Visit #1: Initial Screening and Behavioral Interventions

1. Screen for UI
   
   
2. Conduct Brief UI History, Pertinent Past Medical History, and Review of Systems
   
   
3. Treat Factors that Cause or Exacerbate UI
   
   
4. Rule Out/Discover Pathologic Conditions
   
   
5. Perform Urinalysis
   
   
6. Discuss Behavioral Therapy
   
   
7. Provide Behavioral Therapy Handout and Bladder Diary
   
   
8. Consider Special Challenges of Managing Incontinence in Cognitively Impaired Persons
   
   
9. Schedule Patient to Return in 1-2 Months

I. Screen for UI in all adult patients:

Screening for Incontinence -
Ask The Patient:
Have you had any problems with bladder/urine control?

If the patient answers "yes," then ask the following questions to determine the type of UI (See Table 1):

Defining Type of Incontinence -
Ask The Patient:

1. Do you leak urine when you lift something, cough, or sneeze?
   
   
2. Do you have sudden urges to urinate and then leak urine before you can reach the bathroom?
   
   
3. Do you ever leak urine without any physical activity or warning?

ICD9 Codes for various types of UI

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II. Conduct Brief UI History, Pertinent Past Medical History, and Review of Systems.

Ask about all medications taken, including over-the-counter medications and products (vitamins, herbals, medicinals, teas, etc.). Ask about caffeine use. NOTE: Medications that can cause/contribute to urinary frequency and incontinence include alpha-adrenergic blockers or agonists, calcium channel blockers, antidepressants, anti-anxiety medications, neuroleptics, antihistamines, diuretics, caffeine, anti-Parkinsonism medications, antispasmodics, and hypnotics.

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III. Treat Factors that Cause or Exacerbate UI.

(See Table 2)

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IV. Rule out/discover any pathologic conditions that can be associated with UI, such as urinary tract infections, diabetes, malignancy, or benign prostatic hyperplasia (BPH).

To Discover Potentially Treatable Factors Related to Incontinence -
Ask The Patient:

1. Have you experienced any bleeding, pelvic pain, or pain with urination?
   
   
2. Was the onset of symptoms sudden? (Sudden onset could indicate infection, new medication, or a neurological problem).
   
   
3. Do you wake up and have to urinate at night? (If "yes," this is classified as nocturia (See Table 3).
   
   
4. Have you experienced constipation? (Treat, if necessary, since constipation can worsen incontinence).

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V. Perform Urinalysis.

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VI. Discuss Behavioral Therapy.

• Behavioral therapy should be the first line of treatment because it has no side effects and is completely effective for many patients. (8,9) Pharmacologic therapy may add to the effectiveness of behavioral therapy, but behavioral therapy should be tried alone first.
  
  
• Behavioral therapy has multiple components. It may involve performing pelvic floor muscle exercises and timing bathroom visits to "train" the bladder to better resist the urge to void so frequently.
  • Pelvic floor muscle exercises benefit women and men with urge and stress incontinence. (10,11)
  • For demented/forgetful patients, the best behavioral strategy is timed or prompted voiding. (See Table 4)
  
  
• Discuss performing pelvic floor muscle exercises and/or prompted voiding, and give the patient the relevant instructional handouts (click here for "Behavioral Therapy and Performing Pelvic Floor Muscle Exercises" and "Voiding Schedule," formatted for printing.)
  
  
• Suggest community-based resources that can teach pelvic floor muscle exercises (urology or gynecology departments, RNs, PTs).
  
  
• Explain that behavioral therapy often takes at least 6 weeks for results to be apparent.

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VII. Give the Patient the "Bladder Diary".

Give the Patient the "Bladder Diary" (click here for bladder diary, formatted for printing) to record a 1-day history of voiding. The bladder diary should be completed the day after the first appointment and brought to the second visit.

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VIII. Cognitive Impairment Requires Special Management for Patients and Caregivers.

(See Table 4)

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IX. Schedule patient to return in 1-2 months.

Focusing the return visit entirely on UI is quite appropriate and may be more effective.

NEXT: Visit Two

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