Clinical Review

Office evaluation of overactive bladder: 4 easy steps

OBG Manag. 2003 December;15(12):17-27

References

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Step 1Ask the right questions, get voiding diary, assess quality of life

Most women can be thoroughly evaluated within the clinical practice setting of any gynecologist. The first and most important aspect of this assessment is understanding and appreciating the severity of a patient’s lower urinary tract symptoms. This can be done by asking pointed questions, in the following approximate sequence:

Do you have problems with accidental loss of urine?
How many months or years have you had leakage?
Do you have to wear pads or protective clothing to prevent or help with urinary loss? If so, how many pads do you wear a day?
How many trips do you make to the bathroom during the day? At night?
Do you ever wet the bed while sleeping?
Are you bothered by a strong sense of urgency to void? Can you overcome it?
Do you sometimes fail to reach the bathroom in time?
Does the sound, sight, or feel of running water cause you to lose urine?
Do you lose urine when you cough, sneeze, run, or lift heavy objects?
Do you lose urine with posture changes, standing, or walking?
Do you feel as though you are constantly wet?
Do you feel as though your bladder is completely empty after passing urine?
Do you have difficulty starting a stream of urine?

Also ask about pelvic organ prolapse, defecatory dysfunction, and sexual dysfunction.

Take a thorough medical history, as well as a surgical history with emphasison previous bladder or gynecologic procedures.

Also review all prescription medications.

48-hour voiding diary. Give the patient a voiding diary to fill out 48 hours prior to her office visit. The reason: The diary often reveals more information than can be elicited from the patient’s history. For example, it may highlight daily activities associated with voiding, such as excessive consumption of liquids, high caffeine intake, high-impact exercise, and so on.

Quality-of-life assessment. An objective means of quantifying the effects of incontinence on the woman’s quality of life is recommended. We use the short form of the Incontinence Impact Questionnaire and the Urinary Distress Inventory.

Step 2Perform ‘eyeball’ cystometry, a simple and revealing office test

Ask the patient to go to the restroom and comfortably empty her bladder into a urine-collection device to determine the amount voided. Have a nurse measure the postvoid residual using a soft red rubber catheter. A sample can be taken for urinalysis and, if necessary, sent for culture.

Next, perform a simple filling or “eyeball” cystometry. Connect a Toomey syringe to the end of the red rubber catheter and pour sterile water into it. Ask the patient to tell you when she feels the first sensation of filling, first desire to void, strong urge to void, and maximum capacity, recording the levels at which each occurs. During filling, any evidence of bladder contraction will be revealed by a rise in the column of water. Record any significant discomfort or other observations during the filling portion of the study. When maximum capacity is reached, remove the catheter.

Step 3Conduct a thorough physical assessment

With the patient in the supine position, separate the labia and ask her to cough forcefully and perform the Valsalva maneuver 3 times, recording any evidence of water or urine loss through the urethral meatus. (If the patient has advanced pelvic organ prolapse, try to reduce the prolapse to eliminate any anatomic distortion of the urethra.)

Then ask the patient to stand with a full bladder and to squat, again having her cough forcefully 3 times. Record any additional urinary loss. Finally, ask the patient to void and again record the amount voided.

After the patient has emptied her bladder, again ask her to cough forcefully 3 times in the supine position, noting any evidence of leakage from the urethra (empty supine stress test).

Perform an overall inspection of the perineum and external genitalia and record a description in the patient’s chart.

Attempt to elicit an anal wink, and perform a brief neurological examination to ensure that spinal cord segments S2, S3, and S4 are intact. Next, gently insert a finger into the vagina and ask the patient to forcefully squeeze around it. Record the forcefulness of the squeeze on a scale of 0 to 5, with 0 being no appreciable movement and 5 being the most forceful squeeze possible. During this portion of the exam, instruct the patient on how to perform a Kegel exercise without recruiting the muscles of the buttocks and the abdominal wall.

Next, use a finger to gently massage the urethra, looking for any possible discharge from the urethral meatus that would be consistent with urethral diverticulum. Also note any tenderness or pain elicited during the exam.