primary cause of UI. Treat cystitis or urethritis when the rest of the clinical picture confirms them. Unexplained, persistent microhematuria requires investigation (Chapter 10.2).
C. Postvoiding urine volume. The patient should be catheterized immediately after voiding. In general, the postvoid urine volume should be less than 50 ml. Volumes in the range of 100 to 200 ml may suggest impaired bladder contractility or obstruction. Volumes greater than 200 ml strongly suggest obstruction.
D. Blood urea nitrogen, creatinine, and glucose are simple blood tests that help rule out underlying renal disease and diabetes.
E. Special tests are available via urologic consultation to further delineate the cause of UI. These include cystoscopy, cystometry, and other voiding studies. Up to two-thirds of patients can be successfully treated without urologic referral.
Diagnostic assessment
The clinical history is the most important factor leading to the correct diagnosis and successful treatment of urinary incontinence. However, it is an imperfect tool at best. In one review, clinical history had a sensitivity and specificity for stress incontinence of 0.90 and 0.50, respectively. For detrusor instability, the figures were 0.74 and 0.55 (2).
The task becomes even more problematic when considering the reluctance of patients to talk about their symptoms and the tendency for UI to be of a mixed type. Response to therapy (or lack thereof) often drives the practical management of this condition. Lack of response to multiple trials of therapy is a good indication for consulting a urologist. Remember, that your initial assessment will often be incorrect, so keep an open mind and consider all possible diagnoses. Finally, recall that UI frequently involves more than one causal factor. For example, many elderly people have a functional component (can’t get to the toilet quickly) in addition to one of the other types.
References
1. Urinary incontinence in adults: acute and chronic management. AHCPR Clinical Practice Guideline, No. 2 (1996 Update) Accessed August 1999; http://text.nlm.nih.gov/
ftrs/gateway/
2. Jensen JK, Nielsen FR, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994;83(5):904–910.
3. Finding out about incontinence. AAFP Patient Information Handout (1998) Accessed August 1999; http://www.aafp.org/patientinfo/incont.html
4. Goode PS, Burgio KL. Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients. Am J Med Sci 1997;314(4):262–267.
5. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician 1998;57(11):2665–2687. Accessed August 1999; http://www.aafp.org/afp/
980600ap/weiss.html
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urinary Incontinence:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
On examination, test for stress-induced leakage with a full bladder, palpate for bladder distension after voiding, and check for post-void residual. Do a pelvic examination looking for pelvic floor laxity, atrophic vaginitis, urethritis, or pelvic mass, and a rectal examination for tone, fecal impaction, and prostate nodule. Check perineal sensation and neurosacral reflexes including volitional anal contraction, anal wink (anal contraction in response to a light scratch of the perineal skin), and bulbocavernosus reflex (anal contraction in response to a light squeeze of the penis or clitoris). An intact reflex arc but absent perineal sensation suggests a cord lesion or multiple sclerosis.
Urge incontinence: Due to detrusor overactivity. Urine loss is accompanied by a strong desire to void. Incontinence is preceded by a warning of seconds to minutes. Leakage is periodic but frequent, and nocturnal incontinence is common. Voluntary control of the anal sphincter is intact, and sacral sensation and reflexes are preserved. The post-void residual is low. It is usually a result of detrusor instability caused by stroke, Alzheimer dementia, brain tumor, Parkinson disease, bladder outlet obstruction, spinal cord lesion, or interstitial cystitis.
Reflex incontinence: Due to an excessive pressure response to bladder filling. Voiding occurs without stress or warning. Sacral reflexes are preserved, but voluntary sphincter control and perineal sensation are impaired. Post-void residual is increased. Usually caused by a spinal cord lesion, incontinence may be mimicked by cortical damage with decreased awareness of signals to void.
Stress incontinence: Due to failure of the sphincter to remain closed during bladder filling. Incontinence of small amounts of urine occurs with increased abdominal pressure (e.g., coughing, laughing, sneezing). Stress-induced detrusor instability is suggested by a 5 to 15 second delay between stress and leakage, and by nocturnal leakage.
Overflow incontinence: Due to impaired detrusor contractility and/or bladder outlet obstruction. There is frequent leakage of small amounts of urine, hesitancy, decreased flow, and incomplete emptying. The post-void residual is increased, and the bladder is palpable. Common mechanisms include bladder outlet obstruction caused by benign prostatic hypertrophy or urethral stricture; decreased detrusor tone due to a herniated disc; or peripheral neuropathy caused by diabetes, pernicious anemia, tabes, or cauda equina.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Urinary incontinence:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary Incontinence:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fecal Incontinence:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
In childwith normal physical exam, most common causes of fecal incontinenceare maturational delay, developmental conflict, stress-related factors,and constipation. If primary psychologic disturbance exists, furtherevaluation should be performed by clinical psychologist or psychiatrist.History and physical exam can screenfor a neurologic disorder. Relaxed anal sphincter tone, decreasedperianal sensation, lower extremity weakness, and urinary incontinencesuggest spinal cord lesion. Combination of spine radiography, CT,and MRI is usually diagnostic.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Enuresis:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child's daily fluid intake. Does he drink much after dinner? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur at home and away from home? Ask the parents how they've tried to manage the problem, and have them describe the child's toilet training. Observe the child's and parents' attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.
Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child's gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he can occasionally control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Fecal incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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