• Categorize the symptoms as stress urinary incontinence, urgency incontinence, mixed urinary incontinence, or incontinence due to another cause (such as a fistula, urethral diverticulum or chronic urinary retention).
• From the history:
• Determine whether the incontinence occurred:
• When coughing, sneezing, lifting, or exercising — likely to be stress urinary incontinence.
• When there was sudden urgency, or the person felt that they needed to empty their bladder but could not reach the toilet fast enough, often accompanied by frequency and nocturia — likely to be urgency incontinence associated with overactive bladder syndrome.
• If symptoms of stress urinary incontinence and urgency incontinence both occur — likely to be mixed urinary incontinence.
• If the incontinence is associated with neither of the above (this is rare), ask about:
• Voiding difficulty (hesitancy, straining to void, poor or intermittent urinary stream, and recurrent dribbling incontinence) — likely to be chronic urinary retention (overflow incontinence).
• Constant passive leakage of urine and often total incontinence — likely to be a fistula (vesicovaginal, urethrovaginal, or ureterovaginal).
• Post-void dribbling, dyspareunia, and dysuria — consider a urethral diverticulum.
• Look for:
• Stress urinary incontinence.
• During pelvic examination, ask the woman to cough with a full bladder and observe the external urethral meatus for leakage at the time of the first cough.
• The absence of urine leakage on coughing does not rule out stress urinary incontinence; this may be due to an empty bladder. Sometimes a full bladder may cause urethral obstruction and an absence of stress urinary incontinence. A cough may also precipitate a detrusor contraction.
• Cystourethrocele.
• Over 50% of women with stress urinary incontinence have a cystourethrocele.
• Chronic urinary retention (overflow incontinence).
• Examine the abdomen for a palpable bladder. However, an enlarged bladder may be difficult to palpate.
• Urethral diverticulum.
• During vaginal examination, feel for a soft, tender mass on the anterior vaginal wall and look for urethral discharge or tenderness.
• Tests:
• No laboratory tests are necessary to determine whether the woman has stress urinary incontinence or urgency incontinence.
• A residual urine measurement is needed to diagnose chronic urinary retention (overflow incontinence).
• Formal urodynamic testing (multichannel cystometry) is not recommended before starting conservative treatment.
• Tests of urethral competence, magnetic resonance imaging, and cystoscopy are not recommended in the initial assessment of women with urinary incontinence.

Recommendations on history taking and examination

• These recommendations are based on expert advice found in guidelines from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2006] the Canadian Urological Association [Canadian Urological Association et al, 2006] the American College of Obstetrics and Gynaecologists [American College of Obstetrics and Gynecologists, 2005], a study group statement from the Royal College of Obstetricians and Gynaecologists [RCOG, 2002], in review articles [DTB, 2001; O'Neil and Gilmour, 2003; Rogers, 2008] and a textbook [Drife and Magowan, 2004].

Palpation of the bladder

• The sensitivity of bimanual examination is poor. One study [Nygaard, 1996] compared bimanual examination with catheterization. Volumes of post-void residual urine were estimated for 50 women with urinary incontinence by bimanual examination and then immediately by catheterization. Only one of the seven women who had post-void urine greater than 50 mL was detected by bimanual examination. Therefore, bimanual examination had a sensitivity of 14%, specificity of 67%, positive predictive value of 7%, and negative predictive value of 82%.

Recommendations on testing

• Expert opinion from NICE [National Collaborating Centre for Women's and Children's Health, 2006] is that evidence is sufficient to recommend that urodynamic testing is not required before initiating conservative treatment in women with urinary incontinence.
• NICE [National Collaborating Centre for Women's and Children's Health, 2006] does not recommend:
• Cystoscopy as part of the initial assessment, as available evidence does not support its role.
• Routine use of magnetic resonance imaging, computed tomography, radiography, or ultrasonography, as evidence for their use is lacking.
• Tests for urethral incompetence (Q-tip, Bonney, Marshall, and fluid-bridge tests).