Urinary incontinence in women. How to determine when surgery is not the answer

Diagnosis of a nonanatomic cause of urinary incontinence in a female patient depends on the examiner's powers of observation and willingness to listen and take a thorough history and perform a meticulous physical examination to identify symptoms that seem atypical of stress incontinence. In particular, the external genitalia, urethra, vagina, perineum, and lower extremities should be carefully examined. Also, thorough assessment of neurologic status is a must because abnormal neurologic function of the bladder is an absolute contraindication to surgery. Laboratory studies to rule out infection, intrinsic urinary tract disease, and associated medical problems presenting as voiding difficulties must be performed when deemed appropriate. Tests of bladder capacity and intravesical pressure and internal examination of the bladder and urethra may be done when the problem is not straightforward. In the majority of patients, however, the cause of urinary incontinence can be diagnosed or strongly suspected without such studies. Most likely to benefit from systematic evaluation and, depending on the findings, pharmacologic therapy are patients whose urinary incontinence does not match the pattern usual for stress incontinence. These patients may or may not have a demonstrable anatomic lesion, but their voiding complaints are definitely inconsistent with stress incontinence. Medical management may also produce great improvement in incontinent patients who are unfit for surgery or have undergone one or more failed operations. Most patients with atypical voiding problems, including those in whom incontinence develops after pelvic surgery, can meet with a great degree of success if evaluated and treated as described herein.