Urinary incontinence physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.[1]
Physical examination
Appearance of the Patient
- Patients with Urinary Incontinence usually appear obese (check BMI)[2]
- Assses the patient cognitive status, mobility and presence of edma[3]
Vital Signs
- Patient with urinary incontinence usually has normal vital signs.
Skin
- Skin examination of patients with Urinary incontinence can show rashes,infections, sores and ulcers [4].
HEENT
- HEENT examination of patients with Urinary incontinence is usually normal.
Neck
- Neck examination of patients with Urinary incontinence is usually normal.
Lungs
- Examine for chronic obstructive pulmonary disease or bronchitis[5]
Heart
- Check for signs of volume overload or congestive heart failure for example, rales and pedal edema[5]
Abdomen
- Check for a palpable abdominal massess and for a palpable bladder [5]
- Check for signs indictive for collagen disorder like presence of striae.[6]
- Check for costovertebral angle tenderness.[7]
Back
- Palpate vertebra from up to down, (from the neck to coccyx) and check for any abnormalities that may be a cause for urinary incontinence.[6]
- Check for costovertebral angle tenderness.[7]
Genitourinary
- Genitourinary examination of patients with urinary incontinence:
- The urogenital examination might reveal vaginal atrophy and incontinence-associated dermatitis (that is, damage to the skin with exposure to urine)[7].
- Stress Test:
- If there's loss of urine while coughing or Valsalva maneuver indicates positive test.[6]
- The test is done when the patient is in a dorsal position. If urine loss is not visible switch to squatting position. If still not visible then in standing position asking her to keep her feet on the ground at shoulder distance, lift the saree/gown and looking for urine loss on the floor in between her feet or trickling down of urine through the thighs.[6]
- Bonney's test:
- If the stress test is positive , Do bonney's test.[6]
- Place the patient in the dorsal position. Doctor should place the middle and index fingers in the anterior vaginal wall on either sides of the urethra and push upward and backward to restore the posterior urethra-vesical angle and stabilizing the urethra. After that, the patient is asked to cough and checked for urine loss.If there is no urine loss, then the test is positive (which indicates distortion of posterior urethra-vesical angle is the cause of stress urinary incontinence). However, this test has limited value in stress incontinence evaluation[6].
- Stress Test:
- Examine for pelvic organ prolapse during a Valsalva maneuver over≥6 seconds, staging of pelvic organ prolapse is described by Pelvic Organ Prolapse Quantification (POP-Q)but a simplified description (S-POP-Q) has also been validated for use in clinical practice, which is a staging system that depends on assessment after emptying the bladder[7].
- Simplified description (S-POP-Q) staging system only detects anatomical descent and does not detect the normal range, stage two descent is found in up to 50% of women, Only a weak-to-moderate correlation between anatomical descent and urinary symptoms has been described, common symptoms of prolapse is a vaginal bulge, sensation of heaviness or difficulty in voiding[7].
- Women with stage 2-4 pelvic organ prolapse may have anatomical distortion that may kink the urethra, which can cause a false-negative cough stress test. Thus, reducing the prolapse digitally without distorting the bladder neck while performing a cough stress test might be of value. However, limited evidence has been reported on how to optimally reduce urethral kinking for the test[7].
- Digital examination for pelvic floor muscle tone[7].
- Levator ani muscle strength assessment (digital palpation)
- Place the fingers on the posterior vagina at least 2–4 cm above the hymenal ring while the patient is in the dorsal position. Palpate both sides of the levator ani muscle to assess its resting tone, bulk, and spasticity. Afterthat, ask the pateint to contract the pelvic floor muscles maximally as long as possible. Rectus abdominis, adductors of the thigh, and gluteus muscles are not supposed to be contracted[6]. Now, levator ani is evaluated regarding muscle contraction (present/absent), strength and duration of contraction, and the ability to elevate the P/V fingers[6]. Grading is done according to the modified Oxford Scale
| Score | Levator ani strength |
|---|---|
| 0/5 | No contraction |
| 1/5 | Flicker, barely perceptible |
| 2/5 | Loose hold, (1-2 seconds) |
| 3/5 | Firmer hold, (1-2 seconds) |
| 4/5 | Good squeeze, 3-4 s, pulls fingers in and up loosely |
| 5/5 | Stronger squeeze, 3-4 s, pulls finger in and up snugly |
- Abnormalities such as urethral diverticula and pelvic masses can also be detected while assessing for pelvic organ prolapse.[7]
- Speculum examination can help in assessing each vaginal compartment and in assessing for any extra-urethral loss of urine that may suggest a fistula[7].
- Rectal examination should be done if there's bowel dysfunction or neurological symptoms to asses for tone and sphincter squeeze, bowel dysfunction should prompt a general neurological examination, including testing of the S2-S4 nerve distribution [7].
- Urethral hypermobility test:
- Inspection: Inspect the patient during coughing or doing Valsalva maneuver. If there is urethral hypermobility, then the anterior vaginal wall will rotate outward, and external urethral meatus will rotate upward toward the ceiling [6].
- Q-tip test/cotton swab test:This test is done in dorsal/dorsal lithotomy position. A sterile lubricated cotton-tipped swab is introduced through the urethra to the bladder and withdrawn up to the level of urethrovesical junction. The position of the cotton swab in relation to the horizontal is observed – usually resting angle is 0° or nearer to 0°. Then, the patient is asked to cough or do Valsalva, and movement of the swab stick is observed. If the straining makes an angle of 30° or more, i.e., moving away from the horizontal, it is diagnosed with the hypermobile urethra. The mere presence of hypermobile urethra is not diagnostic of stress urinary incontinence, but this test has prognostic value if the operation is contemplated [6].
Neuromuscular
- Examine for signs of dementia and alerted mental status like delirium [5].
- Examine for normal pressure hydrocephalus and Cerebral vascular accident [5]
- Examine for Spinal stenosis [5]:
- cervical stenosis can cause damage to detrusor upper motor neurons.
- lumbar stenosis can cause areflexia.
- Sacral reflex – to check for pudendal nerve integrity. Two reflexes are tested:
- Anal reflex – Elicited by stroking the perianal skin lightly and observing for anal sphincter contraction. If the contraction is not observed, then feel it by palpation of the sphincter[6]
- Bulbocavernosus reflex – Elicited by tapping or squeezing the clitoris lightly and observing for contraction of the bulbocavernosus muscle and/or external anal sphincter [6].
- The absence of one or both sacral reflexes signifies lower motor neuron lesion, usually resulting from trauma during delivery[6].
Extremities
- Examine joints for signs of arthritis and mobility restricion [5]
- Peripheral edema of lower extremities[5]
- Asses mobility of joints, hypermobile joint can be indictive for collagen disorder[6]
References
- ↑ Tran LN, Puckett Y. PMID 32644521 Check
|pmid=value (help). Missing or empty|title=(help) - ↑ "Incontinence & Female Urology [Dr.Edmond Wong]".
- ↑ "Urinaryincontinence final".
- ↑ "Woman Health-Incontinence&Pelvic Organ Prolapse".
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 "Diagnosis of Urinary Incontinence - American Family Physician".
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 "Approach to a woman with urinary incontinence".
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 "Urinary incontinence in women".
- ↑ "Approach to a woman with urinary incontinence".
- ↑ "Urethral hypermobility causes, symptoms, diagnosis, treatment & prognosis".