Physical examination

1. Neurologic examination. Normal sensation in the perineal and the back of the leg confirms intact sensory enervation of the lower urinary tract. Sacral reflex activity is tested via the anal reflex-stroking the skin with a cotton swab adjacent to the anus causes reflex contraction of the external anal sphincter. Pelvic floor muscle tone can be assessed by voluntary contraction of the anal sphincter and vagina during a bimanual exam.

2. Pelvic exam should be performed to assess the external genitalia, perineal sensation, presence of pelvic organ prolapse (cystocele, enterocele, rectocele, uterine prolapse), estrogen status, and pelvic muscle strength. A bimanual exam with rectovaginal exam should be done to rule out pelvic masses.

3. Observation of urine loss while the patient has a full bladder can be performed by having the patient cough vigorously in the standing position. If instantaneous leakage occurs with cough, stress urinary incontinence is likely while detrusor instability (urge incontinence) is suggested by delayed or sustained leakage.

4. Urethral hypermobility due to loss of bladder neck support can be assessed using a cotton swab test. A sterile, lubricated cotton swab is inserted transurethrally into the bladder and then withdrawn slowly until resistance is felt, then the patient is then asked to cough or perform a Valsalva maneuver. A 30 deflection indicates urethral hypermobility.

D. Post-void residual is useful to rule out overflow incontinence and incomplete bladder emptying, and a urinalysis and/or urine culture to rule out urinary tract infection. After a normal void, a post-void residual urine volume is determined using a catheterization or bladder scan. A post-void residual should be less than below 100 cc.

E. Cystometry is used to measure the pressure volume relationship of the bladder as it distends. Complex cystometry uses specialized equipment with pressure catheters to record bladder pressures. Simple cystometry can readily be performed in the office with a red rubber catheter, a syringe, and sterile water.

F. Urinalysis or urine culture should be obtained. Creatinine BUN, glucose, and calcium are recommended if compromised renal function is suspected or if polyuria is present.

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