Physical and ivestigation in incontinence

[Jose Ricardo de Mello Brandao]

I wanted to have more information about physical examination and investigation for patients on the spectrum of OAB/stress incontinence. Elderly women are often not comfortable (or have physical difficulties) with gynecological examination, how useful that is. Do we still try to do the Q-tip test? Imaging: should we normally do pelvic US, particularly for women, to check for urinary retention? I find it hard to trust bladder examination, specially on obese patients. Being a possible partial contraindication of antimuscarinic agents, is it safe to prescribe it without doing it?

[echo_wpbaycrest_admin]

Hi Jose,

Here is some information gathered from our Hub team:

PART 1:
As a Continence Advisor, the physical exam IS part of the assessment. I normally start with a pre and post void bladder scan just to rule out any retention issues first. With the physical exam, I, nor do many of my colleagues use a speculum. What we are mainly looking for are atrophic changes, irritation, drainage etc. I will assess pelvic muscle tone by asking patients to tighten their rectum. Asking the patient to cough will allow to see whether there is any loss of urine (stress) or any presence of pelvic organ prolapse, cystocele, or rectocele. I do not do the Q-tip test. By not using a speculum, it is less invasive and normally accepted by most patients.

I do agree that for many elderly women, they have not had physical exam in several years but often it will prove their symptoms by actually “seeing” what is going on. Vaginal atrophy can be seen on inspection of perineum and thus is very likely impacting on bladder tissues as well. Many women might not realize they have a prolapse at all. I think imaging will depend on what symptoms are present but agree that obesity is difficult to obtain a bladder scan accurately.

Changes in fluid, caffeine, hygiene and toileting are all what I would normally review and change BEFORE looking at any medication. Sometimes they are not needed when the above are corrected.

Hope this helps…..I am open to feedback anytime!

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PART 2:
With respect to the physical examination not all women presenting with incontinence need a pelvic examination prior to initiating behavioral or medical therapy as long as the symptoms allow the clinician to differentiate between stress versus urgency incontinence and there is no systemic or other evidence of pelvic pathology.

Women with atypical symptoms, diagnostic uncertainty, or failure of initial treatment strategies should undergo pelvic examination with special attention to evaluate for pelvic floor muscle integrity, vaginal atrophy, pelvic masses, and advanced pelvic organ prolapse beyond the hymen.
stress test — Confirmation of the diagnosis of stress urinary incontinence (SUI) includes visualizing leakage of urine from the urethra during a urinary stress test (also referred to as a cough stress test or cough test). Instantaneous leakage with cough suggests SUI. Delayed leakage suggests detrusor overactivity incontinence, especially if there is a large flow of leakage that is difficult for the patient to stop.

The urinary stress test consists of having a patient with a full bladder Valsalva (tense her abdominal muscles) or cough
Assessing urethral mobility — Urethral hypermobility (also referred to as bladder neck hypermobility) is present in most women who have primary SUI. In our practice, we no longer formally test for urethral hypermobility, since the presence or absence of hypermobility does not appear to change management. Historically, the urethral cotton swab test (Q-tip test) was the most common test used to evaluate urethral mobility for gynecologists. However, the cotton swab test has questionable test-retest and interobserver reliability. It is not possible to assess the accuracy of this and other tests of urethral hypermobility, since there is no accepted gold standard.
Postvoid residual volume — Measurement of the postvoid residual volume (PVR) is performed to exclude overflow incontinence or other types of voiding dysfunction. To measure the PVR, the patient is asked to start with a full bladder and void as she normally would (without additional effort to fully empty the bladder). The residual urine in the bladder is measured either by catheterization or bladder sonography. Normally, women should be able to void at least 80 percent of the total bladder volume and have residual urine less than 50 cc immediately after voiding. In general, a PVR of greater than 200 cc may be suggestive of voiding dysfunction or detrusor weakness; the range of normal values for PVR and treatment options remains controversial (these values may vary in elderly women or those with advanced pelvic organ prolapse).

https://www.uptodate.com/contents/surgical-management-of-stress-urinary-incontinence-in-women-preoperative-evaluation-for-a-primary-procedure?search=q%20tip%20test&source=search_result&selectedTitle=1~5&usage_type=default&display_rank=1

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