CHAPTER 9 Committee 5 Initial Assessment of Incontinence Chairman D STASKIN (USA) Co-chairman PHILTON (UK) Members A. EMMANUEL (UK), P. G OODE (USA), I. MILLS (UK), B. SHULL (USA), M. YOSHIDA (JAPAN), R. ZUBIETA (CHILE) 485 CONTENTS 3. SYMPTOM ASSESSMENT INTRODUCTION 4. PHYSICAL EXAMINATION I. LOWER URINARY TRACT 5. URINALYSIS AND URINE CYTOLOGY SYMPTOMS 6. MEASUREMENT OF THE SERUM PROSTATE- 1. STORAGE SYMPTOMS SPECIFIC ANTIGEN (PSA) 2. VOIDING SYMPTOMS 7. MEASUREMENT OF PVR 3. POST-MICTURITION SYMPTOMS IV. THE GERIATRIC PATIENT 4. MEASURING THE FREQUENCY AND SEVERI- TY OF LOWER URINARY TRACT SYMPTOMS 1. HISTORY 5. POST VOID RESIDUAL URINE VOLUME 2. PHYSICAL EXAMINATION 6. URINALYSIS IN THE EVALUATION OF THE PATIENT WITH LUTS V. THE PAEDIATRIC PATIENT II. THE FEMALE PATIENT PHYSICAL EXAMINATION VI. THE NEUROLOGICAL PATIENT 1. GENERAL MEDICAL HISTORY 2. URINARY SYMPTOMS PHYSICAL EXAMINATION 3. OTHER SYMPTOMS OF PELVIC FLOOR DYS- VII. FAECAL INCONTINENCE FUNCTION ASSESSMENT 4. PHYSICAL EXAMINATION 1. HISTORY 5. PELVIC ORGAN PROLAPSE 2. EXAMINATION 6. RECTAL EXAMINATION 3. FUTURE RESEARCH 7. ADDITIONAL BASIC EVALUATION VIII. OVERALL III. THE MALE PATIENT RECOMMENDATIONS URINARY INCONTINENCE 1. CHARACTERISTICS OF MALE INCONTINENCE REFERENCES 2. GENERAL MEDICAL HISTORY 486 Initial Assessment of Incontinence D STASKIN, P HILTON A. EMMANUEL, P. GOODE, I. MILLS, B. SHULL, M. YOSHIDA, R. ZUBIETA 3. institute empiric or disease specific therapy based INTRODUCTION on the risk and benefit of the untreated condition, the nature of the intervention and the alternative Urinary (UI) and faecal incontinence (FI) are a therapies concern for individuals of all ages and both sexes. 4. prompt the recommendation of additional more This committee report primarily addresses the role of complex testing or specialist referral. the initial clinical assessment of urinary incontinen- ce in female and male patients. In addition to urina- Lower urinary tract symptoms are defined from the ry incontinence the symptom assessment is expan- individual’s perspective and are either volunteered ded to include lower urinary tract symptoms (LUTS) by, or elicited from the individual or described by the individual’s caregiver. Whilst LUTS cannot be used and signs of lower urinary tract dysfunction (LUTD) to make a definitive diagnosis of LUTD, they may be without urinary loss. The sub-populations of female suggestive, and may also indicate pathologies other patients with pelvic prolapse, male patients with than LUTD, such as urinary infection or more prostatic enlargement, the paediatric and geriatric serious underlying conditions. Signs suggestive of age groups, and the neurologically impaired are LUTD are observed by the physician including considered separately. Recommendations are also simple means to verify symptoms and quantify them. made in a separate sub-section for the initial evalua- In each specific circumstance, urinary or faecal tion of those patients who present with faecal incon- incontinence should be further described by speci- tinence. These sub-sections should be utilized in fying relevant factors such as type, frequency, seve- conjunction with other Committee Reports and the rity, precipitating factors, social impact, effect on final recommendations of the Consultation, which hygiene and quality of life, the measures used to are presented in simplified form as treatment algo- contain the leakage and whether or not the individual rithms in Management Recommendations III. seeks or desires help. A clinical assessment of the For the purpose of this report, the ‘initial assessment’ efficiency of bladder or colorectal storage and emp- represents the components of the history, physical tying, and basic laboratory tests such urinalysis as examination, and laboratory testing, and if deemed testing for urinary or faecal infection or blood should necessary, radiographic tests and simple or more be considered before instituting therapy, or initiating complex testing that may be recommended in order special investigations. More advanced testing of to: lower urinary tract or colorectal storage or emptying, additional laboratory analysis for lower urinary tract 1. establish a presumptive or condition specific dia- or colorectal organ system related infection or mali- gnosis, and exclude underlying organ-specific gnancy, and fluid balance / renal function and dieta- related or unrelated conditions that would require ry / alimentary tract function should be dictated by intervention the findings of the basic evaluation. 2. assess the level of bother and desire for interven- Pathology may affect urinary or faecal production, or tion from information obtained from the patient or the cognitive, motivational, physical, and environ- caregiver mental factors that determine the ability to perform 487 toileting functions effectively. The physician should the patient voids eight or more times in 24 hours). elicit neurological symptoms and signs that may Increased daytime frequency may arise in the pre- indicate alterations in the control of the lower urina- sence of a normal bladder capacity when there is ry tract or bowel function. excessive fluid intake, or when bladder capacity is The requirements of specific sub-populations negate restricted secondary to detrusor overactivity, impai- the ability to recommend a ‘universal’ initial evalua- red bladder compliance, or increased bladder sensa- tion. Specific risks for combined storage and emp- tion. tying abnormalities and upper urinary tract dysfunc- NOCTURIA is the complaint that the individual has to tion in the neurogenic bladder population, mandates wake at night one or more times to void (NIH - the a more involved initial evaluation. Congenital and statement that the patient wakes from sleep to pass maturational issues in the paediatric subgroup and urine). The term ‘night time frequency’ differs from medical co-morbidity in the geriatric group present that for nocturia, as it includes voids that occur after unique challenges. Prostatic obstruction in the male the individual has gone to bed, but before he/she has and pelvic prolapse in the female present uniquely gone to sleep, and voids which occur in the early different challenges related to lower urinary tract morning which prevent the individual from getting function. back to sleep as he/she wishes. These voids before Empiric therapy based on the initial assessment must and after sleep may need to be considered in resear- consider the degree of bother, and the costs of further ch studies, for example, in nocturnal polyuria. If this evaluation, balanced against the consequences of a definition were used then an adapted definition of failure to diagnose an underlying condition, the risk daytime frequency would need to be used with it. and benefits of conservative management or pharma- Nocturia may arise for similar reasons to daytime cological therapy and the need for an accurate dia- frequency, but may also occur with congestive heart gnosis before more complex intervention. The bur- failure due to increased venous return on lying flat, den of these conditions and the availability of resources require that primary intervention strategies or to reversal of the normal circadian rhythm in anti- be formulated from evidence based decisions emana- diuretic hormone secretion. ting from the initial evaluation. URGENCY is the complaint of a sudden compelling desire to pass urine which is difficult to defer (NIH – the statement that the patient feels a strong need to I. LOWER URINARY TRACT pass urine for fear of leakage). SYMPTOMS URINARY INCONTINENCE is the complaint of any involuntary leakage of urine. In each specific cir- Symptoms are either volunteered by, or elicited cumstance, urinary incontinence should be further from, the individual or may be described by the indi- described by specifying relevant factors such as type, vidual’s caregiver. The International Continence frequency, severity, precipitating factors, social Society (ICS) has classified lower urinary tract impact, effect on hygiene and quality of life, the symptoms (LUTS) into storage, voiding, and post- measures used to contain the leakage (wearing of micturition symptoms. [1] The National Institutes of protection, number and type of pads and change of Health (NIH) recommend similar (but not identical) underwear or outer clothes) and whether or not the standards of terminology in pelvic floor disorders. individual seeks or desires help because of urinary [2] Although an accurate urological history will not incontinence. Urinary leakage may need to be distin- establish a definitive diagnosis it will ultimately guished from sweating or vaginal discharge. guide investigation and treatment. [1] STRESS URINARY INCONTINENCE is the complaint of The following section summarises the definitions of involuntary leakage on effort or exertion, or on snee- symptoms described by the International Continence zing or coughing (NIH – the patient’s or caregiver’s Society. [1] NIH definitions are given (in italics and statement of involuntary loss of urine during physi- in parentheses) where they differ from ICS termino- cal exertion). logy. URGE URINARY INCONTINENCE is the complaint of 1. STORAGE SYMPTOMS involuntary leakage accompanied by or immediately INCREASED DAYTIME FREQUENCY is the complaint of preceded by urgency. Urge incontinence can present voiding too often by day (NIH - the statement that in different symptomatic forms; for example, as fre- 488 quent small losses between micturitions or as a catas- ipheral