The evaluation of stress incontinence prior to primary surgery.

OBJECTIVE: To provide clinical guidelines for the evaluation of women with stress urinary incontinence prior to primary anti-incontinence surgery. OPTIONS: The modalities of evaluation range from basic pelvic examination through to the use of adjuncts including ultrasound and urodynamic testing. OUTCOMES: These guidelines provide a comprehensive approach to the preoperative evaluation of urinary incontinence to ensure that excessive evaluation is avoided without sacrificing diagnostic accuracy. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Comprehensive evaluation of women considering surgery to treat urinary incontinence is essential to rule out causes of incontinence that may not be amenable to surgical treatment. Simplifying the evaluation minimizes the discomfort and embarrassment potentially experienced by women. RECOMMENDATIONS: 1. Thorough evaluation of each woman is essential to determine the underlying etiology of the urinary incontinence and to guide management. (II-3B) 2. Preoperative pelvic examination should be performed to identify pelvic masses that may provoke lower urinary tract symptoms (e.g., a large fibroid uterus impinging on the bladder), concomitant pelvic organ prolapse, and to rule out latent stress incontinence. All of these findings may necessitate a modification of the surgical approach. (III-C) 3. Hypermobility of the urethra should be confirmed preoperatively, as women with fixed, well-supported bladder necks are less likely to experience a cure following standard anti-incontinence procedures. (II-2B) 4. Stress incontinence should be objectively demonstrated prior to anti-incontinence surgery. (III-B) 5. The volume of postvoid residual urine should be measured prior to anti-incontinence surgery. Elevated postvoid residual volumes are uncommon and should signal the need for further evaluation of the voiding mechanism. (III-C) 6. Urinary tract infection should be identified and treated prior to initiating further investigation or therapeutic intervention for urinary incontinence. (II-2B) 7. In women presenting with pure stress incontinence that can be objectively demonstrated during examination, preoperative urodynamic testing is not necessary (II-3B). For women with other lower urinary tract symptoms and/or mixed urinary incontinence, the clinician s judgment must guide the use of preoperative urodynamic testing (II-3B). VALIDATION: These guidelines have been approved by the Urogynaecology Committee and the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.