The Science of Incontinence: Strategies for Accurate Assessment - Diane Newman

July 21, 2023

In this presentation, Diane Newman reviews the process of incontinence assessment based on her 35+ years of experience in the field. She provides an extensive list of the aspects covered in a basic incontinence assessment, including a patient history, the utility of a diary, and the importance of a physical examination. Dr. Newman emphasizes the role of the healthcare provider in initiating discussions about bladder control, given the societal stigma and patient embarrassment associated with the topic. She shares disconcerting statistics about women waiting years before seeking help and the minority of patients receiving treatment. Dr. Newman further breaks down the methods for obtaining a comprehensive history of bladder symptoms and the importance of assessing the severity and type of incontinence. She also details the value of a bladder diary and a focused physical exam in making a holistic evaluation. The presentation is aimed at enabling providers to make a significant impact on patients suffering from lower urinary tract symptoms.


Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

Read the Full Video Transcript

Diane Newman: Welcome. I'm Diane Newman. I'm a continence nurse specialist. I'm an adult nurse practitioner. I'm going to present incontinence assessment, so assessment of that individual patient, man or woman, who has urinary incontinence or other lower urinary tract symptoms.

This is another presentation, another review, in a series of presentations that you'll find on Awaken Pelvic Health. My nurse provider patient portal, trying to give you all the information I have from my 35 plus years experience in this area. Let's talk a little bit about the basic incontinence assessment that you would do on a patient.

This is a list of all the assessment, and it's a basic assessment that every individual who has lower urinary tract symptoms would need. It's a basic assessment. And basically includes a history, a diary would be very helpful, and a physical examination, which is more of a focused exam. It's modified than what you would do to the lower urinary tract, and then a urinalysis. Let's go through each one.

The most important thing is the provider or the person getting or doing this assessment because most patients do not want to talk about bladder control. Actually I published an article about talking to patients, which you can find in a nurse practitioner journal.

My bio in my CV with all my publications is found on Awaken Pelvic Health so if you needed more information, please pull any of my articles and use them for your practice. But basically you want to have an attitude towards this, that the patient really wants to tell you everything because the assessment's so very important, especially the history. Talking to that patient is key.

I want to give you this information because it's a little disturbing to me, as someone who's been in this field a long time, but basically with 85% of cases of women discussing their incontinence with a physician, the patient had to raise the issue. Even though this is such a prevalent problem, 30% of women have it throughout their lifespan. Men will have it after prostate cancer treatments or enlargement of the prostate. The patient has, especially with women, have to initiate it. The physician or the provider does not bring it up and that's a problem.

Then more than 50% of women who discussed their problem with a healthcare provider waited years before coming forward. The data shows that women on average will wait three to six years. Men, couple months. Men will not put up with this problem. And then only 34% of patients who discussed the problem or the provider discussed their problem received treatment. So is that because the provider didn't think there was treatment or the patient didn't want it? We don't know. But the point is that you, the provider, the one that's doing the assessment is key to really making an impact on men and women with low urinary tract symptoms.

And again, women, there's been articles that they're just too embarrassed about it. It's a hidden problem. There's a stigma associated with it.

So the first thing you want to do is a history of those bladder symptoms. And here's a list, of characteristics of the urine. How much is occurring, how severe is it. When does it occur? Is it at nighttime or is it daytime with men after prostate cancer surgery who have post post prostatectomy incontinence. They have more leakage at night when their pelvic floor muscle is fatigued because they've been up all day. They've been active. What is a trigger? I cough, laugh, sneeze. After urgency occurs after that strong urge, Diane, I rush to the bathroom. That's when it happens. And then is it patient voiding? When they're active, when they're lying down, how often do they get up? So it really gets some of that history.

How long has the incontinence occurred? Or how long have they had bladder symptoms? A lot of times you'll hear with patients it's a chronic problem. Oh, I have it for years, but now it's worse. With women, I tend to see them come forward during the menopausal years because they've been dealing with stress incontinence, which is only an episodic small amount. I wear a thin pad, but now I really have a problem once they go through menopause. So the issue is how long has the problem been going on?

And then I go over, do they wear any products. Some women with slight incontinence will tell you that they don't. They just get their underwear a little wet. Some will just use panty liners. Some will use what I call protective underwear, which is like a pull-on product similar to underwear. They've become very stylish.

Now I've had patients where they have on peach, very thin protective underwear that I don't even realize that they have a product on. They are very absorbent. They have a middle layer that's a absorbent kind of gel that pulls the urine into the gel similar to what's in a kitty litter. So against the skin there's no wetness. So against that perineum.

So I try to determine severity of incontinence by how many of the pads they use. I don't make my patients weigh their pads, but if they tell me they're wearing four protective underwear that are 50% or greater saturated, that's probably a more severe problem. Or if they tell me they're wearing two thin panty liners a day, that may not be as much of a problem as far as it's the severity. Someone who's wearing an adult brief, which some people were to refer to as a diaper wearing those, they may have a more severe problem.

So that kind of gives me an idea of how severe the problem is as far as urine leakage. Or if they don't have problems, they just have your urgency frequency, they don't really leak. That also helps me. I then do an environmental, a functional assessment, especially an older adult. Do they have mobility issues? What is their environment like? Especially like do they work? Where do they work? Do they have ... can they void at will? That's a British term. What that means is they're in a job where the bathroom's accessible whenever they want it. I practiced in the urology office, we have lots of bathrooms. So if I have to go, I go. Someone who's in a grocery store who's at the checkout counter, who may get just two breaks a day and lunch, if they get urgency, a strong urge or worry about leakage, do they leave the cash register while they're checking someone out and go to the bathroom? Probably not.

In schools. I've done focus groups in part of my NIH Prevention Plus grant. A study that we're doing is we interviewed school aged children. And they talk about a guard. That they have to have a pass to go to the bathroom. So there's a gatekeeper. So really what is the environment like? I don't just mean the home environment. Where is the toilet if they're working. If they're in school, you know that type of thing. Functional, can they get to the bathroom? If it's an older individual, can they take off their clothing? Do they have the dexterity? At night, do they get up to go to the bathroom? I worry, "how many times are you getting up at night to pee?" I say. Well if it's three times, are they going to fall? And I really worry about that.

And then the most important thing is what is the patient's expectations? There's two things I ask. What is most bothersome to you? When I do a history and I hear about the amount of incontinence, frequency, urgency, what is in my head as far as the most bothersome symptom that I've assessed may not be what the patient tells you. One of the stories I always tell is an older woman who had significant incontinence, she managed it really well, but she would go to Atlantic City once a week because what happens it's a deal in Philadelphia, you get $10 of coins to play the slot machines. And she would go to Atlantic City once a week. That was her only excursion during the week. She talked about the scenario that she took the bus down to Atlantic City because it's about an hour or so away from Philadelphia. The bus was free as part of the deal that the casinos give them.

And there was no bathroom on the bus. She'd get to the casino. There was a line at the girls' women's bathroom, which all of us know about, us women. You guys don't understand that you know don't have lines. And she'd wait and she would lose machine. Someone else would have it. So she stopped going. So her goal, what was bothersome to her was that Atlantic City trip and her expectations is I would help her get to Atlantic City. So what is the most bothersome symptom and what do they expect from you? And I think it's really important that in that initial visit you set that up is what is the patient's expectations? I go through a medication history review, what they're taking because there's so many medications that can impact the bladder and there's a lot of combination medications like anti-hypertensive medications that combine the diuretic with it.

So I want to know, is the incontinence, are there bladder symptoms, urgency, frequency because they start on new medication recently, maybe the medication, a new one prescribed is triggering their symptoms or worsening their symptoms. Or what are they doing that might impact. You'd be surprised how many medications do impact the bladder. And that's something the clinicians need to understand and know about. And here's a list.

Then I get together in my head, what is the type of incontinence they have. Is it stress, urine released with laughing, coughing, sneezing. Is it urge? It occurs after urgency. The questions are do you leak any urine when you laugh, cough, and sneeze? Do you bend over and leak urine? Do you have urinary urgency where you have intense desire to rush to the bathroom and you leak urine on the way to the bathroom. So that's urgency incontinence. How much do you leak? That gives me an idea.

A lot of individuals, especially aging individuals say they have both symptoms. If they're a man, again with prostate issues, they may just have stress incontinence, but most have mixed incontinence. There's other types. Functional is that if I could just get to the bathroom, like someone say with MS whose wheelchair bound can't really make it to the bathroom in time, it's more of a functional problem. Overflow incontinence is rare, but what that means is they just leak little bits, their stream is decreased and they may have urinary retention. So I try to determine what the type is so I can come up with what my plan of care is.

And I want to bring up the fact that in urology we see a lot of men with BPH. Okay? So the issue is that a man with BPH will have urgency, frequency, they don't leak urine. And they'll tell me I have to go to the bathroom frequently because that prostate is squeezing the outlet, the urethra at the sphincter and the bladder's getting bigger, hypertrophy causing urgency, frequency. And they go frequently because they feel that urgency, but also they fear leakage although they may never have leaked. So men with BPH are a group of patients that I see.

Now the next thing that's so helpful is a bladder diary. I sometimes have a difficult time convincing patients to do one for me. It's like a food diary that you use, say if you're on Weight Watchers. But really how often do you go to the bathroom? Do you leak urine? What's a trigger? I laugh, cough, or sneeze. I was rushing to the bathroom. Is there a trigger? Do they have urgency maybe? And what are they drinking? The amount, the type of drinks.

And the diary. A one day. If I can get a one day is fine. Three days is probably all you need to do. I'll tell individuals who work, do it over the weekend or give me one day's worth. Some people do a frequency volume chart, which means how much actually they're voiding. Someone who tells me they're voiding every hour. And I'll say, "how much are you voiding?" And they'll say, "well I think it's a lot." I have them do a frequency volume chart because invariably it's usually small volume. So that gives me idea of the quantity of urine they're voiding.

This is one that's been completed. And you can see the frequency is 12 times, which is abnormal. Remember anything over eight and they're drinking 76 ounces of fluid. And you can see cola. You can see coffee there. The other thing I want you to be aware of, there are a lot of apps on the internet that they can do to track their bladder. So bladder diaries or apps, and I recommend sometimes people that really want to do that and want to do it throughout the day to use an app.

Next is a physical exam and really it's a very focused exam and you start with a abdominal exam. Do they have any pain when you do palpation? Super pubic tenderness. Sometimes patients with interstitial studies will have pain with urgency and whenever they urinate that pain goes away. So I do do an abdominal exam. I then go to a pelvic exam. In women, you want to look and see any discharge, odor. I do a modified half speculum exam to check for prolapse. I also do a digital pelvic floor muscle assessment to determine, are they able to contract their pelvic floor.

In men, you want to look at the skin in both men and women. You want to see the meatus. Is it open? Scrotal issues. If they still have their foreskin. Is it movable? That type of thing. And can it retract? You want to, on a rectal exam, look around. Do they have hemorrhoids, fecal staining? You want to do a rectal sphincter tone check too to determine basically whether they have any type of tone in the rectum. And in men, that's how I check the pelvic floor muscle strength, is rectally. In women, I do a vaginal digital exam as well as a rectal exam.

And then neurologic. One of the big key for neur for neurologic issue, as far as sensation, mental status, is that an issue? Do they have a cognitive impairment? But do they have a sensation in the perineum? Do they, with a cotton tip swab, I will touch the perineum. Do they feel that? Do they have sensation? A lot of individuals with incontinence have lacked sensation in the perineum, so they don't know when they have to go. And some of them will tell you that they don't know that they're leaking. Neurologically, their gait. Can they walk to the bathroom? Reflexes the anal wink, that type of thing. I will do a neurologic exam.

And then finally I will check for the urine. You want to rule out infection, blood in the urine. So you should do a urinalysis. We do dipsticks in urology offices. Maybe that's what you do in your office. If you're questioning it, send it for microscopic urinalysis. Of course, if they have any positive or they have signs and symptoms of infection, you want to do a culture. Remember, to the symptoms of a urinary tract infection is urgency frequency. So you want to rule that out.

Most individuals with incontinence or lower urinary tract symptoms, such urgency, frequency, do not have an infection. But you do want to rule out. You also want to rule out the presence of blood, as of course that could be a sign of bladder cancer.

So basically that's all you do with a physical exam. It's a basic exam. As far as urodynamic cystoscopy, we don't recommend that for the basic intervention such as drug therapy or behavioral therapy, as far as doing urodynamics. But if you question their symptoms, if their symptoms feel abnormal, if they have say neurologic impairments such as MS, you probably would want to do urodynamic studies. But again, for the basic assessment, they're not necessarily necessary. Thanks so much.