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Presence or absence of urinary incontinence assessed (GER)

CPT4 code

Name of the Procedure:

Presence or Absence of Urinary Incontinence Assessed (GER) Common Names: Urinary Incontinence Evaluation, Bladder Control Assessment


This procedure involves evaluating whether a person is experiencing urinary incontinence—an involuntary leakage of urine. It typically includes a series of questions, physical examinations, and possibly specialized tests to determine the presence or absence of urinary incontinence.


Medical Condition
  • Urinary Incontinence ##### Goals
  • Determine if a patient has urinary incontinence.
  • Identify the type and severity of urinary incontinence.
  • Formulate a plan for treatment or management based on findings.


  • Frequent, urgent need to urinate.
  • Inability to control urination.
  • Urine leakage during physical activity, coughing, or sneezing. ##### Patient Criteria
  • Both male and female patients showing signs of urinary leakage.
  • Older adults, as incontinence is more common with aging.
  • Pregnant or postpartum women.
  • Patients with neurological conditions affecting bladder control.


Pre-Procedure Instructions
  • Write down recent symptoms and their frequency.
  • List any medications currently being taken. ##### Assessments Required
  • Medical history review.
  • Bladder diary to log fluid intake and urination patterns over a few days.

Procedure Description

Steps Involved
  1. Medical History and Symptom Review: The healthcare provider asks about symptoms, medical history, and lifestyle factors.
  2. Physical Examination: Focuses on the abdomen and pelvic area in women, and may include a prostate exam in men.
  3. Urine Sample: Taken to check for infection or other abnormalities.
  4. Specialized Tests: May include a urodynamic test to measure bladder function, or an ultrasound to assess the bladder.
Tools and Equipment:
  • Examination table
  • Ultrasound machine (if needed)
  • Urodynamic testing apparatus (if needed)
  • Urine collection container
Anesthesia or Sedation:
  • Generally, none required.


Typically, the assessment takes 30 minutes to 1 hour.


Can be performed in an outpatient clinic, urologist's office, or a hospital setting.


  • Primary care physician
  • Urologist or gynecologist
  • Nurse or medical assistant

Risks and Complications

Common Risks
  • Slight discomfort during physical examination or urine sample collection. ##### Rare Risks
  • Infection or irritation from catheterization (if urodynamic tests are performed).


  • Accurate diagnosis of urinary incontinence.
  • Tailored treatment plan to improve quality of life.
  • Initial results and next steps usually available immediately or within a few days.


  • No significant recovery time required.
  • Follow-up appointments may be needed for treatment or further testing.
  • Patients may be advised on lifestyle changes or exercises immediately post-assessment.


Other Options
  • Initial self-management strategies including pelvic floor exercises without formal assessment.
  • Over-the-counter products for managing symptoms. ##### Pros and Cons
  • Alternatives Pros: Less invasive, immediate.
  • Alternatives Cons: Less accurate, may delay appropriate treatment.

Patient Experience

Patients may feel a bit embarrassed discussing symptoms but should know it is a common issue that healthcare providers are trained to handle sensitively. Discomfort during physical examination or testing is usually minimal, and pain management is rarely required.

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