To identify any causes or conditions that may exacerbate urinary incontinence or overactive bladder:

• Perform dipstick analysis of the urine in all women presenting with urinary incontinence to test for active infection and glycosuria.
• If the woman has symptoms of a urinary tract infection (UTI) and dipstick analysis is positive for both leukocytes and nitrites, send a mid-stream urine sample (MSU) and offer an antibiotic whilst waiting for the culture result.
• If the woman has symptoms of a UTI and dipstick analysis is positive for either leukocytes or nitrites (but not both), send an MSU and consider offering an antibiotic whilst waiting for the culture result.
• If the woman has symptoms of a UTI and dipstick analysis is negative for both nitrites and leukocytes, depending on clinical symptoms, decide whether to send an MSU and whether to offer an antibiotic.
• If the woman has no symptoms of a UTI and dipstick analysis is positive for both leukocytes and nitrites, send an MSU and do not offer antibiotics without the result of the urine culture.
• If the woman has no symptoms of a UTI and dipstick analysis is negative for either leukocytes or nitrites or both, do not routinely send an MSU and do not offer antibiotics.
• Perform a vaginal examination.
• Test for weak pelvic musculature by asking the woman to squeeze the examining finger to assess the strength and endurance of muscle tone.
• Look for evidence of pelvic organ prolapse — central (vault), anterior (cystocele), or posterior (rectocele), and atrophic vaginitis.
• Look for a pelvic mass.
• Ask about previous investigations and treatment, urinary tract disorders, low spinal surgery, previous surgery for incontinence, prolapse or hysterectomy, ano-rectal problems, and obstetric history.
• Previous surgery for urinary incontinence or pelvic organ prolapse may interfere with the normal support mechanisms of the vagina and urethra.
• Consider whether medication (including over-the-counter medication, such as herbal diuretics) could be causing or exacerbating the incontinence.
• Consider other factors, such as:
• Obesity.
• Smoking.
• High fluid, alcohol, and caffeine intake.
• Constipation.
• Consider and look for neurological conditions (particularly if there is urgency and/or chronic urinary retention [overflow incontinence]).
• Consider and look for systemic disease, such as heart failure and diabetes mellitus (particularly if there is urgency incontinence and nocturia).
• In elderly women in particular, look for cognitive impairment and consider the effect of restricted mobility and dexterity.

• The strength of pelvic floor muscle contractions may be assessed digitally. The Oxford grading system is an example of a grading scale that is used to quantify the strength of the contraction.
• Proposed definitions are [Laycock and Jerwood, 2001]:
• 0 = no contraction. No discernible muscle contraction.
• 1 = flicker. A flicker or pulsation is felt under the examiner's finger.
• 2 = weak. An increase in tension is detected, without any discernible lift.
• 3 = moderate. There is lifting of the muscle belly and also elevation of the posterior vaginal wall.
• 4 = good. Increased tension and a good contraction elevate the posterior vaginal wall against resistance (pressure by the examining finger applied to the posterior vaginal wall).
• 5 = strong. Strong resistance is applied to the elevation of the posterior vaginal wall. The examiner's finger is squeezed and drawn into the vagina.
• Clinical guidelines for 'the physiotherapy management of females aged 16–65 years with stress urinary incontinence' by the Chartered Society of Physiotherapists state that the Oxford grading system has been shown to be reliable by inter-rater and test-retest reliability studies. This assessment is the key to the selection of treatment: women with a grade of 3, 4, or 5 are recommended pelvic floor muscle exercises and any other appropriate treatment available [Chartered Society of Physiotherapy, 2001].

These recommendations reflect expert advice found in clinical guidelines from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2006] and 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], and a Drug and Therapeutics Bulletin [DTB, 2001].

Exclude urinary tract infection

• Urinary tract infection may cause frequency, urgency, and incontinence. It causes urgency incontinence more often than stress incontinence [Rogers, 2008].

Management of the results of dipstick testing

• The recommendations regarding dipstick testing of urine are in line with those of NICE [National Collaborating Centre for Women's and Children's Health, 2006], which based its recommendations regarding dipstick testing of urine on the results of an observational study (n = 265) that aimed to find out the usefulness of using urine reagent strips in screening women with urinary incontinence for urinary tract infections (UTIs) [Buchsbaum et al, 2004]. The study did not document whether the participants had symptoms of a UTI. The urine culture result was used as a gold standard, and the following were calculated:
• Prevalence of UTI: 12%.
• Sensitivity: 29%. The dipstick test was positive in 9 of 11 women with a UTI.
• Specificity: 99%. The dipstick test was negative in 232 of 234 women without a UTI.
• Positive predictive value: 82%. Of 11 women with a positive dipstick result, 9 also had a positive urine culture.
• Negative predictive value: 91%. Of 254 women with a negative dipstick result, 232 also had a negative urine culture.
• Positive predictive values increase with increasing prevalence (or prior probability) and negative predictive values decrease with increasing prevalence (or prior probability). Therefore, if the clinical judgement is that the probability of UTI is high, a negative dipstick result should not be used to exclude UTI. In other words, if the prior probability is thought to be substantial (or if the risk of complications or severe disease is thought to be substantial), consider sending a mid-stream urine sample and offering an antibiotic even when the dipstick result is negative.

Digital assessment of pelvic floor muscle contraction

• Evidence for digital pelvic floor muscle assessment is lacking. However, expert opinion from NICE is that treatment decisions will be directed by whether a woman is able to contract her pelvic floor muscles. NICE therefore recommends that routine digital assessment of pelvic floor muscle contraction should be done before the use of supervised pelvic floor muscle training for the treatment of urinary incontinence [National Collaborating Centre for Women's and Children's Health, 2006].