- Confirm history of urinary incontinence. Ask about duration, mode of onset, severity, effect, current medications, past medical history and associated symptoms. Consider obtaining a voiding diary
- Rule out transient or reversible causes. A useful mnemonic is DIAPPERS (delirium, infection of the urinary tract, atrophic urethritis or vaginitis, pharmaceuticals, psychologic causes, especially severe depression, excess urine output from conditions or states such as hyperglycemia, restricted mobility and stool impaction)
- On physical examination check for bladder distension, perform rectal and vaginal examinations, assess mobility, dexterity and cognition, and perform a manoeuvre to provoke stress incontinence. Ascertain the presence of residual urine after voiding and select laboratory tests (e.g., urinalysis, urine culture and determination of urine creatinine level). If the postvoid amount of residual urine is over 200 mL, renal ultrasonography should be done to rule out hydronephrosis; if this condition is present the patient requires decompression
- Decide whether the patient should be referred to a specialist or have urodynamic studies done, or both (see text for details)
- Encourage all patients to have a moderate fluid intake, to restrict the consumption of caffeine-containing beverages, to try to alleviate aggravating or precipitating factors, and to use appropriate continence aids
- Make an empirical diagnostic categorization. Bladder retraining (or prompted voiding for cognitively impaired patients) and pelvic floor exercises (for women) can be effective for both urge and stress incontinence. Use drugs for urge incontinence in patients who do not respond adequately to nonpharmacologic measures. Estrogen replacement is often used for stress incontinence in women. Augmented voiding techniques (such as Credé's method [application of suprapubic pressure], Valsalva's, or straining, manoeuvre and "double voiding") after voiding has begun can help in the presence of incomplete emptying. Consider surgery for overflow incontinence due to obstruction and for severe stress incontinence that does not respond to conservative measures. Bladder atony can often be managed by intermittent catheterization
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