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			O U R S E R V I C E S Diagnosing Incontinence: What You Can Expect At Your First Visit Proper Diagnosis Is The First Step In Treatment If you have a problem, make an appointment at the UCSF Women's Continence Center. Incontinence is treatable, but most women do not seek help. Keep a diary that includes how often you urinate during the day, a record of the times and events surrounding leakage, and what you are drinking. This can help your health care provider make the proper diagnosis and thus decide on the appropriate treatment. At your first visit, your UCSF Women's Continence Center provider will do a complete history and physical exam (including a pelvic exam and urinalysis). If your problem is complex, additional tests may be done at a later visit. Further details about what your provider may ask or do are provided below. Office Consultation The information below provides an overview of the types of questions your health care provider may ask your during your initial office consultation. An overview of some of the tests that may be conducted is also provided. General Assessment Symptom Assessment Physical Exam Assessment Additional Diagnostic Assessment Other Tests General Assessment Information Your Provider May Collect A detailed yet focused history about your past and present urinary difficulties. Your medical history, especially with regards to urologic, gynecologic, or neurologic disease. The medications you use. Bringing a complete list of your current medications is always helpful. As you can see below, a wide variety of medications may have a side effect on your urinary function so your doctor needs to know. Diabetes medicines (Insulin, Glyburide^®, Glucophage^®, etc.) Drugs to treat depression (Wellbutrin^®, Prozac^®, Zoloft^®, Paxil^®, etc.) Antipsychotics Sedatives (Valium^®, Ativan^®, etc.) Narcotics (Codeine^®, Duragesic^®, Vicodin^®, MS Contin^®, etc) Many over-the-counter cold/flu and diet medications Blood pressure medications Previous surgeries, especially urologic, gynecologic, or neurosurgical surgeries. Back to top Symptom Information Your Provider May Collect The 3 Incontinence Questions: http://www.ucsf.edu/wcc/PatientSummary.pdf The duration and characteristics of the urinary incontinence. The most bothersome symptoms -- helps to guide therapy. The frequency, timing, and amount of your voids and incontinent episodes. The events that make you loose your urine. Information about other lower urinary tract symptoms. Your fluid intake pattern. Do you drink caffeine or alcohol? Information about previous incontinence evaluations and treatments. The amount and type of protections (pads, briefs, diapers) you use. Your expectations for outcomes of treatment. An assessment of your mobility, home, or other social factors. The severity of leakage: Position of leakage: lying, sitting or standing position Protection requirement: pads per day, wetness of pads Problem: severe enough for you to consider surgery? Information about any neurologic symptoms: weakness or numbness in legs, decreased awareness of when your bladder is full, headaches, visual disturbances, difficulties with walking or balance, or severe uncontrolled loss of stool and/or flatus. Back to top Physical Exam Assessment Depending on the particular details of your medical history, your doctor may proceed to any or all of the following physical evaluations. NEUROLOGIC EXAM: This will evaluate the strength, sensation, and reflexes in your legs. PELVIC EXAMINATION: This will assess whether you have any pelvic relaxation or prolapse. POST VOID RESIDUAL URINE ASSESSMENT: This is a simple assessment to check how much urine remains in your bladder within 15 minutes of voiding. It offers an estimation of your bladder's ability to efficiently "empty the tank". OTHER ASSESSMENTS: At the same time a postvoid residual is checked, the same urine sample may be analyzed for other parameters, such as blood, sugar, crystals, or signs of infection. Such an evaluation can be accomplished with an office urine dipstick or the hospital laboratory's microscopic urinalysis. URINE CULTURE: If a urine dipstick or urinalysis suggests signs of acute infection, a urine culture will be sent to the microbiology lab. In approximately 24 to 48 hours, bacterial growth can be detected and the specific strain identified. PELVIC FLOOR ASSESSMENT: As part of the pelvic examination, your provider will evaluate the strength of your pelvic floor muscles, and particularly, your own ability to contract and relax the appropriate muscle group. COUGH STRESS TEST: This is a test whereby your doctor instills water into your bladder, and then asks you to cough or strain in the same manner that would cause you to leak urine in your daily life. This test can be performed in the office or incorporated into more elaborate urodynamics testing URINARY DIARY: Sometimes details about your fluid intake and urine output are crucial to making the right diagnosis. Because this is not typically the sort of information we take notice of in our daily lives, your provider will give you a bladder diary, and a measuring receptacle. You may be asked to carefully record the time and amount of any fluids you drink and the urine you void over a complete 24 hour period. You may be asked to repeat this 24 hour diary for 3 to 5 days. This allows us to notice patterns that might be important to planning your treatment. Back to top Additional Diagnostic Tests When the clinical picture seems less straightforward, or multiple previous therapies have been unsuccessful; your doctor may decide to pursue further diagnostic testing. Below is a list of some clinical scenarios that are more complex and merit further testing: Uncertain diagnosis for bladder problems Inability to develop successful treatment plan Other conditions Hematuria (blood in urine) without infection Recurrent bladder infections Elevated post-void residual urine volume Neurologic condition Unimproved incontinence symptoms Failed treatment Considering surgery Failed surgical procedure Urodynamic Studies The purpose of these studies is to evaluate the anatomic and functional status of the bladder and urethra, reproducing your symptoms. Testing may include a cystometrogram, urethral pressure profile, and/or uroflowmetry CYSTOMETROGRAM: For this test, catheters are placed in your bladder and vagina or rectum so that the physician can reproduce your daily urinary symptoms. During the test, fluid will be infused in a controlled fashion to determine various characteristics about your bladder's function, for example: Your perception of water filling the bladder Any urgency to urinate Any uncontrollable bladder contractions The volume at which your bladder cannot comfortably hold any more The pressures that develop within your bladder during the fluid storage process STRESS TESTING: You may be asked to perform a number of maneuvers (such as coughing, changing positions, or bouncing on your heel) with the catheter in place in an effort to reproduce any symptoms of urine leakage or incontinence. URETHRAL PRESSURE PROFILE: For the test, the catheter in your urethra may be to manipulated to measure your urethral function. UROFLOWMETRY: During urination, a specially devised receptacle will measure the varying rate of urine flow, as well as duration of the urination process. PRESSURE VOIDING STUDY: Your doctor may use this test to identify abnormal voiding patterns or urine outflow obstruction Back to top Other Tests CYSTOSCOPY: This slender fiberoptic instrument is inserted via the urethra into the bladder. It enables your doctor to view the interior anatomy of the bladder and urethra in great detail. It is typically an outpatient diagnostic procedure performed for the following common symptoms: Blood (hematuria) or pus (pyuria) in urine with no bacteria present Bladder infections which are unusually difficult to treat New onset irritative voiding symptoms New onset bladder pain Suspected foreign body in the bladder Urodynamics fail to duplicate incontinence symptoms RADIOLOGIC TESTS: Identify upper or lower urinary tract structural abnormalities Intravenous pyelogram (IVP) This test involves the administration of intravenous (IV) dye to your bloodstream. The goal is to then obtain x-ray snapshots of the entire urinary tract over the time period that the kidneys are processing the injected dye from the bloodstream. This test cannot be performed in those patients with a known allergic reaction to IV contrast dye, or those with abnormal kidney function CT scan of abdomen and pelvis This is a test in which an x-ray machine takes a rapid sequence of 2-dimensional thin cross-sections of the body in the area of interest. This exam can be performed with or without contrast dye in some clinical situations-mostly, this depends on what your doctor is looking for. The x-ray pictures obtained provide great anatomic detail of most of the internal organs. Ultrasound Unlike the previous two tests, this one does not involve x-rays. It utilizes a skin probe that directs sound waves to bounce off the body's internal organs in order to produce an anatomic picture. It can be a very useful screening tool for a number of the above indications. Back to top Questions or comments about this Web site may be sent to coe@obgyn.ucsf.edu. Last updated: 10/14/2009 The University of California, San Francisco, CA 94143, (415) 476-9000 Copyright © 2009, The Regents of the University of California.