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
Summary
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.
Purpose
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.
Indications
Symptoms
- 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.
Preparation
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
- Medical History and Symptom Review: The healthcare provider asks about symptoms, medical history, and lifestyle factors.
- Physical Examination: Focuses on the abdomen and pelvic area in women, and may include a prostate exam in men.
- Urine Sample: Taken to check for infection or other abnormalities.
- 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.
Duration
Typically, the assessment takes 30 minutes to 1 hour.
Setting
Can be performed in an outpatient clinic, urologist's office, or a hospital setting.
Personnel
- 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).
Benefits
- 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.
Recovery
- 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.
Alternatives
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.