The basic evaluation for urinary incontinence includes a history, physical

examination, direct observation of urine loss, measurement of postvoid

residual (PVR) volume - Post-void residual evaluation is by measuring the
remaining urine in the bladder shortly after a voluntary void; this can be
accomplished through ultrasound, bladder scan, or by directly measuring the
urine volume drained by a urinary catheter. Urinary catheterization is the
gold standard for measuring the post-void residua, urine culture, and urinalysis.
The goal of initial testing is to rule out UTI, neuromuscular disorders, and pelvic
support
defects, all of which are associated with urinary incontinence. The patient
should be asked about her fluid intake, the relationship between her
symptoms and fluid intake and activity, and medications. A voiding diary
may be helpful in this evaluation process.

The presence of urethral hypermobility is sometimes assessed by the Qtip test.

With the patient in the lithotomy position, a cotton-tipped swab
lubricated with lidocaine jelly is placed into the bladder and pulled back
until resistance is met. Then the patient is asked to bear down. If there is
urethral hypermobility, the end of the swab rotates upward, suggesting that
the urethral–vesicular junction (UVJ) is being deflected downward by the
intra-abdominal pressure. If the angle of the Q-tip rotation is greater than
30°, it is considered a positive test. The Q-tip test does not predict
incontinence, but provides more detail to the physical examination, and is
the only validated method for measurement of the anterior, posterior, and
apical pelvic compartments.

Urodynamic testing may also be useful. These tests measure the pressure
and volume of the bladder as it fills and the flow rate as it empties. In
single-channel urodynamic testing, the patient voids and the volume is
recorded. A urinary catheter is then placed, and the PVR urine is recorded.
The bladder is filled in a retrograde fashion. The patient is asked to note
the first sensation that her bladder is being filled. She then is asked to note
when she has a desire to void and when she can no longer hold her urine.
Normal values are 100 to 150 cc for first sensation, 250 cc for first desire
to void, and 500 to 600 cc for maximum capacity. In multichannel
urodynamic testing, a transducer is placed in the vagina or rectum to
measure intra-abdominal pressure. A transducer is placed in the bladder,
and electromyogram pads are placed along the perineum. This form of
testing provides an assessment of the entire pelvic floor, and an
uninhibited bladder contraction can be clearly documented.

Cystourethroscopy, in which a slender, lighted scope is introduced into

the bladder, is used to identify bladder lesions and foreign bodies, as well
as urethral diverticula, fistulas, urethral strictures, and intrinsic sphincter
deficiency. It is not routinely indicated as part of the surgical procedure for
incontinence.

Lifestyle interventions that may help modify incontinence include weight

loss, caffeine reduction, fluid management, reduction of physical exertion
(e.g., work and exercise), cessation of smoking, and relief of constipation.

Pelvic muscle training (Kegel exercises) can be extremely effective in

treating some forms of incontinence, especially stress incontinence. These
exercises strengthen the pelvic floor and, thus, decrease the degree of
urethral hypermobility. The patient is instructed to repeatedly tighten her
pelvic floor muscles as though she were voluntarily stopping a urine
stream.When performed correctly, these exercises have success rates of about 85%.

Behavioral training is aimed at increasing the patient’s bladder control

and capacity by gradually increasing the amount of time between voids.

A number of pharmacologic agents appear to be effective for treating

frequency, urgency, and urge incontinence.Generally,
drugs improve symptoms of detrusor overactivity by inhibiting
the contractile activity of the bladder. These agents can be broadly
classified into anticholinergic agents, tricyclic antidepressants,
musculotropic drugs,