Is a telehealth consultation appropriate for a patient with new onset incontinence, considering their overall health status and potential underlying causes?

Telehealth for New Onset Incontinence

Yes, you can initiate a telehealth evaluation for a patient with new incontinence, but with important limitations—you must arrange for urinalysis at a local laboratory, recognize that physical examination and post-void residual measurement will be deferred, and plan for in-office follow-up if the patient doesn't respond to initial treatment. 1

When Telehealth is Appropriate

The American Urological Association explicitly states that telemedicine is a viable option for patients with overactive bladder and incontinence symptoms, though it will not allow for all elements of the initial in-office evaluation. 1

Key components you CAN accomplish via telehealth:

• Comprehensive medical history including detailed assessment of bladder symptoms (urgency, frequency, nocturia, leakage patterns) 1
• Symptom characterization to determine incontinence type (stress, urgency, overflow, mixed, or functional) 2
• Review of voiding diary if you have the patient complete one prior to the visit 2
• Assessment of quality of life impact and patient treatment preferences 1
• Medication review to identify contributing drugs (diuretics, anticholinergics) 1
• Evaluation of comorbidities such as diabetes, constipation, BPH, obesity, or neurologic disorders 1

Critical Limitations of Telehealth for Incontinence

What you CANNOT do via telehealth (and must arrange separately):

• Physical examination including abdominal, pelvic, and neurologic assessment 1
• Cough stress test to diagnose stress incontinence 2
• Post-void residual (PVR) measurement 1
• Direct urinalysis (though this can be obtained at a local laboratory or by reviewing recent results) 1

Mandatory Laboratory Work

You must obtain urinalysis on all patients with new incontinence symptoms, even via telehealth. 1 This can be accomplished by:

• Ordering labs at a local laboratory facility
• Reviewing recent urinalysis results if available within an appropriate timeframe 1
• Performing urine culture if urinalysis suggests infection or hematuria 1

When In-Office Evaluation is Required

Plan for in-office follow-up with physical examination, PVR measurement, and urinalysis if: 1

• The patient doesn't respond to initial therapy after telehealth evaluation
• Red flag symptoms are present: hematuria, obstructive symptoms, recurrent UTIs, or pelvic pain 2
• High-risk features requiring PVR measurement: concomitant emptying symptoms, history of urinary retention, enlarged prostate, neurologic disorders, prior incontinence or prostate surgery, or long-standing diabetes 1
• The incontinence type remains unclear after initial telehealth assessment 2

Initial Treatment You Can Initiate via Telehealth

For overactive bladder/urgency incontinence, you can immediately start: 1, 3

• Behavioral therapies (first-line for all patients):

  • Timed voiding and bladder training 1, 3
  • Urgency suppression techniques 1, 3
  • Fluid management (reduce intake by 25%, limit evening fluids) 3
  • Caffeine and alcohol avoidance 1, 3
  • Pelvic floor muscle training instructions 1, 3

• Pharmacologic therapy (if behavioral therapy alone is insufficient):

  • Mirabegron 25-50 mg daily (preferred due to lower cognitive risk) 3
  • Antimuscarinics as alternative (darifenacine, fésotérodine, oxybutynine, solifénacine, toltérodine) 3

Common Pitfalls to Avoid

Do not prescribe antimuscarinics via telehealth without: 1, 3

• Confirming absence of narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention
• Measuring PVR in high-risk patients (those with emptying symptoms, neurologic disorders, enlarged prostate, diabetes, or prior retention) 1
• Understanding that PVR >250-300 mL is a contraindication 3

Do not assume telehealth is sufficient for all incontinence presentations. Stress incontinence diagnosis typically requires physical examination with cough stress test, which cannot be performed remotely. 2

Documentation Requirements

Document in the clinical record: "Teleconsultation is provided with the consent of the patient" and note the limitations of remote evaluation. 1

Bottom Line Algorithm

1. Conduct telehealth visit with comprehensive history and symptom assessment 1
2. Order urinalysis at local laboratory (mandatory for all patients) 1
3. Initiate behavioral therapies immediately for all patients 1, 3
4. Consider pharmacologic therapy if symptoms are moderate-to-severe and no contraindications exist 3
5. Schedule in-office follow-up if: no response to treatment, red flags present, high-risk features requiring PVR, or diagnosis remains unclear 1, 2

Telehealth is particularly effective for initial evaluation and behavioral therapy initiation in uncomplicated urgency incontinence, with studies showing successful implementation in this population. 4 However, maintain a low threshold for transitioning to in-person evaluation when clinical features suggest complexity or when initial treatment fails. 1