The Basic Evaluation of Urinary Incontinence

1. The Basic Evaluation of Urinary Incontinence

2. Educational Objectives • After this presentation, the participant should be able to perform an initial evaluation of a woman with urinary incontinence. • This lecture will enable the participant to choose appropriate urodynamic tests and understand the purpose and limitations of each. • After this session the clinician will understand which patients require more advanced testing.

3. What is Urinary Incontinence? • The loss of urine beyond the patients‘ control which is of social or hygienic significance to the patient.

5. Types of Urinary Incontinence • Stress Urinary Incontinence A. Urethral Hyper mobility B. Intrinsic Sphincteric Deficiency • Urge incontinence • Mixed incontinence

6. Urethral hypermobility Displacement of urethra during sudden increase in abdominal pressure Decreases pressure transmission Pathophysiology of Stress Urinary Incontinence

7. Hypermobile Urethra

8. GSUI:Intrinsic Sphincteric Deficiency • Weak urethral sphincter • With or without urethral hypermobility • Risk: Prior incontinence surgery • Presentation: severe, recurrent incontinence

9. Urge Incontinence

10. UI Symptoms Do Not Equate to Underlying Conditions Symptoms Underlying Condition 4% 33% Stress Urge 51% Mixed 12% Other • 4 out of 5 women with incontinence have stress symptoms (pure or combined with urge) • 3 out of 4 have urodynamic stress incontinence (USI) as proven by urodynamic testing (pure or combined with detrusor overactivity [DO]) Adapted from: Weidner AC, et al. Am J Obstet Gynecol. 2001;184(2):20-27.

11. Treatment of Incontinence • Stress urinary incontinence 1.Urethral hyper mobility -- Conventional Surgery 2. Intrinsic Sphincter Deficiency-- Sling Collagen • Urge incontinence ----- drugs • Mixed incontinence ---- Symptoms?

12. Treatment Failures • The vast majority of treatment failures, whether medical or surgical, result not from poorly performed therapy, but a poorly chosen therapy. • Urodynamic evaluation can help you choose the proper therapy

14. Question? • Should I operate on this patient without urodynamic studies? The real question: Do I understand the patient’s problem well enough to formulate a reasonable treatment plan?

16. Definition • Urodynamic testing is the dynamic study of the transport, storage, and evacuation of urine by the urinary tract. • The tests range from simple studies to sophisticated software programs and high-tech video imaging.

17. Purpose of Urodynamics • Urodynamics should provide a better understanding of the pathophysiology contributing to the patient’s symptoms, rather than generate a list to validate surgical indications. • Urodynamic data is objective • The patients symptoms are subjective • Our evaluations should consider both the subjective and objective information

18. The Evaluation of Urinary Stress Incontinence (many years ago) • Abdominal Hysterectomy—MMK or Burch • Vaginal Hysterectomy-----Anterior repair

19. Evaluation of Urinary Incontinence • History • Physical examination • Voiding diary • Post void residual • Stress test • Urinalysis, Urine culture • Q-tip test • Urodynamic testing ? (simple or sophisticated?)

20. Transient Causes of Urinary Incontinence (DIAPPERS) • Delirium • Infection • Atrophic vaginitis • Pharmacologic • Psychological • Endocrine • Restricted mobility • Stool Impaction

21. AHCPR guidelines for basic evaluation • History of urine loss with physical activity • Voiding diary demonstrates normal voiding habits (8 or less voids per day, and 2 or less voids per night) • No history or findings suggestive of neurological abnormalities • No previous anti-incontinence or radical pelvic surgery • Normal post void residual (less than 100cc) • Pelvic examination demonstrating urethral hyper mobility • Not pregnant

23. History Requiring Further Evaluation • Recurrent urinary tract infections • Continuous (non-episodic) incontinence • Painful or frequent voids (more than 8 per day or 2 per night) • Greater than 4,000 ml 24 hr. voided volume • History consistent with neurological disease • Failed incontinence procedures • Greater than 65 years of age • Diabetes Mellitus • Radical Pelvic surgery or radiation therapy

24. Voiding Diary Helps Assess History • Fluid intake • Time, type, amount • Urine output • Time, amount • Urine leakage • Time, amount • Precipitating events (cough, sneeze, exercise, sex, etc.) • Associated symptoms (urgency, dysuria, etc.) • Pad usage • Number, type

25. Voiding Diary • Helpful for documenting and measuring the severity and timing of the incontinence • One week record is highly reliable for measuring urinary frequency, nocturia, and number of incontinent episodes, but is not reliable for diagnosing the type of incontinence. • Further evaluation needed if: * output greater than 4,000 cc/24 hours * more than 8 voids per day or 2 per night (Wyman, Obstet Gynecol,1998)

26. Urine Voiding Diary *Leakage: 0=no leakage; 1=drops; 2=wet underwear or light pad; 3=soaked pad or clothing.

27. Urinalysis • Bacteriuria • Hematuria • Pyuria • Glycosuria • Proteinuria

28. Physical Examination • Further Evaluation needed: Fistula Diverticula Severe Pelvic Organ Prolapse Large Pelvic mass Neurological abnormalities Markedly decreased muscle strength

29. Neurological Evaluation • Cranial nerves • Muscle strength • Deep tendon reflexes • Sensory function • Sacral cord integrity • Up to 25% of patients with MS or Parkinsonism present with urinary incontinence. (Galloway,1983) Any neurological abnormalities should receive further evaluation

33. Cotton swab test Demonstrates urethral hypermobility Other Basic Tests

34. Q-TIP TEST • Most consider a greater than 30 degrees change as positive • Sensitivity for USI ----- 80% • Specificity for USI ----- 42% (Tapp, Ob Gyn, Jan 2005)

35. Other Basic Tests • Postvoid residual

36. Post Void Residual (PVR) • Consensus is that PVR of less than 50 cc is normal • AHCPR recommends multi channel urodynamics for a PVR of greater than 100 cc • Most experts consider greater than 200 cc PVR definitely abnormal

37. Stress Test • A classical sign—observation of leakage on coughing • International Continence Society no longer requires a positive stress test for the diagnosis of urinary incontinence • “Can use information from frequency volume charts, pad tests, and validated symptom and quality of life questionnaires to verify and quantify symptoms” ( International Continence Society,2003)

38. Cough Stress Test • Most perform it with at least 300cc fluid in the bladder • The greater the bladder volume, the lower the Valsalva leak point pressure. (Miklos,1995)

39. How Valid is the Stress test? • 92% sensitivity for urodynamic SUI • 56% specificity for urodynamic SUI • 68% positive predictive value • 89% negative predictive value (Weidner 2001) (Most consider a negative stress test an indication for further testing)

40. Eyeball cystometry Detects bladder (?) contractions and compliance, residual urine, and determines bladder capacity Precedes stress test Can not determine detrusor or urethral pressure Urodynamic Testing

41. Simple Cystometry • Although simple office cystometry was left out from the AHCPR recommendations, many feel it should be considered an essential part of the basic evaluation of the incontinent patient, because it plays a vital role in the diagnosis of both stress incontinence and detrusor overactivity (instability). • Bergman (1989) found simple urodynamics sufficient to establish a diagnosis in 75-80 % of patients in his study.

42. Simple Cystometry

43. Equipment for Simple Cystometry • 500cc sterile saline (body temperature) • Foley catheter (indwelling?) • 60 cc Foley tipped syringe • Graduated beaker • Cheap stop watch • “Hat” insert for commode

44. Sequence of Simple Cystometry • Timed void (with stop watch) • Post void residual (catheterized specimen for urinalysis or culture if needed) • Empty supine test • Filling cystometry • Provocative testing • Cough stress test (can be repeated)

45. Timed Voiding • Meet patient in clinic with full bladder (hers) • Have patient void as she normally does and time from start to finish (including interruptions). • Measure voided volume in the “hat” • Normal voiding flow rates range between 12 and 20 ml/sec (Abrams1988) • Fantyl (1982) recommended further testing for those having average flow rates below 15cc/sec • Most recommend further studies for average flow rates below 10 cc/sec

46. Empty Supine Test • The test is performed by having the patient perform a Valsalva’s maneuver while in the supine position with 100-200cc fluid in the bladder. Any leakage is considered a positive test • Lobel (1996) found a positive test to have a 70 % sensitivity and a 90% negative predictive value for detecting urethral closure pressures below 20 cm water. • Hsu (1999) found a similar correlation with Valsalva Leak point Pressures of under 100 cm water . • A positive empty supine test is an indication for multi channel testing to rule out Intrinsic Sphincter Deficiency

50. Filling Cystometry • First sensation ----150cc • First urge to void ----200-300cc • Max capacity --- 400-500cc • Compliance -- resting pressure < 8cm • No uninhibited pressure rises > 15 cm • Any abnormalities are indication for further testing