A urinary symptom/voiding diary or bladder log can provide patient-reported information that may be helpful to the clinician. The data obtained from this material are considered some of the most important components of the evaluation process.
A diary/journal completed by the patient at home can be the focal point of the office visit and serve as the framework for collecting the previously described historical information. When reviewing the diary, look for patterns and associations. How frequent are the symptoms? Is there any regularity to them? What activity was occurring at the time of leakage? Does consumption of a particular food or beverage seem to be associated with urge or incontinence or both?
Even frail older women living independently are capable of keeping an accurate diary for three days (these do not have to be consecutive days). Diaries need to be configured with a larger font, follow the health-literacy guidelines and allow enough space for the individual to make notes. The form should also include space to record the number of times that undergarments, clothes or absorbent products needed to be changed. A section for bowel movements can also be helpful in diagnosing constipation.
Finally, the diary can be used as a monitoring tool to determine the effectiveness of interventions. Free forms are available on the Internet.
Older adults are often taking multiple medications, and a complete review should be performed at least yearly. Asking patients to bring in all the medications they have at home is a common approach used to gain perspective on past and current health issues. This technique has been called the “brown bag test.”24 The review should include not only prescription medications but all OTC drugs, home remedies and supplemental or alternative herbal therapies, as well as a report of caffeine and alcohol intake.
During a medication review, the clinician often discovers the potential reason for the patient’s UI. Any suspicious medication should be decreased or carefully discontinued, if possible. For the patient who requires a particular class of drugs, consider substituting within the class with a medication that has a different side-effect profile.
Last, talking with the older woman about her goals and expectations of treatment is crucial to the therapeutic patient-provider relationship as well as the patient’s QOL. Are the goals and expectations realistic? Is the time frame reasonable? Is a support system in place? Will treatment be affordable for the patient? Will the treatment plan fit with the patient’s lifestyle? Is the patient able to understand and comprehend treatment plans? Is she motivated?
While these questions may seem logical, they are often not considered by the clinician, and sometimes patients have unrealistic expectations. Acquiring this specific information helps in the clinical decision-making process.
Physical examination. The physical examination must be approached carefully, taking into consideration the age, overall health status and history of the individual, and the clinical setting.15 The physical exam helps clarify possible causes of transient UI, detect underlying conditions and causes associated with persistent UI, evaluate comorbid conditions and determine functional ability.
What the examination includes is different for each woman and is dependent on the data collected during history-taking and review of the completed patient forms. General appearance, cognitive status, skin integrity, and cardiopulmonary status are important indicators of overall patient health. In addition, look for lower-extremity edema, palpate peripheral pulses and check for venous insufficiency.
Functional status — especially mobility — is one of the keys to controlling UI. The first part of a mobility assessment can begin with observation of the patient as she is escorted to the examination room. Observe whether an assistive device is being used (and if it is being used correctly); whether the patient requires support from the wall, handrail, or another person; and whether she requires a rest period. Watch her gait pattern and balance. Notice the type of shoe she is wearing and ask whether this is her usual footgear.
In the examination room, pay attention to how the patient gets on and off the examination table and up and down from a chair; for example, does she need assistance or use the arms of the chair? When entering the room, extend your hand for a handshake, as this can provide information about the patient’s vision, strength, dexterity and gross coordination. These are all integral aspects of the toileting experience and manipulation of clothing.
The neurologic examination should include a measure of cognition. Lower-extremity and perineal sensation and anal and bulbocavernosus reflexes should be assessed if the patient can tolerate the examination. The abdominal assessment should include checking for diastasis recti, masses, hernias, ascites and organomegaly, all of which can influence intra-abdominal pressure and urinary-tract function.
In some older women, the gynecologic examination needs to be approached in a conservative manner, keeping it as minimally invasive as possible. Consider performing a digital examination rather than a speculum examination.25 Assess for perineal dermatitis, pelvic-organ prolapse, pelvic-floor muscle tone and presence of anatomic abnormalities. Document any atrophy, vaginal stenosis or scar tissue.
The ability of the older woman to tolerate a rectal examination should also be considered. If the clinician decides to perform this assessment, explanations about what is being done and why can make the examination tolerable for the patient and allow the clinician to gain valuable information. The rectal examination should include looking for skin irritation, perianal lesions, masses and hemorrhoids, and checking sphincter tone and perianal sensation. If stool is present in the anal canal, test for occult blood.
Diagnostic studies. Diagnostic tests should be conducted only if knowing the results will clarify the diagnosis, guide treatment decisions, or change treatment interventions.26 Whether to send a urine specimen for laboratory analysis is controversial. Some authors believe urinalysis (UA) by dipstick testing is useful in ruling out bladder infection and in detecting the presence of glucose, protein and hemoglobin.27
If findings are negative, the specimen does not need to be sent to the laboratory for further analysis. If dipstick findings are positive, the specimen should be sent for microscopy and culture and sensitivity.
In 2010, the International Scientific Committee on Incontinence strongly recommended UA as a diagnostic measure but indicated that testing could range from dipstick to urine microscopy and culture when indicated.28 Thus, the decision about which diagnostic tests should be done lies within the clinician’s judgment but should include consideration of costs and usefulness of the information obtained.
In older women with suspected voiding dysfunction, prevoid, portable, noninvasive ultrasonography should be performed with the bladder full. This test provides an estimate of bladder capacity. The postvoid residual urine volume (PVR) is performed within five minutes of an intentional void.
When determining PVR, bladder ultrasound is preferable to in-out catheterization because of the latter’s potential for trauma and infection. A PVR ≤50 mL is considered normal, while a PVR of 50 to 100 mL is suggestive of weakness or possible obstruction; a PVR >100 mL is considered abnormal and a PVR >200 mL may indicate the need for referral.29
Recently, obtaining PVR has been found to be of little help unless the patient has recurrent UTIs, neurologic disorders or pelvic-organ prolapse beyond the introitus.22 Since bladder ultrasound may not be available in many practice settings, PVR should not be considered an essential component of an initial UI workup.