Thursday, December 20, 2012

female urinary incontinence 2- evaluation


Evaluation of Urinary Incontinence


History

  1. Type of incontinence (Urge or Stress)Immediate leak after coughing or standing up is stress incontinence.
    Leaking after a few seconds is a detrusor contraction.
  2. Straining to void/incomplete emptying (?overflow)
  3. Medications (Alpha-blockers)
  4. Frequency ( > 7 - 8 Diurnal voids)
  5. Pattern (Diurnal, nocturnal, after taking medications)
  6. Associated symptoms (Dysuria, haematuria, suprapubic or perineal discomfort) - Bladder Carcinoma, Bladder Stone or infection.
  7. Alteration in bowel habits / sexual function
  8. Other diseases (cancer, diabetes, neurologic disease)

Voiding Record

A diary kept over a 24 or 48 hour period which records the times and volumes that the patient voids will give an idea of the largest single voided volume but also of frequency and polyuria and severity of incontinence problems.

Date
Time
Volume voided (mL)
Wet or Dry
Volume of Incontinence
Comments
cough, sneeze, running water on way to toilet, volume tea coffee, alcohol, etc.

Physical Examination

  1. Abdominal examination - distended bladder, abdominal mass
  2. Pelvic Examination - atrophic vaginitis/urethritis, pelvic muscle laxity, bladder neck descent, cystocoele, rectocoele, uterine/vault prolapse, pelvic mass
  3. Stress test - leakage with a full bladder after coughing - immediate (stress incontinence) or delayed (? Detrusor contraction). Bilateral elevation of the vaginal wall, lateral to the bladder neck, will stop leakage in patients with hypermobility of the urethra, but not in patients with intrinsic sphincter dysfunction.
  4. Rectal examination - skin irritation, anal sphincter control, faecal inpaction
  5. Neurologic examination - mental status, sacral reflexes, perineal sensation (S2,3,4)
  6. Other medical conditions - congestive heart failure, peripheral oedema

Post Void Residual Urine

This test is essential in all incontinent women and distinguishes between true incontinence (residual urine <50 mL) and overflow incontinence (residual urine>100 mL)

Laboratory Investigation

Creatinine and Electrolytes, fasting Glucose and Calcium (for patients with Polyuria).
Renal Ultrasound in patients with incomplete emptying.
Urine Culture.

Urodynamic Evaluation of Urinary Incontinence  

In approximately 10 - 15% of women with symptoms that appear to indicate stress incontinence, their condition is actually due to detrusor instability (coughing can stimulate a detrusor contraction)  Urodynamic testing reveals that approximately 20% of women with symptoms of urge, frequency, and overactive urge incontinence actually have underlying genuine stress incontinence, rather than detrusor overactivity (This is called "sensory urgency"). Urgency is absent in 20% of patients with detrusor overactivity. 

1. Residual Urine
This test is essential in all incontinent women and distinguishes between True Incontinence (Residual urine < 50 mL), and Overflow Incontinence (Residual urine >100 mL).

2. Uroflow
A poor flow could be an indication of urethral obstruction and should be treated during surgery to prevent post-operative retention or difficulty to void.
 

 


3. Pressure flow study
A small catheter in the bladder measures the pressure during voiding while her flow is also measured. This helps to differentiate true urethral obstruction from underactivity of the Detrusor.
Obstruction = detrusor pressure more than 50 cm water and flow < 15 mL/s.
Detrusor Pressure

4. Cystometrogram
The pressure in the bladder and rectum is measured during bladder filling. Intra-abdominal pressure is subtracted from bladder pressure to give a real indication of Detrusor function.

 

 


5. Abdominal Leak-Point Pressure (ALPP)
This is the measurement of the total bladder pressure during coughing or valsalva manoeuvre to determine the pressure in the bladder required to induce leakage. In hypermobility of the urethra, the ALPP will be more than 60 cm water, but with Intrinsic Sphincter Dysfunction, the ALPP is less than 60 cm water and often less than 20 cm water.


6. Cystoscopy
To evaluate the urethral closing mechanism and to exclude other pathology.

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