The initial assessment of the patient should include a frequency and volume chart; the patient records the time and the volume of urine passed, together with any episodes of leakage that may occur over a period of 7 days. The number of incontinence pads used per day should also be recorded. During a 24 hour cycle, the normal individual passes urine between 4 and 8 times, with maximum volumes between 300 - 600 ml and a total output of 1200 - 1800 ml.

The frequent passage of small volumes of urine with urinary incontinence suggests either a bladder of small capacity or one that fails to empty completely. Reduced capacity may be due to habit (possibly from fear of incontinence), to hypersensitivity from infection or stones, to an unstable bladder from detrusor overactivity or to a contracted bladder from chronic inflammatory changes or carcinoma.

The bladder that fails to empty completely may be palpable if it is holding more than 300 ml, or it may be demonstrable on a plain X-ray or an ultrasound scan.

Urinary leakage with a normal bladder capacity suggests sphincter weakness as in stress incontinence, but urodynamic investigations may be necessary to confirm this. Urodynamic studies have a vital role in differentiating the various types of incontinence, namely stress, urge, overflow and reflex or neuropathic incontinence.

On the clinical examination, the option of taking a specimen of urine using a fine 12 or 14 FG disposable catheter should be given consideration when examining female patients. Patients handicapped by age, immobility, obesity etc cannot easily provide an MSU without a high risk of contamination and, in such cases, the report of bacteriuria with or without pyuria can be misleading. Examination of the urine is such a routine test, but the path report does need judicious interpretation.

Patients with urinary incontinence and a cystocoele usually require video-urodynamic studies before the correct course of management can be planned. Those with uterine prolapse are usually directed to the gynaecological clinic, but many elderly women have evidence of atrophic vaginitis which responds well to local oestrogen creams. These are best applied digitally rather than through a plastic introducer which can make them sore.

Obese patients should be advised about strict dieting. This is a therapeutic exercise as well as an essential preoperative requisite.

Please complete the confidential form  as accurately as possible.

Please note the time you pass your water and the volume passed. Any measuring jug will do for this purpose. Obviously when you are at work it may be inconvenient to measure the volume; in this case, record only the time. However, at other times please try to record both.

If you wet yourself at any time, record the time and underneath write the letter "W".

Day-time means when you are up; night-time means when you are in bed.

An example is provided below to help you :

AVERAGE DAILY FLUID INTAKE (in cups) = ______________________________

1. Each time you empty your bladder measure the volume in mls (millilitres) and write it in one of the hourly boxes (there is room to write several volumes in each box if necessary). You do not need to write the exact times. If you leak urine, write a W in the box.

2. Please mark the time you go to bed each night and get up for the day with a line across the space.

3. Record for ONE WEEK prior to your appointment.

4. Your chart that you bring to the clinic should look similar to the one illustrated below. It has a day filled in as an example.

5. You do not need to write down drinks unless the doctor has requested this.

This is a common problem that causes distress to males of all age groups, thought to be related to a failure of the bulbo-spongiosum muscle to contract and thus empty the distal urethra. It does not indicate a prostatic disorder and does not, by itself, require referral. Some patients can be helped simply by showing them how to compress the bulb of the urethra in the perineum after voiding.

A plain X-ray should be performed to exclude bladder stones; if taken after micturition the film also provides a rough estimate of the volume of residual urine from the size of the soft tissue bladder shadow. An ultrasound scan can give a quantitative estimate of the residual volume of urine and an accurate, non-invasive display of urinary tract anatomy but, compared to the Intravenous Urogram, it fails to provide any indication of renal function.

Patients may be referred to this service or, in some Health Authorities, patients may refer themselves for advice on the practical management of their incontinence. The Continence Advisor will assess the patient either at home or hospital, and prepare a report covering the social and physical aspects of the problem. A wide range of appliances are available and it is important to select the most appropriate and economic type. Some patients prefer to discuss this problem with a well-informed nurse.

Patients with frequency, urgency and urge incontinence form a large group of regular clinic attenders, and it is well worth introducing a trial of bladder training. The frequency and volume chart often shows that they can hold reasonable volumes of 300 ml urine or more at times, particularly during sleep; those who never hold more than 200 ml should be referred to hospital for further investigations. In the absence of any obvious abnormality on clinical examination and a negative urine culture, it is worth giving the patient a trial of bladder training reinforced with an anticholinergic preparation. The patient should be instructed to pass urine "by the clock", starting with an interval such as every two hours which can be managed without too much difficulty. This interval is gradually increased to two or three hours and the patient should keep a chart one day a week to monitor progress. A mild sedative at night can be useful particularly for those who wake at regular times during sleep to pass urine. An anticholinergic preparation such as Oxybutynin 2.5 mg can be used to support the training regime with 2 - 6 tablets a day; Propantheline bromide or Imipramine are alternative preparations.
If there is no response to such a trial, further investigations should be arranged.