The unspeakable illness: the work-up of female urinary incontinence.

The work-up for female urinary incontinence--i.e., diagnosis and, perhaps, initial therapy-is a rational, multi-step procedure, complicated by the reticence of patients concerning their problem (except when the chief complaint is interference with sexual relations). The chief causes of incontinence are (genuine) stress incontinence and overactive bladder (OABR, although there is a continuum between them. Diagnosis begins with a review of symptoms and thorough history-taking, followed by testing: a urination diary and in-office neurologic and gynecologic tests, preceded by a thorough physical examination including all relevant gynecologic and neurologic aspects, the latter centered around S2-4--the so-called Q-tip test. If tests are inconclusive, or if medical history is suggestive, the patient is referred to a urodynamic laboratory for multi-channel urodynamic testing and other tests requiring sophisticated urodynamic equipment. Treatment plans include pharmacologic therapy of OAB and surgery, but are often less drastic.