Pocket ObGyn – Urine Incontinence

Pocket ObGyn – Urine Incontinence
See Abbreviations

Definition

Involuntary leakage of urine:

Stress urinary incontinence (SUI): Complaints of involuntary leakage of urine w/ cough, sneezing, or exertional maneuvers that abdominal pres

Urge urinary incontinence (UUI): Complaints of involuntary leakage of urine w/ sensation of urgency, often referred to as OAB

Mixed urinary incontinence (MUI): Combination of both SUI & UUI Continuous urinary incontinence: Complaint of continuous leakage Overflow incontinence: Complaint of involuntary loss of urine preceded by an

inability to empty the bladder (a/w overdistention & urinary retention due to obst or neurologic causes)

Epidemiology

Prevalence of 25–55% in Western countries
May be as high as 50% in nursing home pts & 40% in postmenopausal women
Many women will not address this issue w/ their physicians due to May lead to signif impairment in QOL

Etiology

Age, childbearing, obesity, medical diagnoses (diabetes, stroke, spinal cord injury)
Hysterectomy & menopause w/ inconsistent results

Pathophysiology (N Engl J Med 1985;313:800; Obstet Gynecol 2005;105:1533)

Impairment in the physiologic voiding mech
Functional incontinence – incontinence occurring b/c of factors unrelated to the physiologic voiding mech

Remember mnemonic DIAPPERS (Delirium, Infxn, Atrophic urethritis & vaginitis, Pharmacologic [diuretics, sedatives, anticholinergics, CCB, a blockers], Psychologic [depression], Endocrine [calcium, gluc], Restricted mobility, Stool impaction)

Genitourinary etiologies include filling & storage disorders (SUI, UUI, MUI), fistulae (vesicovaginal, ureterovaginal, or urethrovaginal), congen (ectopic ureter, epispadias)

Clinical Manifestations

Hx: Provides the most insight to cause, type, & Include the following: Voiding frequency, noctural voiding frequency, number of episodes of incontinence & vol a/w episodes, number of pads used, bowel incontinence, bulge sx, diet (including caffeine & EtOH intake), medical & surgical hx, obstetrical & gynecologic hx, neurologic conditions (diabetes, multi sclerosis, disk dz, & stroke), pulm conditions, smoking, & meds
Consider having the pt keep a voiding diary over 3–7 d
Physical exam: Complete full physical exam including gynecologic, rectal, & genital/ lower neurologic Include POP-Q (see POP section)
Urethral mobility: May be assessed w/ the Q-tip test & helps aid in the dx of stress incontinence

A Q-tip is placed in the urethra to the level of the vesical neck & assessment of the change of axis is performed while asking the pt to Valsalva.

An angle of >30° is indicative of urethral hypermobility

Cough stress test
PVR to determine if urinary retention an issue <50 mL adequate bladder emptying,

>200 mL considered inadeq.

Initial Workup

Lab test: Clean midstream or catheterized urine sample for urinalysis & culture Bld testing including BUN, Cr, gluc, & calcium

Subsequent Workup

Urodynamic testing: A test that evaluates stress incontinence, detrusor instability,

1st sensation, desire to void, bladder compliance, & bladder capacity

Recommended in the following circumstances: (1) dx unclear, (2) Surg being considered, (3) marked POP present which may have underlying de novo incontinence, or (4) a neurologic condition exists.

Measurements:

Uroflowmetry: Assesses ability to empty bladder, meter assesses flow rate

Filling cystometry: Measures detrusor fxn including sensation, compliance, capacity, & evid of uninhibited detrusor contractions Pres catheters are placed in the blad- der & vagina or rectum while the bladder is retrofilled. Detrusor activity is deter- mined by Pves (pres in bladder) – Pabd (pres in abd, measured by vaginal/rectal catheter). Individual measurements are recorded throughout the tracing including LPP, 1st desire & maximal bladder capacity ® ISD – Valsalva LPP <60 cm H₂O

Urethral pres profile: Evaluate for ISD, dual sensor catheter is used to deter-

mine MUCP & functional urethral length ® ISD – MUCP is 20 cm H₂O or less

Cystourethroscopy: May be req for eval of microscopic hematuria, irritative voiding sx w/o evid of infxn & persistent hematuria in women >50 yo, or suspicion of suburethral mass

Treatment

Behavioral approaches:

Lifestyle modification: Weight loss, caffeine, EtOH, or fluid intake reduction, decreased weight bearing, smoking cessation, & constip relief, “bladder diet”

Bladder training: May aid in UUI & MUI

Kegel exercises: Strengthen the voluntary periurethral & perivaginal muscles, may be augmented w/ biofeedback training or electrostimulation via a pelvic floor physical therapist

• Medical management:

Estrogen may urethral bld flow, a-adrenergic receptor sens, & build collagen but is not proven to help in incontinence & some trials suggest incontinence may be worsened

Antichol medication is often used for UUI or MUI