Thursday, May 22, 2014

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 6)

1- History
The purpose of history taking is to determine the type of urinary incontinence (UI) that is bothersome to the patient.
Urinary incontinence is commonly classified as stress, urge, postural, continuous (or total), insensible (spontaneous), coital, or incontinence associated with chronic urinary retention (previously referred to as overflow incontinence); nocturnal enuresis; or some combination thereof (5, 6).
The history should include questions about the type of incontinence (eg, stress, urge, mixed), precipitating events, and frequency of occurrence, severity, pad use, and effect of symptoms on activities of daily living.
Questions should be asked to assess symptoms related to bladder storage and emptying functions. Storage symptoms include frequency, nocturia, urgency, and incontinence. Emptying or voiding symptoms include hesitancy, slow stream, intermittency, straining to void, spraying of urinary stream, feeling of incomplete emptying, need to immediately revoid, post micturition leakage, position-dependent micturition, and dysuria. Health care providers can use validated questionnaires to evaluate bother, severity, and the relative contribution of urge UI and SUI symptoms (Box 1). Patients with uncomplicated SUI will have classic symptoms of leakage on effort or physical exertion. In contrast, inability to reach the toilet that is associated with urgency indicates the presence of urge UI.

Box 1 Examples of Validated Urinary Incontinence Questionnaires
* Urogenital Distress Inventory (UDI)*
* Incontinence Impact Questionnaire (IIQ)*
* Questionnaire for Urinary Incontinence Diagnosis (QUID)†
* Incontinence-Quality of Life Questionnaire (I-QoL)‡
* Incontinence Severity Index (ISI)§
* International Consultation on Incontinence Questionnaire (ICIQ)‖
*Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3:291–306 and Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995;14:131–9.
†Bradley CS, Rahn DD, Nygaard IE, Barber MD, Nager CW, Kenton KS, et al. The questionnaire for urinary incontinence diagnosis (QUID): validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence. Neurourol Urodyn 2010;29:727–34.
‡Brown JS, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet Gynecol 1999;94:66–70.
§Sandvik H, Seim A, Vanvik A, Hunskaar S. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Urodyn 2000; 19:137–45.‖
Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23:322–30.

Negative responses to queries regarding symptoms of predominant urgency, incomplete emptying, incontinence associated with chronic urinary retention (previously referred to as overflow incontinence), functional impairment, continuous leakage, and incomplete emptying are consistent with uncomplicated SUI (Table 1). Absence of cognitive impairment typically rules out a functional component to the incontinence, and a lack of continuous leakage in women with recent pelvic surgery or radiation exposure points away from the presence of a fistula.

After the urologic history, thorough medical and neurologic histories should be obtained. Certain conditions, such as diabetes and neurologic disorders, can cause UI. In addition, a complete list of the patient’s medications (including nonprescription medications) should be obtained to determine whether individual drugs may be influencing the function of the bladder or urethra, which leads to UI or voiding difficulties (3). Agents that can affect lower urinary tract function include diuretics, caffeine, alcohol, narcotic analgesics, anticholinergic drugs, antihistamines, psychotropic drugs, alpha-adrenergicblockers, alpha-adrenergic agonists, and calcium-channel blockers. Surgical, gynecologic, and obstetric histories also should be elicited. Findings on history taking that are consistent with a diagnosis of uncomplicated SUI are listed in Table 1. Physical examination and office tests are needed to confirm the uncomplicated SUI diagnosis (see following sections).



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