How should I assess and classify urinary incontinence in a post‑menopausal woman presenting with stress leakage, urgency, frequency, incomplete emptying and recurrent urinary‑tract infections?

Assessment and Classification of Urinary Incontinence

Initial Symptom Characterization

Begin by distinguishing between stress urinary incontinence (leakage with physical exertion, coughing, laughing) and urgency urinary incontinence (leakage with sudden compelling urge to void), as this determines the entire treatment pathway. 1

Your patient presents with a complex picture suggesting mixed urinary incontinence given both stress leakage and urgency symptoms. 2

Essential Clinical Assessment Components

History Taking - The Cornerstone

Document the following specific symptom patterns:

• Stress incontinence symptoms: Leakage with coughing, sneezing, laughing, or physical activity 2, 1
• Urgency incontinence symptoms: Sudden compelling urge to void that is difficult to defer, associated with leakage 2
• Frequency: Document daytime voids (traditionally >7 during waking hours is abnormal, though variable) 2
• Nocturia: Number of times waking to void (≥3 episodes constitutes significant bother) 2
• Incomplete emptying sensation: May indicate overflow incontinence or detrusor underactivity 2
• Recurrent UTIs: Requires investigation for anatomical abnormalities or post-void residual 2

Validated Questionnaires

Use standardized instruments to objectively document symptom severity:

• I-PSS (International Prostate Symptom Score): Assesses 3 storage symptoms (frequency, nocturia, urgency) and 4 voiding symptoms (incomplete emptying, intermittency, straining, weak stream) 2
• ICIQ-MLUTS: Evaluates 8 storage symptoms and 5 voiding symptoms with bother scores on 0-10 scale 2

Physical Examination

Perform these specific assessments:

• Pelvic examination: Evaluate for pelvic organ prolapse (grade III or greater may require urodynamics) 3, 1
• Cough stress test: With comfortably full bladder, observe for leakage during cough to objectively demonstrate stress incontinence 1

Objective Diagnostic Tools

Voiding Diary (Frequency-Volume Chart)

Obtain a 3-day voiding diary—this is crucial for reliably measuring frequency and incontinence episodes rather than relying on patient recall. 2, 4, 1

The diary should document:

• Time and volume of each void
• Incontinence episodes and associated activities
• Fluid intake
• Distinguishes nocturnal polyuria (>20-33% of 24-hour output during sleep) from true nocturia 2

Laboratory and Imaging

• Urinalysis: Essential to exclude infection or hematuria 1
• Post-void residual (PVR): Measure via transabdominal ultrasound to rule out overflow incontinence; repeat if elevated due to high intra-individual variability 2, 1
• Imaging: Not routinely indicated for uncomplicated recurrent UTIs; reserve for suspected anatomical abnormalities 2

Classification System

Stress Urinary Incontinence

Involuntary leakage with increased intra-abdominal pressure (coughing, sneezing, exercise) due to urethral sphincter failure 2

Urgency Urinary Incontinence

Involuntary leakage associated with sudden compelling urge to void, often part of overactive bladder syndrome (urgency ± incontinence + frequency + nocturia) 2

Mixed Urinary Incontinence

Your patient likely has this—combination of both stress and urgency components. 2 In mixed incontinence, it can be difficult to distinguish which episodes are stress versus urgency-related, so total incontinence episodes are often tracked. 2

Overflow Incontinence

Leakage due to bladder overdistension; suggested by incomplete emptying sensation and elevated PVR 1

When to Consider Urodynamics

Urodynamics should NOT be performed routinely in uncomplicated cases. 3 Reserve for:

• Prior anti-incontinence or prolapse surgery 3
• Significant mixed incontinence where treatment direction is unclear 3
• Negative stress test despite typical stress incontinence symptoms 3
• Elevated post-void residual or significant voiding dysfunction 3
• Grade III or greater pelvic organ prolapse 3

Critical Pitfalls in This Case

The recurrent UTIs and incomplete emptying symptoms are red flags requiring additional evaluation:

• Measure PVR to exclude retention contributing to UTIs 1
• Consider anatomical evaluation if UTIs persist despite treatment 2
• Incomplete emptying may indicate detrusor underactivity or outlet obstruction, complicating surgical planning for stress incontinence 2

In mixed incontinence, determine which component bothers the patient most, as this guides initial treatment priority. 2 Stress incontinence typically requires pelvic floor muscle training first, while urgency requires bladder training. 2, 1