Clinical Consult

Each month, questions with a common theme will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

This Month's Question:

Stress urinary incontinence (SUI) is a condition that can be screened for and managed in the primary care setting. At what point should a primary care clinician refer a patient with SUI to a specialist?

Response by Karen Sasso, MSN, RN, APN, CCCN, posted 07/29/2005:

Three types of urinary incontinence (UI), namely, stress, urge, and mixed, account for approximately 90% of adult UI cases.¹ Stress UI, the most common of the three for women younger than 60 years, is defined as the involuntary loss of urine during coughing, sneezing, laughing, or physical exertion.^2,3

Primary care clinicians are in a strategic position to reduce the incidence of UI, including SUI, by promoting continence.³ This involves the incorporation of strategies for bladder health into routine healthcare and focused instruction in the areas of appropriate fluid intake, regular voiding intervals, weight optimization, smoking cessation, and prophylactic pelvic floor muscle exercise. Together, these strategies can play a significant role in reducing the incidence of UI and SUI, as well as optimizing treatment outcomes.

Standardized question sets during office visits can be used to assess the presence of UI and SUI, particularly at its initial stages, when early intervention offers potential stabilization of the condition. The Association of Women's Health, Obstetric and Neonatal Nurses at http://www.awhonn.org/ and others, such as The Collaborative to Support Urinary Incontinence and Women's Health at http://www.stressui.org/clinical_tools.htm, have developed screening tools that include a set of standardized questions that can be incorporated into health history forms for assessing the presence or absence of UI symptoms in women.⁴

Once the primary care clinician has been alerted to the possible presence of UI, a more complete evaluation can take place. Newman has provided a detailed checklist tool for SUI assessment involving a UI-focused, definitive patient history; a voiding diary protocol; a physical examination protocol involving general, abdominal, genital, anorectal, and neurologic assessments; urologic testing; and ultimately, guidelines for referral to a specialist.⁵ Also, Gray has written an update on both screening and diagnosis of UI and stresses the importance of managing UI in primary care.^1,6

The majority of patients with SUI or other forms of UI can be successfully managed in the primary care setting with behavioral, pharmacotherapeutic, or device therapy. Regarding pharmacotherapy, although options are available for the treatment of urge incontinence, to date none are available for SUI. However, an investigational serotonin and norepinephrine reuptake inhibitor currently in clinical trials has been shown to reduce the frequency of SUI episodes in women and could lead to a novel pharmacotherapy for SUI.⁷

The overriding reason for referral involves the inability to appropriately manage individuals with SUI, which includes an inconclusive diagnosis; an uncertain treatment plan; or a lack of response to behavioral, pharmacotherapeutic, or device therapy or surgery. Referrals are required if previous prolapse therapy has failed or if any related surgery to correct incontinence has failed. Referrals may be required in patients with significant neurologic lesions causing denervation to the bladder and sphincter, urinary retention, or structural defects (pelvic organ prolapse, cystocele, or rectocele).³

Cystocele, rectocele, and pelvic organ prolapse can be ruled out with a simple pelvic examination. To identify patients with neurologic lesions, primary care clinicians should include, as part of their health history, relevant questions pertaining to possible comorbid conditions, such as multiple sclerosis, Parkinson's disease, spinal cord lesions, stroke, back injuries, or diabetic neuropathy. In patients with a history of neurologic disease or in those who present with bladder dysfunction, bowel dysfunction, and sexual dysfunction, neurologic evaluation is merited.³

Patients who have a history of recurrent urinary tract infections (UTI) or present with hematuria not related to a UTI should be referred to a specialist. Further investigation is warranted to rule out the possibility of urolithiasis or neoplasm of the lower and upper urinary tract (K. Sasso, written communication, July 2005).

References

1. Gray M. Assessment and management of urinary incontinence. Nurse Pract. 2005;30:32-43.

2. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc. 1998;46:473-480.

3. Doughty DB. Promoting continence: simple strategies with major impact. Ostomy Wound Manage. 2003;49:46-52.

4. Sampselle CM, Wyman JF, Thomas KK, et al. Continence for women: evaluation of AWHONN's third research utilization project. J Wound Ostomy Continence Nurs. 2000;27:100-108.

5. Newman DK. Stress urinary incontinence in women: involuntary urine leakage during physical exertion affects countless women. Am J Nurs. 2003;103:2-11.

6. Gray M. The importance of screening, assessing, and managing urinary incontinence in primary care. J Am Acad Nurse Pract. 2003;15:102-107.

7. Dmochowski RR, Miklos JR, Norton PA, Zinner NR, Yalcin I, Bump RC, and the Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170:1259-1263.