Urinary incontinence physical examination: Difference between revisions

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VisualWikitext

Latest revision as of 00:58, 3 June 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.^[1]

Physical examination

Appearance of the Patient

Patients with Urinary Incontinence usually appear obese (check BMI)^[2]
Assses the patient cognitive status, mobility and presence of edma^[3]

Vital Signs

Patient with urinary incontinence usually has normal vital signs.

Skin

Skin examination of patients with Urinary incontinence can show rashes,infections, sores and ulcers ^[4].

HEENT

HEENT examination of patients with Urinary incontinence is usually normal.

Neck

Neck examination of patients with Urinary incontinence is usually normal.

Lungs

Examine for chronic obstructive pulmonary disease or bronchitis^[5]

Heart

Check for signs of volume overload or congestive heart failure for example, rales and pedal edema^[5]

Abdomen

Check for a palpable abdominal massess and for a palpable bladder ^[5]
Check for signs indictive for collagen disorder like presence of striae.^[6]
Check for costovertebral angle tenderness.^[7]

Back

Palpate vertebra from up to down, (from the neck to coccyx) and check for any abnormalities that may be a cause for urinary incontinence.^[6]
Check for costovertebral angle tenderness.^[7]

Genitourinary

Genitourinary examination of patients with urinary incontinence:
The urogenital examination might reveal vaginal atrophy and incontinence-associated dermatitis (that is, damage to the skin with exposure to urine)^[7].
- Stress Test:
  - If there's loss of urine while coughing or Valsalva maneuver indicates positive test.^[6]
  - The test is done when the patient is in a dorsal position. If urine loss is not visible switch to squatting position. If still not visible then in standing position asking her to keep her feet on the ground at shoulder distance, lift the saree/gown and looking for urine loss on the floor in between her feet or trickling down of urine through the thighs.^[6]
- Bonney's test:
  - If the stress test is positive , Do bonney's test.^[6]
  - Place the patient in the dorsal position. Doctor should place the middle and index fingers in the anterior vaginal wall on either sides of the urethra and push upward and backward to restore the posterior urethra-vesical angle and stabilizing the urethra. After that, the patient is asked to cough and checked for urine loss.If there is no urine loss, then the test is positive (which indicates distortion of posterior urethra-vesical angle is the cause of stress urinary incontinence). However, this test has limited value in stress incontinence evaluation^[6].
Examine for pelvic organ prolapse during a Valsalva maneuver over≥6 seconds, staging of pelvic organ prolapse is described by Pelvic Organ Prolapse Quantification (POP-Q)but a simplified description (S-POP-Q) has also been validated for use in clinical practice, which is a staging system that depends on assessment after emptying the bladder^[7].
Simplified description (S-POP-Q) staging system only detects anatomical descent and does not detect the normal range, stage two descent is found in up to 50% of women, Only a weak-to-moderate correlation between anatomical descent and urinary symptoms has been described, common symptoms of prolapse is a vaginal bulge, sensation of heaviness or difficulty in voiding^[7].
Women with stage 2-4 pelvic organ prolapse may have anatomical distortion that may kink the urethra, which can cause a false-negative cough stress test. Thus, reducing the prolapse digitally without distorting the bladder neck while performing a cough stress test might be of value. However, limited evidence has been reported on how to optimally reduce urethral kinking for the test^[7].
Digital examination for pelvic floor muscle tone^[7].
Levator ani muscle strength assessment (digital palpation)
- Place the fingers on the posterior vagina at least 2–4 cm above the hymenal ring while the patient is in the dorsal position. Palpate both sides of the levator ani muscle to assess its resting tone, bulk, and spasticity. Afterthat, ask the pateint to contract the pelvic floor muscles maximally as long as possible. Rectus abdominis, adductors of the thigh, and gluteus muscles are not supposed to be contracted^[6]. Now, levator ani is evaluated regarding muscle contraction (present/absent), strength and duration of contraction, and the ability to elevate the P/V fingers^[6]. Grading is done according to the modified Oxford Scale

Levator ani muscle strength assessment (Modified Oxford Scale)^[8]
Score	Levator ani strength
0/5	No contraction
1/5	Flicker, barely perceptible
2/5	Loose hold, (1-2 seconds)
3/5	Firmer hold, (1-2 seconds)
4/5	Good squeeze, 3-4 s, pulls fingers in and up loosely
5/5	Stronger squeeze, 3-4 s, pulls finger in and up snugly

Abnormalities such as urethral diverticula and pelvic masses can also be detected while assessing for pelvic organ prolapse.^[7]
Speculum examination can help in assessing each vaginal compartment and in assessing for any extra-urethral loss of urine that may suggest a fistula^[7].
Rectal examination should be done if there's bowel dysfunction or neurological symptoms to asses for tone and sphincter squeeze, bowel dysfunction should prompt a general neurological examination, including testing of the S2-S4 nerve distribution ^[7].
Urethral hypermobility test:
- Inspection: Inspect the patient during coughing or doing Valsalva maneuver. If there is urethral hypermobility, then the anterior vaginal wall will rotate outward, and external urethral meatus will rotate upward toward the ceiling ^[6].
- Q-tip test/cotton swab test:This test is done in dorsal/dorsal lithotomy position. A sterile lubricated cotton-tipped swab is introduced through the urethra to the bladder and withdrawn up to the level of urethrovesical junction. The position of the cotton swab in relation to the horizontal is observed – usually resting angle is 0° or nearer to 0°. Then, the patient is asked to cough or do Valsalva, and movement of the swab stick is observed. If the straining makes an angle of 30° or more, i.e., moving away from the horizontal, it is diagnosed with the hypermobile urethra. The mere presence of hypermobile urethra is not diagnostic of stress urinary incontinence, but this test has prognostic value if the operation is contemplated ^[6].

^[9]

Neuromuscular

Examine for signs of dementia and alerted mental status like delirium ^[5].
Examine for normal pressure hydrocephalus and Cerebral vascular accident ^[5]
Examine for Spinal stenosis ^[5]:
- cervical stenosis can cause damage to detrusor upper motor neurons.
- lumbar stenosis can cause areflexia.
Sacral reflex – to check for pudendal nerve integrity. Two reflexes are tested:
Anal reflex – Elicited by stroking the perianal skin lightly and observing for anal sphincter contraction. If the contraction is not observed, then feel it by palpation of the sphincter^[6]
Bulbocavernosus reflex – Elicited by tapping or squeezing the clitoris lightly and observing for contraction of the bulbocavernosus muscle and/or external anal sphincter ^[6].
The absence of one or both sacral reflexes signifies lower motor neuron lesion, usually resulting from trauma during delivery^[6].

Extremities

Examine joints for signs of arthritis and mobility restricion ^[5]
Peripheral edema of lower extremities^[5]
Asses mobility of joints, hypermobile joint can be indictive for collagen disorder^[6]

References

↑ Tran LN, Puckett Y. PMID 32644521 Check |pmid= value (help). Missing or empty |title= (help)
↑ "Incontinence & Female Urology [Dr.Edmond Wong]".
↑ "Urinaryincontinence final".
↑ "Woman Health-Incontinence&Pelvic Organ Prolapse".
↑ ^5.0 ^5.1 ^5.2 ^5.3 ^5.4 ^5.5 ^5.6 ^5.7 "Diagnosis of Urinary Incontinence - American Family Physician".
↑ ^6.00 ^6.01 ^6.02 ^6.03 ^6.04 ^6.05 ^6.06 ^6.07 ^6.08 ^6.09 ^6.10 ^6.11 ^6.12 ^6.13 "Approach to a woman with urinary incontinence".
↑ ^7.0 ^7.1 ^7.2 ^7.3 ^7.4 ^7.5 ^7.6 ^7.7 ^7.8 ^7.9 "Urinary incontinence in women".
↑ "Approach to a woman with urinary incontinence".
↑ "Urethral hypermobility causes, symptoms, diagnosis, treatment & prognosis".

Template:WH Template:WS

[pmid32644521-1] Tran LN, Puckett Y. PMID 32644521 Check |pmid= value (help). Missing or empty |title= (help)

[urlIncontinence_&_Female_Urology_[Dr.Edmond_Wong]-2] "Incontinence & Female Urology [Dr.Edmond Wong]".

[urlUrinaryincontinence_final-3] "Urinaryincontinence final".

[urlWoman_Health-Incontinence&Pelvic_Organ_Prolapse-4] "Woman Health-Incontinence&Pelvic Organ Prolapse".

[urlDiagnosis_of_Urinary_Incontinence_-_American_Family_Physician-5] 5.0 ^5.1 ^5.2 ^5.3 ^5.4 ^5.5 ^5.6 ^5.7 "Diagnosis of Urinary Incontinence - American Family Physician".

[urlApproach_to_a_woman_with_urinary_incontinence-6] 6.00 ^6.01 ^6.02 ^6.03 ^6.04 ^6.05 ^6.06 ^6.07 ^6.08 ^6.09 ^6.10 ^6.11 ^6.12 ^6.13 "Approach to a woman with urinary incontinence".

[urlUrinary_incontinence_in_women-7] 7.0 ^7.1 ^7.2 ^7.3 ^7.4 ^7.5 ^7.6 ^7.7 ^7.8 ^7.9 "Urinary incontinence in women".

[urlApproach_to_a_woman_with_urinary_incontinence2-8] "Approach to a woman with urinary incontinence".

[urlUrethral_hypermobility_causes,_symptoms,_diagnosis,_treatment_&_prognosis-9] "Urethral hypermobility causes, symptoms, diagnosis, treatment & prognosis".

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@@ Line 7: / Line 7: @@
 ==Physical examination==
-Physical examination of patients with [disease name] is usually normal.
-OR
+===Appearance of the Patient===
-Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
-OR
-The presence of [finding(s)] on physical examination is diagnostic of [disease name].
-OR
-The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
-===Appearance of the Patient===
+*Patients with Urinary Incontinence usually appear obese (check BMI)<ref name="urlIncontinence & Female Urology [Dr.Edmond Wong]">{{cite web |url=https://www.slideshare.net/edwong56/incontinence-female-edmond |title=Incontinence & Female Urology [Dr.Edmond Wong] |format= |work= |accessdate=}}</ref>
-*Patients with [disease name] usually appear [general appearance].
+*Assses the patient cognitive status, mobility and presence of edma<ref name="urlUrinaryincontinence final">{{cite web |url=https://www.slideshare.net/nishanthps88/urinaryincontinence-final-78235043 |title=Urinaryincontinence final |format= |work= |accessdate=}}</ref>
 ===Vital Signs===
+*Patient with urinary incontinence usually has normal vital signs.
-*High-grade / low-grade fever
+===Skin===
-*[[Hypothermia]] / hyperthermia may be present
-*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
-*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
-*Tachypnea / bradypnea
-*Kussmal respirations may be present in _____ (advanced disease state)
-*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
-*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
-===Skin===
+*Skin examination of patients with [[Urinary incontinence]] can show rashes,infections, sores and ulcers <ref name="urlWoman Health-Incontinence&Pelvic Organ Prolapse">{{cite web |url=https://www.slideshare.net/rahilanajihah/woman-healthincontinencepelvic-organ-prolapse?qid=b9cb6ef7-b21a-42d5-9e73-29d4a6d740d9&v=&b=&from_search=1 |title=Woman Health-Incontinence&Pelvic Organ Prolapse |format= |work= |accessdate=}}</ref>.
-* Skin examination of patients with [[Urinary incontinence]] is usually normal.
 ===HEENT===
-* HEENT examination of patients with [[Urinary incontinence]] is usually normal.
+*HEENT examination of patients with [[Urinary incontinence]] is usually normal.
 ===Neck===
-* Neck examination of patients with [[Urinary incontinence]] is usually normal.
+*Neck examination of patients with [[Urinary incontinence]] is usually normal.
 ===Lungs===
 *Examine for [[chronic obstructive pulmonary disease]] or [[bronchitis]]<ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>
 ===Heart===
 *Check for signs of volume overload or [[congestive heart failure]] for example, rales and [[pedal edema]]<ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>
 ===Abdomen===
-* Abdominal examination of patients with [disease name] is usually normal.
-OR
+*Check for a palpable abdominal massess and for a palpable bladder <ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>
-*[[Abdominal distension]]
+*Check for signs indictive for [[collagen disorder]] like  presence of striae.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
-*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
+*Check for costovertebral angle tenderness.<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>
-*[[Rebound tenderness]] (positive Blumberg sign)
-*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
-*Guarding may be present
-*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
-*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 ===Back===
-* Back examination of patients with [disease name] is usually normal.
-OR
+*Palpate vertebra from up to down, (from the neck to coccyx) and check for any abnormalities that may be a cause for [[urinary incontinence]].<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
-*Point tenderness over __ vertebrae (e.g. L3-L4)
+*Check for costovertebral angle tenderness.<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>
-*Sacral edema
-*Costovertebral angle tenderness bilaterally/unilaterally
-*Buffalo hump
 ===Genitourinary===
-* Genitourinary examination of patients with urinary incontinence:
-* The urogenital examination might reveal [[vaginal atrophy]] and [[incontinence-associated dermatitis]] (that is, damage to the skin with exposure to urine)<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
+*Genitourinary examination of patients with urinary incontinence:
-** [[Stress Test]]:
+*The urogenital examination might reveal [[vaginal atrophy]] and [[incontinence-associated dermatitis]] (that is, damage to the skin with exposure to urine)<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
-*** If there's loss of urine while coughing or [[Valsalva maneuver]] indicates positive test.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
+**[[Stress Test]]:
-*** The test is done when the patient is in a dorsal position. If urine loss is not visible switch to squatting position. If still not visible then in standing position asking her to keep her feet on the ground at shoulder distance, lift the saree/gown and looking for urine loss on the floor in between her feet or trickling down of urine through the thighs.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
+***If there's loss of urine while coughing or [[Valsalva maneuver]] indicates positive test.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
-** [[Bonney's test]]:
+***The test is done when the patient is in a dorsal position. If urine loss is not visible switch to squatting position. If still not visible then in standing position asking her to keep her feet on the ground at shoulder distance, lift the saree/gown and looking for urine loss on the floor in between her feet or trickling down of urine through the thighs.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
-*** If the stress test is positive , Do bonney's test.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
+**[[Bonney's test]]:
-*** Place the patient in the dorsal position. Doctor should place the middle and index fingers in the anterior vaginal wall on either sides of the urethra and push upward and backward to restore the posterior urethra-vesical angle and stabilizing the urethra. After that, the patient is asked to cough and checked for urine loss.If there is no urine loss, then the test is positive (which indicates distortion of posterior urethra-vesical angle is the cause of stress urinary incontinence). However, this test has limited value in stress incontinence evaluation<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
+***If the stress test is positive , Do bonney's test.<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
-*Examine for [[pelvic organ prolapse]] during a [[Valsalva maneuver]] over≥6 seconds, staging of pelvic organ prolapse is described by [[Pelvic Organ Prolapse Quantification (POP-Q)]]but a [[simplified description (S-POP-Q)]] has also been validated for use in clinical practice, which is a staging system that depend on assessment after emptying the bladder<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>. .
+***Place the patient in the dorsal position. Doctor should place the middle and index fingers in the anterior vaginal wall on either sides of the urethra and push upward and backward to restore the posterior urethra-vesical angle and stabilizing the urethra. After that, the patient is asked to cough and checked for urine loss.If there is no urine loss, then the test is positive (which indicates distortion of posterior urethra-vesical angle is the cause of stress urinary incontinence). However, this test has limited value in stress incontinence evaluation<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
-*[[Simplified description (S-POP-Q)]] staging system only detects anatomical descent and does not detect the normal range, stage two descent is found in up to 50% of women,Only a weak-to-moderate correlation between anatomical descent and urinary symptoms has been described, common symptoms of prolapse is a vaginal bulge, sensation of heaviness or difficulty in voiding<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
+*Examine for [[pelvic organ prolapse]] during a [[Valsalva maneuver]] over≥6 seconds, staging of pelvic organ prolapse is described by [[Pelvic Organ Prolapse Quantification (POP-Q)]]but a [[simplified description (S-POP-Q)]] has also been validated for use in clinical practice, which is a staging system that depends on assessment after emptying the bladder<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
+*[[Simplified description (S-POP-Q)]] staging system only detects anatomical descent and does not detect the normal range, stage two descent is found in up to 50% of women, Only a weak-to-moderate correlation between anatomical descent and urinary symptoms has been described, common symptoms of prolapse is a vaginal bulge, sensation of heaviness or difficulty in voiding<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
 *Women with stage 2-4 pelvic organ prolapse may have anatomical distortion that may kink the urethra, which can cause a false-negative cough stress test. Thus, reducing the prolapse digitally without distorting the bladder neck while performing a cough stress test might be of value. However, limited evidence has been reported on how to optimally reduce urethral kinking for the test<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
 *[[Digital examination]] for pelvic floor muscle tone<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
+*Levator ani muscle strength assessment (digital palpation)
+**Place the fingers on the posterior vagina at least 2–4 cm above the hymenal ring while the patient is in the dorsal position. Palpate both sides of the levator ani muscle to assess its resting tone, bulk, and spasticity. Afterthat, ask the pateint to contract the pelvic floor muscles maximally as long as possible. Rectus abdominis, adductors of the thigh, and gluteus muscles are not supposed to be contracted<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>. Now, levator ani is evaluated regarding muscle contraction (present/absent), strength and duration of contraction, and the ability to elevate the P/V fingers<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>. Grading is done according to the modified Oxford Scale
+{| class="wikitable sortable"
+|+Levator ani muscle strength assessment (Modified Oxford Scale)<ref name="urlApproach to a woman with urinary incontinence2">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
+!Score
+!Levator ani strength
+|-
+!0/5
+!No contraction
+|-
+!1/5
+!Flicker, barely perceptible
+|-
+!2/5
+!Loose hold, (1-2 seconds)
+|-
+|3/5
+|Firmer hold, (1-2 seconds)
+|-
+|4/5
+|Good squeeze, 3-4 s, pulls fingers in and up loosely
+|-
+|5/5
+|Stronger squeeze, 3-4 s, pulls finger in and up snugly
+|}
 *Abnormalities such as [[urethral diverticula]] and pelvic masses can also be detected while assessing for pelvic organ prolapse.<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>
 *[[Speculum examination]] can help in assessing each vaginal compartment and in assessing for any extra-urethral loss of urine that may suggest a fistula<ref name="urlUrinary incontinence in women">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878864/ |title=Urinary incontinence in women |format= |work= |accessdate=}}</ref>.
@@ Line 87: / Line 92: @@
 *[[Urethral hypermobility test]]:
 **Inspection: Inspect the patient during coughing or doing [[Valsalva maneuver]]. If there is urethral hypermobility, then the anterior vaginal wall will rotate outward, and external urethral meatus will rotate upward toward the ceiling <ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
-**Q-tip test/cotton swab test: This test is done in dorsal/dorsal lithotomy position. Sterile lubricated cotton-tipped swab is introduced through the urethra to the bladder and withdrawn up to the level of urethrovesical junction. Position of the cotton swab in relation to the horizontal is observed – usually resting angle is 0° or nearer to 0°. Then, the patient is asked to cough or do Valsalva and movement of the swab stick is observed. If the straining makes an angle of 30° or more, i.e., moving away from the horizontal, it is diagnosed with hypermobile urethra. The mere presence of hypermobile urethra is not diagnostic of [[stress urinary incontinence]], but this test has prognostic value if the operation is contemplated <ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
+**Q-tip test/cotton swab test:This test is done in dorsal/dorsal lithotomy position. A sterile lubricated cotton-tipped swab is introduced through the urethra to the bladder and withdrawn up to the level of urethrovesical junction. The position of the cotton swab in relation to the horizontal is observed – usually resting angle is 0° or nearer to 0°. Then, the patient is asked to cough or do Valsalva, and movement of the swab stick is observed. If the straining makes an angle of 30° or more, i.e., moving away from the horizontal, it is diagnosed with the hypermobile urethra. The mere presence of hypermobile urethra is not diagnostic of [[stress urinary incontinence]], but this test has prognostic value if the operation is contemplated <ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
+[[File:Q-tip-test-urethral-hypermobility.jpg|400px|thumb|center]]<ref name="urlUrethral hypermobility causes, symptoms, diagnosis, treatment & prognosis">{{cite web |url=https://healthjade.net/urethral-hypermobility/ |title=Urethral hypermobility causes, symptoms, diagnosis, treatment & prognosis |format= |work= |accessdate=}}</ref>
 ===Neuromuscular===
-*Examine for signs of [[dementia]] and alerted mental status like [[delirium]] <ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>.
+*Examine for signs of [[dementia]] and alerted mental status like [[delirium]] <ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>.
 *Examine for [[normal pressure hydrocephalus]] and [[Cerebral vascular accident]] <ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>
 *Examine for [[Spinal stenosis]] <ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>:
 **[[cervical stenosis]] can cause damage to detrusor [[upper motor neurons]].
 **[[lumbar stenosis]] can cause [[areflexia]].
+*[[Sacral reflex]] – to check for [[pudendal nerve]] integrity. Two reflexes are tested:
+*[[Anal reflex]] – Elicited by stroking the perianal skin lightly and observing for anal sphincter contraction. If the contraction is not observed, then feel it by palpation of the sphincter<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
+*[[Bulbocavernosus reflex]] – Elicited by tapping or squeezing the clitoris lightly and observing for contraction of the bulbocavernosus muscle and/or external anal sphincter <ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
+*The absence of one or both sacral reflexes signifies lower motor neuron lesion, usually resulting from trauma during delivery<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>.
 ===Extremities===
 *Examine joints for signs of [[arthritis]] and mobility restricion <ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>
 *Peripheral [[edema]] of lower extremities<ref name="urlDiagnosis of Urinary Incontinence - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2013/0415/p543.html |title=Diagnosis of Urinary Incontinence - American Family Physician |format= |work= |accessdate=}}</ref>
+*Asses mobility of joints, hypermobile joint can be indictive for collagen disorder<ref name="urlApproach to a woman with urinary incontinence">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978964/ |title=Approach to a woman with urinary incontinence |format= |work= |accessdate=}}</ref>
 ==References==