EVALUATION OF THE INCONTINENT WOMAN

Assoc. Prof. Gazi YILDIRIM, M.D.

Yeditepe University, Medical Faculty Dept of Ob&Gyn

• To define– incontinence

• To learn– Risk factors for incontinence– Diagnosis of the type of incontinence

• To manage – An incontinent woman

Objectives

DefinitionDefinition

• Urinary incontinence is the inability to control urination which results in unintended urinary flow or leakage

• Urinary incontinence is the inability to control urination which results in unintended urinary flow or leakage

Classification of UIClassification of UI

• 6 major subtypes of urinary incontinence:

– Stress

– Urge (“overactive bladder”)

– Mixed

– Overflow

– Functional

– Other (deformity/lack of continuity)

• 6 major subtypes of urinary incontinence:

– Stress

– Urge (“overactive bladder”)

– Mixed

– Overflow

– Functional

– Other (deformity/lack of continuity)

Stress incontinenceStress 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

• 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 incontinenceStress incontinence

• Causes: – urethral hypermobility due to pelvic floor laxity

– aging– difficult or multiple vaginal deliveries– hysterectomy – other perineal injury (e.g. radiation)

– intrinsic urethral sphincter deficiency – autonomic neuropathy– inadequate estrogen levels – partial denervation

• Causes: – urethral hypermobility due to pelvic floor laxity

– 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 incontinenceStress incontinence

Urge incontinence (overactive bladder, detrusor instability)

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

• 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)

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)

• 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)Urge incontinence (overactive bladder)

Mixed IncontinenceMixed Incontinence

• Refers to patients with both stress incontinence and urge incontinence.

• Helpful to identify the most bothersome symptom and treat accordingly

• Refers to patients with both stress incontinence and urge incontinence.

• Helpful to identify the most bothersome symptom and treat accordingly

Overflow incontinenceOverflow 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)

• 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 incontinenceOverflow 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, anti-

Parkinsonians, narcotics, Ca-channel blockers, vincristine

• 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, anti-

Parkinsonians, narcotics, Ca-channel blockers, vincristine

Overflow incontinenceOverflow incontinence

Functional IncontinenceFunctional 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

• 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 ContinuityDeformity or Lack of Continuity

• Causes:– Vesicovaginal or ureterovaginal fistula, often

as complication of hysterectomy or other pelvic surgery

– Ectopic ureters– Diverticulae

• 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

HistoryHistory

• Identify contributing medical factors – DM– CVA– Lumbar disc disease– Chronic lung disease– fecal impaction– cognitive impairment

• 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

• 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 DiaryBladder Diary

• 24-48 hours

• Requires literacy and significant amount of time and work by patient

• see sample in handout

• 24-48 hours

• Requires literacy and significant amount of time and work by patient

• see sample in handout

Physical ExamPhysical 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

• 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 cystoscope2. Radiography

excretion urography, micturition cystography

3. USG4. Radioisotopes

d1Xd2Xd3X0.7

Pad Tests

• The most useful objective urine loss test in clinical practice

• Normal range: < 2 g of urine/h2-10gr Mild10-50gr Moderate> 50gr Severe

• Pad tests are not recommended in the routine assessment of women with UI

RCOG 2006

Urodynamic testingUrodynamic 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

• 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)

• 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!!!

Urethral Hypermobility Internal Sfyncteric Deficiency

Burch colposuspension Tension-free slings

Periurethral injections

Surgery in urodynamic stress incontinence

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

Obturator Kanal

Üretra

Mesane

Retropubik Midüretral Sling

Minimal İnvaziv Midüretral Sling OperasyonlarıRetropubik Yöntem

Obturator Damar ve sinirlerİnferior epigastrik

damarlar

Eksternal iliakDamarlar

Retropubik (TVT)

Outside-in (TOT)(Dıştan içe)

Transobturator yöntemde teknik

İnside-out (TVT-O)(İçten dışa)

Transobtrator