Initial assessment pathway

Step 1. Ask actively

Many women don't raise incontinence themselves. Ask actively: at routine check-ups, postnatally, around menopause, and in women with obesity, diabetes or chronic cough. A simple question: "Do you ever leak urine when you cough, exercise or on the way to the toilet?"

Step 2. History

• Symptoms: leakage on effort, urgency, daytime frequency, nocturia, amount lost, pad use.
• Duration and course, relation to childbirth, menopause, surgery, new medicines.
• Voiding symptoms: weak stream, straining, feeling of incomplete emptying.
• Red flags: haematuria, pain, recurrent infections, neurological symptoms.
• Obstetric history: parity, mode of delivery, birth weight, instrumental delivery, multiple births.
• Comorbidities: diabetes, COPD, neurological disease, constipation, cognitive impairment, mobility.
• Medicines: diuretics, ACE inhibitors (cough), anticholinergics, sedatives.
• The patient's goals and impact on quality of life and sexual function.

Step 3. Questionnaire and diary

ICIQ-SF quantifies severity (0–21 points) and allows you to track change. Patients can complete it beforehand on this site. Klovning severity bands: 1–5 slight, 6–12 moderate, 13–18 severe, 19–21 very severe.

The bladder diary is kept for at least 3 days: time and volume of voids, fluid intake, episodes of urgency and leakage. It reveals polyuria (more than 40 ml/kg per 24 hours), nocturnal polyuria, low functional bladder capacity, and excessive or inadequate fluid intake.

Step 4. Examination

• abdominal palpation (masses, palpable bladder);
• perineal and vaginal examination: mucosal atrophy, pelvic organ prolapse (POP-Q where possible), fistulae;
• cough stress test with a full bladder;
• digital assessment of voluntary pelvic floor contraction (e.g. modified Oxford scale);
• brief neurological examination if a neurological cause is suspected.

Step 5. Laboratory tests

• urine dipstick for all patients; if infection is suspected, send a sample for culture before starting antibiotics;
• blood glucose if there is polyuria or risk factors for diabetes;
• renal function if chronic retention is suspected.

Step 6. Post-void residual

Measure (preferably with bladder ultrasound) if there are voiding symptoms, recurrent infections, neurological disease or prolapse, and before starting antimuscarinics in at-risk patients.

Step 7. Classification and plan

1. Determine the predominant type: stress, urgency (OAB), mixed or overflow.
2. Exclude and correct reversible causes: infection, constipation, medicines, hyperglycaemia, excessive fluid intake.
3. If there are no red flags, start first-line treatment (see Management pathway).
4. Agree a goal and a follow-up date with the patient.

Referral criteria

• Urgent: visible haematuria; microscopic haematuria in women 50 and over; suspected malignancy; acute retention; neurological symptoms with voiding dysfunction.
• Routine: bladder or urethral pain, recurrent infections, suspected fistula, significant residual urine, symptomatic prolapse, previous continence surgery or radical pelvic procedures, diagnostic uncertainty, failure of first-line treatment.

Sources

1. NICE guideline NG123. 2019. nice.org.uk
2. EAU Guidelines on Non-neurogenic Female LUTS. uroweb.org
3. Avery K, et al. ICIQ. Neurourol Urodyn. 2004;23(4):322–330.
4. Klovning A, et al. Comparison of two questionnaires for assessing the severity of urinary incontinence: The ICIQ-UI SF versus the incontinence severity index. Neurourol Urodyn. 2009;28(5):411–415.