Transcript evaluation of the inkontinent woman

EVALUATION OF THE
INCONTINENT WOMAN
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty
Dept of Ob&Gyn
Objectives
• To define
– incontinence
• To learn
– Risk factors for incontinence
– Diagnosis of the type of incontinence
• To manage
– An incontinent woman
Definition
• Urinary incontinence is the inability to
control urination which results in
unintended urinary flow or leakage
Classification of UI
• 6 major subtypes of urinary incontinence:
– Stress
– Urge (“overactive bladder”)
– Mixed
– Overflow
– Functional
– Other (deformity/lack of continuity)
Stress incontinence
• Signs & Symptoms:
– urine leakage triggered by coughing,
sneezing, laughing, lifting, exercising,
straining
– usually worse standing than supine
– small to moderate volumes of urine
– infrequent nocturnal leakage
– little post-void residual
Stress incontinence
• Causes:
– urethral hypermobility due to pelvic floor laxity
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aging
difficult or multiple vaginal deliveries
hysterectomy
other perineal injury (e.g. radiation)
– intrinsic urethral sphincter deficiency
– autonomic neuropathy
– inadequate estrogen levels
– partial denervation
Stress incontinence
Urge incontinence (overactive bladder, detrusor
instability)
• Symptoms:
– Frequent abrupt, intense urge to urinate that cannot
be voluntarily suppressed
– moderate to large volumes of urine
– nocturnal wetting
– perineal sensation intact
Urge incontinence (overactive bladder, detrusor
instabiliy)
• Cause:
– Inappropriate contraction of detrusor muscle during
bladder filling
– idiopathic
– related to aging (unclear mechanism)
– decreased cortical inhibition (CVA, Parkinson’s disease,
Alzheimer’s disease, brain tumor)
– bladder irritation (UTI, bladder CA, stones)
Urge incontinence (overactive bladder)
Mixed Incontinence
• Refers to patients with both stress
incontinence and urge incontinence.
• Helpful to identify the most bothersome
symptom and treat accordingly
Overflow incontinence
• Signs & Symptoms:
– Frequent voiding/dribbling (worse after fluid load or diuretic)
– small volumes
– without warning
– slow or weak flow
– incomplete bladder emptying
– feel need to strain
– nocturnal wetting
• Bladder hypotonic/flaccid and palpably distended
• Large post-void residual (PVR)
Overflow incontinence
• Causes:
– long-standing outlet obstruction
– detrusor chronically overstretched
– detrusor insufficiency
– lower motor neuron damage due to peripheral
neuropathy or sacral cord injury
– impaired sensation
– peripheral neuropathy, Vit B12 deficiency, SCI
– medications that reduce detrusor tone
– anticholinergics, antidepressants, antipsychotics, antiParkinsonians, narcotics, Ca-channel blockers,
vincristine
Overflow incontinence
Functional Incontinence
• Inability to void independently due to impairment
of physical and/or cognitive function
– disabling illness, bedridden
– frontal lobe dysfunction, lack of awareness
– deliberate incontinence (rare)
• Patient may have other types of incontinence
that are amenable to treatment
• Pure functional incontinence should be a
diagnosis of exclusion
Deformity or Lack of Continuity
• Causes:
– Vesicovaginal or ureterovaginal fistula, often
as complication of hysterectomy or other
pelvic surgery
– Ectopic ureters
– Diverticulae
Pharmacologic Causes
• sedatives
• loop diuretics
• alcohol
• caffeine
• cholinergics
(donepezil)
•  awareness, detrusor
activity Func & O UI
• Diuresis overwhelms
bladder capacity Urge & O
UI
• Polyuria,  awareness 
Urge & Functional UI
• Polyuria,  detrusor activity
 Urge
•
 detrusor activity  Urge
Culligan PJ Urinary Incontinence in women
Evaluation and Management AFP 12-1-01
History
• Identify contributing
medical factors
–
–
–
–
–
–
DM
CVA
Lumbar disc disease
Chronic lung disease
fecal impaction
cognitive impairment
• OB/Gyn Hx
– gravity/parity
– # of vaginal, instrument
assisted and C/S deliveries
– interval between deliveries
– previous hysterectomy,
vaginal and/or bladder surg
– pelvic RT
– trauma
– estrogen status
Bladder Diary
• 24-48 hours
• Requires literacy and significant amount of
time and work by patient
• see sample in handout
Physical Exam
• If screen (+) for UI:
• Have pt void as normally and completely
as possible immediately before exam
• Record volume voided
• Determine PVR within 10 minutes by
catheterization (send urine for UA & Cx)
• PVR > 100ml considered abnormal
Physical Examination
• General examination
• Neck examination (cervical spondylosis)
– should investigate limitations in
cervical lateral rotation and
lateral flexion,
– interosseous muscle wasting,
– Babinski reflex +
interruption of inhibitory tracts to the
detrusor
detrusor overactivity
Physical Examination
• Back examination
– may reveal dimpling or a
hair tuft at the spinal cord
base, suggestive of occult
dysraphism
Physical Examination
• Cardiovascular examination
should look for evidence of
volume overload.
• Abdomen should be palpated
for masses, tenderness, and
bladder distention.
• Extremities should be
examined for joint mobility and
function.
Physical Examination
• Genital examination
– Inspection of the vaginal mucosa
(atrophy, narrowing of the
introitus by posterior synechia,
vault stenosis, and inflammation)
– A bimanual examination (masses
or tenderness)
– Pelvic floor muscle strength
• Rectal examination
– Masses and fecal impaction
Pelvic-floor muscle assessment
International Continence Society
1—no response, cannot
perceive
2—weak squeeze, felt as
a flick
3—moderate squeeze, felt
all around finger
4—strong squeeze, full
fingers compressed
Messelink EJ et al Neurourol Urodynam 2005;24:374–80
Physical Examination
• Neurologic examination
– Sacral root integrity
• perineal sensation,
• tone of the anal sphincter
• the bulbocavernosus reflex
– Cognitive status,
– Motor strength and tone,
– Peripheral sensation for
peripheral neuropathy
Q-tip test
Sensitivity
Specifity
Postvoid Residual Measurement
• Rules out urinary retention
• Poor test-retest reliability (limited
use)
• PVR < 100 cc normal
> 200 cc abnormally
100-200 cc borderline → further investigation
1. Catheter or cystoscope
2. Radiography
excretion urography,
micturition cystography
3. USG
4. Radioisotopes
d1Xd2Xd3X0.7
Pad Tests
• The most useful objective urine loss test in
clinical practice
• Normal range: < 2 g of urine/h
2-10gr
10-50gr
> 50gr
Mild
Moderate
Severe
• Pad tests are not recommended in the
routine assessment of women with UI
RCOG 2006
Urodynamic testing
• PVR: simple test for overflow incontinence
• Cystometry: dx of complicated mixed conditions
– Normal: sense filling between 100-200ml
– non-urgent desire to void at 250-350ml
– detrusor contraction at 400-550ml
• Uroflowmetry: info on outflow obstruction
• Cystoscopy: detects structural abnormalities,
inflammation, masses
• IVP: detects structural abnormalities, urethral narrowing,
incomplete bladder emptying
Endoscopy
• provide unique anatomical information with a
simple, minimally invasive approach
• adjunct to multichannel urodynamics in women
with possible ISD, urethral diverticula, urogenital
fistulae, foreign bodies or urothelial lesions
• Cystoscopy is not recommended in the
initial assessment of women with UI alone
RCOG 2006
Treatment:
Non-surgical
 Fluid management
 Reduce caffeine, alcohol, and smoking
 Bladder retraining
 Pelvic floor exercises
 Pessaries
 Continence devices
Treatment:
Non-surgical
 Hormone replacement therapy
 Medication to help strengthen the urethra
 Medication to help relax the bladder
Non-surgical Treatment:
Fluid management
 Avoid caffeine and alcohol
 Avoid drinking a lot of fluids in the evening
Non-surgical Treatment:
Bladder retraining
 Regular voiding by the clock
 Gradual increase in time between voids
 Double voiding
Non-surgical Treatment:
Physiotherapy
 Pelvic floor exercises
 Vaginal cones
 Devices for reinforcement
Non-surgical Treatment:
Pessaries
 Support devices to correct the prolapse
 Pessaries to hold up the bladder
Non-surgical Treatment:
Hormone replacement
 Systemic
 Local
Vaginal cream
Vaginal estrogen ring
Anticholinergic Drugs (Urge UI)
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Oxybutynin
Tolterodine
Trospium
Darifenacin
Variety of preparations: Immediate Release;
Extended Release; Transdermal
• Outcomes same; Try different agent if one
doesn’t work
***** ALL these drugs suppress the detrusor contractility and MAY CAUSE
URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO
PRESCRIBING!!!
Surgery in urodynamic stress incontinence
Urethral Hypermobility
Burch
colposuspension
Internal Sfyncteric Deficiency
Tension-free slings
Periurethral
injections
Anti-inkontinans Operasyonlar
• Burch kolposuspansiyon
– Burch+Paravajinal Defekt Onarımı
• Mid uretral sling
– Retropubik (TVT)
– Transobturator (TOT)
• Periuretral enjeksiyonlar
Burch Sutures areas
Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the
urethra is one of the two best cures for stress or activity related urine leakage
Minimal İnvaziv Midüretral Sling Operasyonları
Retropubik Yöntem
Retropubik Midüretral Sling
Mesane
İnferior epigastrik
damarlar
Eksternal iliak
Damarlar
Obturator
Damar ve sinirler
Obturator Kanal
Üretra
Retropubik (TVT)
Transobturator yöntemde teknik
Outside-in (TOT)
(Dıştan içe)
İnside-out (TVT-O)
(İçten dışa)
Transobtrator