• Determine what type of incontinence the woman has, and
• Identify any causes or conditions that are exacerbating the urinary incontinence, and
• Determine how severe the incontinence is, and
• Determine the effect of the incontinence on the woman's quality of life.

• 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.

In depth

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.

In depth

• Ask how often the woman is incontinent, at what times, and during which activities.
• Ask about the use of pads or changing of clothing.
• Ask the woman whether she restricts her daily fluid intake and how often she passes urine, including at night.
• Ask the woman to keep a bladder diary for 3 days to document the amount and types of fluids drunk, individual voided volume, frequency of micturition, episodes of incontinence, and pad and clothing changes. Ask her also to record episodes of urgency.
• Ask about associated symptoms, such as daytime and night-time urinary frequency.

In depth

• Ask about the effect on her social life.
• Ask about the effect on sexual function.
• Consider using an assessment tool, such as the International Consultation on Incontinence Questionnaire.
• Also assess desire for treatment, and expectations and motivation.

In depth

• Refer urgently (within 2 weeks) to a urologist if the woman has:
• Macroscopic (visible) haematuria without urinary tract infection.
• Unexplained microscopic (non-visible) haematuria and is 50 years of age or older.
• Recurrent or persistent urinary tract infection with haematuria and is 40 years of age or older.
• A suspected malignant mass arising from the urinary tract or pelvis.
• Refer to an appropriate specialist (urologist or urogynaecologist), using clinical judgement to determine urgency, if there is:
• A bladder that is palpable on abdominal or bimanual examination after voiding and/or chronic urinary retention (overflow incontinence)/voiding difficulties. The post-void residual volume will need to be measured.
• Symptomatic pelvic organ prolapse that is visible at or below the introitus.
• Persistent bladder or urethral pain (refer urgently if cancer is suspected).
• A pelvic mass that is clinically benign, such as uterine enlargement.
• Associated faecal incontinence.
• Suspected or known neurological disease.
• Suspected urogenital fistula.
• A history of previous prolapse surgery, incontinence surgery, pelvic cancer surgery, or previous radiation therapy.
• Recurrent urinary tract infection.
• Microscopic (non-visible) haematuria in a woman who is younger than 50 years of age.
• Refer to a renal physician if there is also proteinuria or raised serum creatinine levels.
• Refer non-urgently to a urologist if there is no proteinuria and serum creatinine level is normal.
• Complex comorbid medical disease and multiple medications.

In depth