Measures to Take

Comments, Examples

Visit 1: Initial screening and behavioral interventions

Screen for UI in all adult patients

Ask “Have you had any problems with bladder or urine control?” If yes, then ask:

“Do you leak urine when you lift something, cough, or sneeze?”

“Do you have sudden urge to urinate and then leak urine before you can reach the bathroom?”

“Do you ever leak urine with any physical activity or warning?”

Conduct brief UI history, pertinent past medical history, and review of systems

Review lower urinary tract symptoms

Target system review at medical conditions and functional impairments associated with UI

Review all medications and fluid intake

Ask about UI impact on quality of life

Evaluate for any pathologic conditions (eg, UTI, malignancy)

Ask about bleeding, pelvic pain, dysuria, sudden UI onset

Screen for neurologic symptoms

Perform physical examination

Assess patient’s mobility, volume status (including checking for pedal edema)

Perform rectal examination—note sphincter strength with voluntary contraction. Perform pelvic examination and note any significant pelvic organ prolapse (consider gynecology referral if past the introitus); check pelvic muscle contraction during manual examination

Perform clinical stress test, if possible

Include PVR, if time allows (see visit 2)

Urinalysis

Flags: hematuria, glycosuria (see text, regarding pyuria and bacteriuria)

General management and behavioral therapy

Physical therapy for patients with impaired mobility; bedside commode

Volume management (eg, adjust intake, diuretics, compression hose, foot elevation)

See text for behavioral therapies

Medication review

See Table 26.1

Ask patient to complete a 2- to 3-day bladder diary

For sample bladder diary see http://www.healthinaging.org/public_education/bladder_control.php

Visit 2 (4–8 weeks): Detailed evaluation and treatment

Review completed bladder diary

See text

Re-review UI and lower urinary tract symptoms

Review fluid intake for volume and caffeine, which can contribute to UI

Assess response to therapy aimed at transient factors

Evaluate further

Ideally, PVR should be assessed in all patients; it should always be done in men and in persons with diabetes mellitus, neurologic disorders, significant pelvic prolapse, or taking medications that impair detrusor contractility; may be done by catheterization or ultrasound by provider or referral

Perform clinical stress test, if possible and not done previously

Refine treatment

Review and reinforce general management and behavioral therapy

Consider antimuscarinic medication for patients with urge UI (see text, p 000)

Consider referral for further evaluation and treatment

Referral for biofeedback- or electrical stimulation-assisted pelvic muscle exercises for women with mixed or stress UI

Other indications: persistent pelvic pain, hematuria, urinary retention, elevated PVR (> 200–300 mL, possibly lower in men); persistent postprostatectomy UI; bothersome pelvic prolapse (or try pessary); patient requests surgical consultation for stress UI or possible bladder outlet obstruction; diagnosis remains uncertain

Visit 3 (4–6 weeks after visit 2): Treatment evaluation and referral

Evaluate response to therapy

Review behavioral management and response to medications

Titrate medications on basis of UI, adverse effects, and (especially if UI has worsened) PVR

Consider referral for further evaluation and treatment

Indications: same as above, plus failure to respond to empirical therapy