Reliability of the patient's history in the diagnosis of urinary incontinence

Int. J. Gynecol. Obstet., 1990,32: 255-259 International Federation of Gynecology and Obstetrics

255

Reliability of the patient’s history in the diagnosis of urinary incontinence A. Bergman

and K. Bader

USC School of Medicine, Women’s Hospital, Room L-1022, Department of Obstetrics and Gynecology, 1240 N. Mission Road, LOS Angeles, CA 90033 (USA) (Received February 6th, 1989) (Revised and accepted April 26th, 1989)

Abstract The reliability of a patient’s history has been challenged in the preoperative evaluation of stress urinary incontinence. In this study, 122 consecutive patients referred to our Gynecology/Urology clinic were evaluated and an additional 32 control patients (continent women with no urinary symptoms) were evaluated. All patients answered a detailed 64-item questionnaire, and all patients received a complete urodynamic Our detailed questionnaire evaluation. provided a mean positive predictive value of 80% for genuine stress incontinence and 25% for detrusor instability. The conditions leading to a false positive history suggestive of genuine stress incontinence were detrusor instability and urethral diverticulum. The conditions leading to a false positive history suggestive of detrusor instability were urethritis, unstable urethra, vaginitis and polyuria. History alone can be misleading in diagnosing urinary incontinence. Keywords: History; Stress incontinence;

Reli-

ability. Introduction A meticulous history has been regarded as essential in establishing the diagnosis in 0020-7292/90/$03.50 0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland

women with urinary incontinence. Although the accuracy of symptoms and the role of history has been challenged [l-6], they are still cornerstones in the evaluation of urinary The present study was incontinence. undertaken to evaluate prospectively the reliability of the history in the evaluation of female urinary incontinence. Materials and methods One-hundred fifty-four women had a detailed clinical and urodynamic evaluation in the gynecologic urology division of LAC/USC Medical Center between January and May 1988. The patients’ mean age was 54 years and mean parity was 3 (range O-12). Eighty-one patients were premenopausal, and 73 were postmenopausal. One-hundred twenty-two women were referred for evaluation of urinary complaints and 32 patients had no urinary complaints. These 32 patients were women that were followed in the gynecologic clinic for abnormal pap smears and volunteered to participate in the study to serve as a control group. Ninetyseven women gave a history suggestive of genuine stress urinary incontinence, and 25 patients gave a history suggestive of detrusor instability incontinence. Women with history suggestive of mixed bladder instability and stress urinary incontinence were not included in this study (Table I). Clinical and Clinical Research

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Bergman and Bader

Table I.

Selected characteristics of 154 women undergoing a detailed clinincal and urodynamic evaluation.

Genuine stress incontinence (N = 97) Detrusor instability (N = 25) Control group (N = 32)

Mean age (range)

Mean parity (range)

Menopausal status pre/post

57 (29-78)

3 (O-12)

43/54

50 (22-70)

3 (O-10)

14/11

36 (17-67)

1 (O-6)

24/8

Each subject completed a detailed, 64 question questionnaire in her own language (Spanish or English). The questions were again asked in the interview performed by one of authors (K.B.). The questionnaire (modified from Ostergard [7]) has questions relating to various lower urinary pathologies. Many of the questions were repetative to ensure consistency of responses by the patients. The questionnaire has 12 questions for stress urinary incontinence and 24 questions for detrusor instability (Tables II, III). After completion of the questionnaire and the interview, the patients underwent a clinical and urodynamic evaluation of the lower urinary tract. Evaluation included urine culTable II.

ture, neurologic evaluation of S2-S4 lower micturition center [8], Q tip test, pessary test, dynamic water urethrocystoscopy, water urethrocystometry (at a filling rate of 60 ml/ min) and urethral pressure profiles at rest and during stress (repeated coughing). Pressures in the bladder, urethra and abdomen (approximated by vaginal recording) were concomitantly measured using two microtip pressure transducers 3 and 4 French in size (Dantek models 20K60 and 20K62) and recorded on a 6 channel electrophysiologic recorder (Dantek model 2100, Dantek Electronic, NJ). All terminology conforms to that proposed by the International Continence Society [9], except where specifically mentioned. Genuine stress

Evaluation of 12 questions in 97 patients with genuine stress urinary incontinence.

Question

1. Urine loss with cough, sneeze 2. Urine loss with straining 3. Urine loss with walking, running 4. Started after pregnancy/delivery 5. Worsening after menopause 6. Spurt on laugh, lift 7. Loss with standing after sitting-lying 8. Wear protection for loss with strain 9. Wear protection with laugh 10. Protection during day only 11. Loss with getting out of car 12. Unaware of accidentally losing urine Total questions suggestive of genuine stress incontinence (mean + S.D.)

Znt J Gynecol Obstet 32

Sensitivity (070)

Specificity (070)

Predictive value of positive response (Vo)

90

24

95 54 38 13 71 33 63 54 65 38 43

43 71 71 90 67 81 81 80 77 81 77

79 83 75 80 80 76 74 80 74 79 76 74

56 f 17

70 f 23

77 + 12

History taking and urinary incontinence Table III.

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Evaluation of 21 questions in 25 patients with detrusor instability.

Question

Sensitivity (@A)

Specificity (%)

Predictive value of positive response (%)

1, Loss without cough-sneeze 2. Loss after intercourse 3. Loss of large amount on cough-sneezing 4. Uncomfortable need to pass urine before emptying bladder 5. Loss before reaching toilet 6. Painful loss of urine 7. Have to hurry to toilet 8. Uncomfortable with full bladder 9. Uncomfortable without full bladder 10. Voiding more than twice at night 11. Voiding more than twice in first hour of sleep 12. Awaking and then passing urine 13. Painful voiding after intercourse 14. Frequent voiding after intercourse IS. Discomfort disappears after voiding 16. Voiding more frequent than every 2 h 17. Voiding more frequent than every 1 h 18. Urge with feeling-hearing running water 19. Frequency with riding in a car 20. Very wet without cough-sneeze-run 21. Aware when about to lose urine

71 16 32

90 92 97

47 17 29

90 67 8 92 67 8 31

41 87 84 59 87 74 79

37 17 6 20 17 19 20

31 37 4 31 67 31 27 31 29 24 4

83 81 0 82 91 81 81 89 97 89 90

27 20 0 24 49 33 26 40 41 28 8

38 + 29

80& 31

25 f 34

Total questions suggestive of destrusor instability (mean f S.D.)

incontinence was urodynamically diagnosed when there was visible loss of urine during coughing with pressure equalization between bladder and urethra and in the absence of bladder contraction [9]. Detrusor instability was urodynamically diagnosed when uninhibited detrusor contractions of 215 cm/water were recorded on urethrocystometry during bladder filling [9] with a stable urethra. Results Most questions for stress urinary incontinence gave similar predictive values when positive, i.e. in the range of 74-83% (Table II) and in the range of O-49% when questions for detrusor instability were evaluated (Table

III). Mean predictive value of a positive question for stress urinary incontinence was 77% and 25% for questions regarding detrusor instability (Tables II, III). Women who answered most questions affirmatively which would suggest the presence of genuine stress incontinence still had a positive predictive value in the range of 80% (Fig. 1) and only a positive predictive value of approximately 30% when questions for detrusor instability were evaluated. Nineteen of the 97 patients (19.6%) presenting with symptoms suggestive of genuine stress incontinence found on were urodynamic evaluation to have other conditions. Fourteen (74%) had urodynamic findings of detrusor instability without stress incontinence. Nine of these had bladder conClinical and Clinical Research

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Bergman and Bader

(Z)

(20) ??

Fig. 1.

Correlation between numerous positive questions suggestive of genuine stress incontinence and the predictive value of positive questions. Parentheses represent number of patients in each dot.

tractions which were induced by coughing. Four patients had a urethral diverticulum as the only pathology, and one patient had excessive vaginal discharge and negative urodynamic findings. Fourteen of the 25 patients with symptoms suggestive of detrusor instability had other conditions (Table III). Six women (43010)had urethroscopic findings of urethritis and no detrusor instability on urethrocystometry. Three of the 13 had an unstable urethra and a stable bladder. Three patients had vaginitis and vulvitis, and two patients were voiding more than 2000 ml per day and had a stable bladder on urethrocystometric evaluation. All 32 women in the control group had no urinary pathology on clinical and urodynamic evaluation. All women in the control group had a stable bladder and urethra on urethrocystometry and good abdominal pressure transmission to the urethra on urethral closure pressure profiles during coughing (abdominal pressure transmission to the urethra bladder of &lOO%) [9, lo]. Discussion History alone, was found to be suboptimal as a tool in evaluating urinary incontinence. Int J Gynecol Obstet32

Questions with a high sensitivity for genuine stress incontinence (questions 1,2, Table I) had low specificity, leading to a predictive value of a positive answer which was almost always in the range of 80%. The predictive value of a positive answer is the most important information for a clinician, since this describes the likelihood that a positive response predicts a positive urodynamic diagnosis. An 80% positive predictive value means that relying on history alone, the physician may misdiagnose 20% of patients preincontinence. senting as stress urinary Multiple questions addressing the same diagnosis in this study did not increase the accuracy of the history (Fig. 1). The same holds true when evaluating patients with a history suggestive of detrusor instability. Questions with high sensitivity (questions 4,7, Table III) had low specificity, while questions with high specificity (questions l-3,19,21, Table II) had low sensitivity for detrusor instability (Fig. 2). In search of simple diagnostic procedures for urinary incontinence, clinicians may be tempted to rely too much on history and observing loss of urine with cough [11,12]. Observing loss of urine and its relation to cough may be misleading. In fact, the most

Correlation between numerous positive questions Fig. 2. suggestive for detrusor instability and predictive value of positive questions. Parentheses represent number of patients in each dot.

History taking and urinary incontinence

common finding in this series in women with a history suggestive of genuine stress incontinence that was not confirmed by urodynamic findings, was bladder instability where detrusor contractions were induced by coughing. Previous reports have questioned the role of history in distinguishing various lower urinary tract pathologies [1,6,13]. This series demonstrates that the history, even if it is meticulous, may be misleading and result in inappropriate surgical or medical treatment modalities. References Byrne DJ, Hamilton Stewart PA, Gray BK: The role of urodynamics in female urinary stress incontinence. Br J Ural 59: 2281987. Ouslander J, Staskin D, Raz S et al: Clinical vs. urodynamic diagnosis in an incontinence geriatric female population. 3 Urol137: 68,1987. Drutz HO, Mandel F: Urodynamic analysis of urinary incontinence symptoms in women. Am J Obstet Gynecol 134: 789,1979. Fischer-Rasmussen W, Hansen RI, Stage P: Predictive values of diagnostic tests in the evaluation of female urinary stress incontinence. Acta Obstet Gynecol Stand 65: 291, 1986. Reid RE, Owens GF, Laor E et al: Unstable bladder: urodynamic diagnosis and observations in evaluating urinary incontinence in the female. Urology 29: 107, 1987. Glezerman M, Glasner M, Rikover M et al: Evaluation of reliability of history in women complaining of urinary

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stress incontinence. Eur J Obstet Gynecol Reprod Biol21: 159, 1986. 7 Ostergard DR: Data recording forms for gynecologic urology. In: Gynecologic Urology and Urodynamics (ed DR Ostergard), pp 600-603. Williams and Wilkins, Baltimore, MD, 1985. 8 Bradley WE: Urologic oriented neurologic examination. In: Gynecologic Urology and Urodynamics (ed DR Ostergard), pp 63-68. Williams and Wilkins, Baltimore, MD, 1985. 9 Bates P, Bradley WE, Glen E, et al.: The standardization of terminology of lower urinary tract functions. J Ural 121: 551,1979. 10 Hilton P, Stanton SL: Urethral pressure measurement by microtransducer: the results of symptom free women and in those with genuine stress incontinence. Br J Obstet Gynecol90: 919,1983. 11 Fall M, Erlander BE, Peterson S: Evaluation of history and simple supine cystometry as a preoperative test in stress urinary incontinence. Acta Obstet Gynecol Stand 63:241,1984. 12 Walters MD, Shields LE: The diagnostic value of history, physical examination, and the Q-tip cotton swab test in women with urinary incontinence. Am J Obstet Gynecol 159: 145,1988. 13 Bent AE, Richardson DA, Ostergard DR: Diagnosis of lower urinary tract disorders in postmenopausal patients. Am J Obstet GynecolZ45:218,1983. Address for reprints: A. Bergman USC School of Medicine Women’s Hospital, Room L-1022 Department of Obstetrics and G~ecology 1240 N. Mission Road Los Angeles, CA 90033, USA

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