The American College of

Obstetricians and Gynecologists

WOMEN’S HEALTH CARE PHYSICIANS

COMMITTEE OPINION
Number 603 • June 2014
(Reaffirmed 2017)

Committee on Gynecologic Practice

American Urogynecologic Society
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Evaluation of Uncomplicated Stress Urinary

Incontinence in Women Before Surgical Treatment
ABSTRACT: Stress urinary incontinence (SUI) is a condition of involuntary loss of urine on effort, physical
exertion, sneezing, or coughing that is often bothersome to the patient and frequently affects quality of life. When
women are evaluated for SUI, counseling about treatment should begin with conservative options. The minimum
evaluation before primary midurethral sling surgery in women with symptoms of SUI includes the following six
steps: 1) history, 2) urinalysis, 3) physical examination, 4) demonstration of stress incontinence, 5) assessment
of urethral mobility, and 6) measurement of postvoid residual urine volume. For women with uncomplicated SUI
in whom conservative treatment has failed and who desire midurethral sling surgery, evidence indicates that the
performance of preoperative multichannel urodynamic testing versus a basic evaluation does not affect treatment
outcomes. However, women who have complicated SUI may benefit from multichannel urodynamic testing and
other diagnostic tests before initiation of treatment, especially surgery. Clinical judgment should guide the health
care provider’s decision to perform preoperative multichannel urodynamic testing or to refer to a specialist with
appropriate training and experience in female pelvic medicine and reconstructive surgery.

Stress urinary incontinence (SUI) is a condition of invol- Obstetricians and Gynecologists (the College) and the
untary loss of urine on effort, physical exertion, sneezing, American Urogynecologic Society provide recommenda-
or coughing that is often bothersome to the patient and tions for the basic evaluation of a patient with symptoms
frequently affects quality of life. It is estimated to affect of uncomplicated SUI (Table 1) before primary surgical
15.7% of adult women (1). Among women with SUI, repair with a midurethral sling.
77.5% report their symptoms to be bothersome, and of
this group 28.8% report their symptoms to be moderately Basic Evaluation of Stress Urinary
to extremely bothersome; the degree of bother is associ- Incontinence
ated with the severity of SUI (2). When women are evaluated for SUI, counseling about
Treatment options for SUI range from conservative treatment should begin with conservative options. The
to surgical. Conservative options include pelvic muscle minimum evaluation before primary midurethral sling
exercises (with or without physical therapy), behavioral surgery in women with symptoms of SUI includes the
modification, continence-support pessaries, and ureth- following six steps: 1) history, 2) urinalysis, 3) physical
ral inserts (3). In 2010, approximately 260,000 women examination, 4) demonstration of stress incontinence, 5)
in the United States underwent surgical treatment assessment of urethral mobility, and 6) measurement of
of SUI (4). Surgical treatment options include anti- postvoid residual urine volume.
incontinence procedures, such as retropubic urethropex-
ies, autologous fascial slings, urethral bulking agents, History
and synthetic midurethral slings. An evaluation of symp- The purpose of history taking is to determine the type
toms of SUI needs to be completed before performing of urinary incontinence (UI) that is bothersome to the
surgery. In this joint document, the American College of patient. Urinary incontinence is commonly classified
Table 1. Basic Evaluation Findings for Uncomplicated Versus Complicated Stress Urinary Incontinence ^

Findings
Evaluation Uncomplicated Complicated

History* Urinary incontinence associated with involuntary Symptoms of urgency, incomplete emptying,
loss of urine on effort, physical exertion, incontinence associated with chronic urinary retention,
sneezing, or coughing functional impairment, or continuous leakage
Absence of recurrent urinary tract infection Recurrent urinary tract infection†
No prior extensive pelvic surgery Previous extensive or radical pelvic surgery (eg, radical
No prior surgery for stress incontinence hysterectomy)

Prior anti-incontinence surgery or complex urethral

surgery (eg, urethral diverticulectomy or urethrovaginal
fistula repair)
Absence of voiding symptoms Presence of voiding symptoms: hesitancy, slow stream,
intermittency, straining to void, spraying of urinary
stream, feeling of incomplete voiding, need to
immediately revoid, postmicturition leakage, position-
dependent micturition, and dysuria
Absence of medical conditions that can affect Presence of neurologic disease, poorly controlled
lower urinary tract function diabetes mellitus, or dementia
Physical examination Absence of vaginal bulge beyond the hymen Symptoms of vaginal bulge or known pelvic organ
on examination prolapse beyond the hymen confirmed by physical
Absence of urethral abnormality examination, presence of genitourinary fistula, or
urethral diverticulum

Urethral mobility assessment Presence of urethral mobility Absence of urethral mobility
Postvoid residual urine volume Less than 150 mL Greater than or equal to 150 mL
Urinalysis/urine culture Negative result for urinary tract infection or
hematuria
*A complete list of the patient’s medications (including nonprescription medications) should be obtained to determine whether individual drugs may be influencing the func-
tion of the bladder or urethra, which leads to urinary incontinence or voiding difficulties.
†
Recurrent urinary tract infection is defined as three documented infections in 12 months or two documented infections in 6 months.

as stress, urge, postural, continuous (or total), insen- leakage on effort or physical exertion. In contrast, inabil-
sible (spontaneous), coital, or incontinence associated ity to reach the toilet that is associated with urgency indi-
with chronic urinary retention (previously referred to cates the presence of urge UI.
as overflow incontinence); nocturnal enuresis; or some Negative responses to queries regarding symptoms of
combination thereof (5, 6). The history should include predominant urgency, incomplete emptying, incontinence
questions about the type of incontinence (eg, stress, urge, associated with chronic urinary retention (previously
mixed), precipitating events, frequency of occurrence, referred to as overflow incontinence), functional impair-
severity, pad use, and effect of symptoms on activi- ment, continuous leakage, and incomplete emptying are
ties of daily living. Questions should be asked to assess consistent with uncomplicated SUI (Table 1). Absence
symptoms related to bladder storage and emptying func- of cognitive impairment typically rules out a functional
tions. Storage symptoms include frequency, nocturia, component to the incontinence, and a lack of continuous
urgency, and incontinence. Emptying or voiding symp- leakage in women with recent pelvic surgery or radiation
toms include hesitancy, slow stream, intermittency, exposure points away from the presence of a fistula.
straining to void, spraying of urinary stream, feeling of After the urologic history, thorough medical and
incomplete emptying, need to immediately revoid, post- neurologic histories should be obtained. Certain condi-
micturition leakage, position-dependent micturition, and tions, such as diabetes and neurologic disorders, can cause
dysuria. Health care providers can use validated question- UI. In addition, a complete list of the patient’s medica-
naires to evaluate bother, severity, and the relative con- tions (including nonprescription medications) should be
tribution of urge UI and SUI symptoms (Box 1). Patients obtained to determine whether individual drugs may be
with uncomplicated SUI will have classic symptoms of influencing the function of the bladder or urethra, which

2 Committee Opinion No. 603

 Physical Examination
Box 1. Examples of Validated Urinary The primary purpose of the physical examination is
Incontinence Questionnaires ^ to exclude confounding or contributing factors to the
• Urogenital Distress Inventory (UDI)* incontinence or its management. A urethral diverticulum
(an out-pouching of the urethral lumen) can produce
• Incontinence Impact Questionnaire (IIQ)*
incontinence or postvoid dribbling. Occasionally, vaginal
• Questionnaire for Urinary Incontinence Diagnosis discharge can be confused with urinary incontinence.
(QUID)† Extraurethral incontinence, caused by a fistula or ectopic
• Incontinence-Quality of Life Questionnaire (I-QoL)‡ ureter, is rare but can be seen on examination. A lack
• Incontinence Severity Index (ISI)§ of such physical findings indicates the patient may have
• International Consultation on Incontinence uncomplicated SUI.
Questionnaire (ICIQ)|| Evidence of pelvic organ prolapse (POP) beyond
the hymen is consistent with complicated SUI because the
*Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl prolapse can produce a relative obstruction of the urethra
JA. Health-related quality of life measures for women with
urinary incontinence: the Incontinence Impact Questionnaire that can impair bladder emptying. Therefore, it is recom-
and the Urogenital Distress Inventory. Continence Program in mended that all pelvic support compartments (anterior,
Women (CPW) Research Group. Qual Life Res 1994;3:291–306 and posterior, and apical) be assessed (7, 8). Pelvic organ pro-
Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. lapse can mask or reduce the severity of SUI symptoms;
Short forms to assess life quality and symptom distress for urinary
incontinence in women: the Incontinence Impact Questionnaire this is referred to as occult, potential, masked, or hidden
and the Urogenital Distress Inventory. Continence Program for SUI. When POP is reduced with a nonobstructing pes-
Women Research Group. Neurourol Urodyn 1995;14:131–9. sary or large cotton swabs, SUI may become apparent or
†
Bradley CS, Rahn DD, Nygaard IE, Barber MD, Nager CW, Kenton worsen (9). If no POP is found beyond the hymen, then
KS, et al. The questionnaire for urinary incontinence diagnosis the patient’s SUI remains uncomplicated.
(QUID): validity and responsiveness to change in women under-
going non-surgical therapies for treatment of stress predominant Demonstration of Stress Incontinence: Cough
urinary incontinence. Neurourol Urodyn 2010;29:727–34.
‡ Stress Test
Brown JS, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner
SF. Prevalence of urinary incontinence and associated risk fac- Stress urinary incontinence should be objectively demon-
tors in postmenopausal women. Heart & Estrogen/Progestin strated before any anti-incontinence surgery is performed
Replacement Study (HERS) Research Group. Obstet Gynecol
1999;94:66–70.
(10–12). Visualization of fluid loss from the urethra
§ simultaneous with a cough is diagnostic of SUI. Delayed
Sandvik H, Seim A, Vanvik A, Hunskaar S. A severity index
for epidemiological surveys of female urinary incontinence: fluid loss is considered a negative cough stress test result
comparison with 48-hour pad-weighing tests. Neurourol Urodyn and suggests cough-induced detrusor overactivity. The
2000;19:137–45. cough stress test can be performed with the patient in
||
Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. the supine position during the physical examination.
ICIQ: a brief and robust measure for evaluating the symptoms However, if urine leakage is not observed, the cough stress
and impact of urinary incontinence. Neurourol Urodyn 2004;23:
322–30.
test needs to be repeated with the patient standing and
with a full bladder (or a minimum bladder volume of
300 mL) to maximize test sensitivity. Health care provid-
leads to UI or voiding difficulties (3). Agents that can ers often ask patients to come to the office with a full blad-
affect lower urinary tract function include diuretics, caf- der during an initial evaluation so that the cough stress
feine, alcohol, narcotic analgesics, anticholinergic drugs, test can be performed before bladder emptying (12).
antihistamines, psychotropic drugs, alpha-adrenergic To perform the cough stress test in the standing
blockers, alpha-adrenergic agonists, and calcium-channel position, the patient stands near the examination table
blockers. Surgical, gynecologic, and obstetric histories with one foot on the table step. The health care provider
also should be elicited. Findings on history taking that then bends and separates the labia to visualize the ure-
are consistent with a diagnosis of uncomplicated SUI are thral meatus. The patient is then asked to cough while
listed in Table 1. Physical examination and office tests are the health care provider directly visualizes the urethra.
needed to confirm the uncomplicated SUI diagnosis (see If no leakage is observed despite patient symptoms of
following sections). SUI, the health care provider needs to ensure that the
patient had a full bladder by measurement of voided
Urinalysis urine volume and postvoid residual urine volume by
Urinary tract infections should be identified using uri- catheterization or bladder ultrasonography. The health
nalysis and treated before initiating further investigation care provider may need to retrograde fill the bladder
or therapeutic intervention for UI. If the urinalysis result until the patient feels bladder fullness or is holding at least
is negative, the patient’s condition is still consistent with 300 mL of fluid and then repeat the cough stress test.
uncomplicated SUI. If the standing cough stress test result remains negative

Committee Opinion No. 603 3

despite patient symptoms of SUI, then multichannel uro- training and experience in female pelvic medicine and
dynamic testing is recommended. reconstructive surgery.
Assessment of Urethral Mobility Conclusions and Recommendations
Anti-incontinence surgery is more successful in women with Stress urinary incontinence is common in women, and
urethral mobility, defined as a 30 degree or greater displace- obstetrician–gynecologists play an important role in its
ment from the horizontal when the patient is in a supine diagnosis and treatment. The College and the American
lithotomy position and straining. The presence of urethral Urogynecologic Society recommend performance of the
mobility indicates uncomplicated SUI. Lack of ureth- following basic six-step evaluation of a patient with symp-
ral mobility is associated with a 1.9-fold increase in the toms of uncomplicated SUI before primary surgical repair
failure rate of midurethral sling treatment of SUI (13). with a midurethral sling:
The cotton swab test has been the traditional assessment
of urethral mobility (14), but other methods of evaluat- 1. History
ing urethral mobility include measurement of point Aa of 2. Urinalysis
the POP Quantification system, visualization, palpation, 3. Physical examination with an assessment for POP
and ultrasonography (15–17). Patients who lack urethral 4. Cough stress test
mobility may be better candidates for urethral bulking
agents rather than sling or retropubic anti-incontinence 5. Assessment of urethral mobility
procedures. 6. Measurement of postvoid residual urine volume
Postvoid Residual Urine Volume For women with uncomplicated SUI in whom conser-
In the Value of Urodynamic Evaluation trial, only vative treatment has failed and who desire midurethral
women with a postvoid residual urine volume of less than sling surgery, evidence indicates that the performance
150 mL were included in the study as meeting the a priori of preoperative multichannel urodynamic testing versus
definition of uncomplicated SUI (11). The presence of a basic evaluation does not affect treatment outcomes
an elevated postvoid residual urine volume can indicate (11). However, women with complicated SUI may benefit
a bladder-emptying abnormality or incontinence associ- from additional diagnostic evaluation with multichannel
ated with chronic urinary retention (previously referred urodynamic testing, particularly before surgical treat-
to as overflow incontinence). An elevated postvoid resid- ment. In these women, the results of the basic six-step
ual urine volume in the absence of POP is uncommon evaluation and clinical judgment should guide the deci-
and should trigger an evaluation of the bladder-emptying sion to perform preoperative multichannel urodynamic
mechanism, usually with a pressure-flow urodynamic study. testing.

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4 Committee Opinion No. 603

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Copyright June 2014 by the American College of Obstetricians and
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Committee Opinion No. 603 5