ADDIS ABABA UNIVERSITY
FACULTY OF MEDICINE
DEPARTEMENT OF OBSTETRICS AND GYNECOLOGY
Sept 2001
The valuation of urinary incontinence in female
INTRODUCTION
Every human being is born incontinent. However a normal neuromuscular co-ordination
later in life will result in a socially acceptable micturation habit.
Urinary incontinence (UI) is a particular medical problem for women because it is twice
as prevalent among them as it is among men. Epidemiological studies showed a
prevalence of UI to be on average 24% using International Continence Society (ICS)
definition.
The economic impact of UI is also significant. For example in Sweden the estimated
expenditure on incontinence was 2% of the total health budget in 1990. In the USA the
direct financial cost of UI was 10.3 billion per year in 1987.
It also affects the woman's social, psychological and sexual life and well-being. As a
result significant number of incontinent patients never seek medical help.
Because of anatomic and embryological close relationship and common supportive
structures combination of anal incontinence, UI and utero-vaginal prolapse are so
common especially in females. Causes are various and range from simple urinary tract
infection to more complex conditions, which are difficult to diagnose and treat.
Taking the above points into account, each woman with a complaint of UI (Irrespective
of severity) deserves an appropriate evaluation before treatment. Patient should not
undergo clinical and urodynamic tests before a complete history, physical examination;
preferably these tests should be done by the physician who is familiar with the patients
history and physical findings, which make the interpretation of the results less difficult
and more accurate.
Definitions:
UI: Involuntary loss of urine that is of social or hygienic problem and objectively
demonstrable.
Urgency: A strong desire to void that is accompanied by the fear of impending urinary
leakage.
Urinary frequency: Used when the patient voids more than seven limes in 24 hrs with
normal fluid intake.
Stress incontinence: Involuntary loss of urine during events of increased intra abdominal
pressure (coughing, sneezing, physical activities)
Nocturia: Being awakened from sleep by the urge to void 2 times or more per night.
Urge incontinence: Involuntary loss of urine associated with an abrupt and strong desire
to void.
Causes and classification of UI
2 Extra urethral
i. Congenital - Ectopic Ureter
- Bladder extrophy
ii. Acquired - Fistulas
- Vesical
- Ureteric
- Ureteric
- Urethral
- Combination
3 Trans Urethral
1 Genuine stress incontinence (GSI)
4 Anatomic hyper mobility of bladder
neck is urethra
5 Intrinsic sphincter dysfunction
6 Combination
1 Detrusor over activity
7 Idiopathic detrusor instability
8 Neuropathic detrusor hyperreflexia
1 Mixed (i + ii)
2 Urinary retention with bladder distention and overflow
9 GSI
10 Detrusor hyperreflexia with impaired
contractility (DHIC)
11 Combination
1 Urethral diverticulum
2 Congenital urethral abnormalities (e.g. Epispadias)
3 Uninhibited urethral relaxation (urethral instability)
3. Functional and transient in continence (DIAPPERS)
12 Delirium
13 Intention
14 Atrophic urethritis/vaginities
15 Pharmacological cause
16 Psychological cause
17 Excessive urine production
18 Restricted mobility
19 Stool impaction
20 Neurologic diseases that affect the normal neurologic axis causing UI
Evaluation
Objectives: Clarify the patient symptoms
. Objective demonstration of loss of urine
. Determine the etiology of UI using clinical testing
. Identifying those who require more sophisticated tests
Components in patient evaluation: -
. History
. Physical examination (PE) and clinical tests
. U/A and urine culture (urine cytology as appropriate)
. Measurement of post-void residual urine
. Urinary diary (freq /volume bladder chart) multichannel studies
. Others
. U/S
. Cystourethrography
. IVP
. Dye test
. EMG (electromyography)
A. History:
It is helpful in guiding the physician in diagnostic evaluation. History taking
can be facilitated using a questionnaire (filled by the doctor and supplemented
by discussion with the patient.)
The chief complain (s) should be elaborated
Duration, frequency of UI episodes, number of pads used.
Continuous Vs intermittent
Precipitating causes - a cute illness
- Change/use of medication
Special circumstances associated with the chief complaint(s).
Progression
History of previous surgical/medical treatment for the UI
Review of other symptoms of lower urinary tract
- Frequency, urgency, nocturia nocturnal enuresis
- Hesitancy, straining to void, filling of incomplete emptying, poor
flow
- Intermittent flow, post micturation dribbling, acute retention
- Dysuria, pelvic pressure/ pain
- Color and smell of the urine, hematuria
Review medical, surgical, past obstetric history
- Endocrine, neurologic, pulmonary, renal disease previous
gynecologic diseases, obstetric complications
Review drug history for those with direct effect or side effect on the lower
urinary tract.
- Diuretics, sedatives, α-agonist/antagonists, anticholinergics, muscle
relaxants, calcium channel blockers and psychotropic drugs.
B. Voiding diary: (Over 24-72 hrs. Can be extended to one week)
Patient is asked to record: - the time and volume or her spontaneous voids.
Presence or absence of urgency prior to voiding
Volume, time and frequency of incontinence episode
Activities precipitating incontinence
Type and volume of fluid intake.
Information obtained from the diary: - Patient’s normal voiding
pattern, functional bladder capacity. (Max. voided volume), diurnal distribution
of voiding
Normal values for 24hrs diary
Volume = 1500-2500ml
Frequency - < 8
Nocturia - < 2
Average Voided volume - 200-400ml
Maximum voided volume 400-600ml
C. Physical examination (P/E) and clinical tests
General P/E
Neurological examination
Gait & mental status
Lower thoracic lumbar & sacral spine/lower extremities abnormalities
Neurologic examination to detect sensory or motor nerve dysfunction of
the pelvic muscle, bladder and urethra.
Muscle strength & reflexes of the lower limb.
Sensory test cold, touch, pain) skin overlying the perineum, buttock and
medial side of the thigh
Pelvic examination
Estrogen status of the vagina
Tran urethral Vs extra urethral urine leak
Muscle tone assessment
Presence of other pelvic pathologies.
Clinical tests
21 Stress test- for objective demonstration of urinary leakage with stress.
Examination: - with subjectively full bladder on installation of 300ml
sterile saline
22 Position. Lithotomy/standing with feet
spread out to shoulder width.
23 Patient asked to cough repeatedly.
24 Demonstrate for the presence of urinary
leakage simultaneously with
coughing (trans urethral)
25 Pad test- objective demonstration of UI for patients who have not
demonstrated leakage in the stress test.
26 Pre-weighted perineal pad used and
patient completes a 1 hr series of
preset maneuvers, then pad
reweighed.
27 An increase in weight by > 2gm is
indicative of urinary lost.
28 Q-tip test (office cotton swab test)
29 Measurement of the urethral axis as a
method to assess the degree of
mobility of urethrovesical function.
30 Lubricated sterile cotton swab inserted
into the urethra up to the level of
bladder neck
31 Patient asked to cough/strain
32 Maximum deflection of the swab stick
from the horizontal measured using a
simple plastic protractor.
33 A maximum straining angle >300 is
generally taken to represent the presence
of urethral hyper mobility.
iv. Post Vidal residual Urine Measurement
Importance: - Co-existence of voiding problem with UI
- Large residual volume decreases functional bladder capacity, cause bladder
distension and lead to stress incontinence or overflow incontinence or provoke
uninhibited detrusor contraction.
- Stagnant urine pool recurrent UTI
- Should be measured after a spontaneous voiding
- Residual volume >200ml (measured at least in two occasion) is pathological.
v. Urinalysis / Culture
vi. Dye test - for small fistulas
- Diluted methylene blue –for VVF
- Indigo carmine IV 5ml for uretero vaginal fistula.
vii. Urodynamic studies
The purpose of Urodynamic testing is to identify and quantify the etiologic factors
contributing to lower urinary tract dysfunction.
- Pressure volume relation of the bladder is measured
- Assesses bladder sensation, bladder capacity bladder compliance and detrusor
activity.
Simple cystometry
- Crude diagnostic modality
- Has shown a positive value of 85% when compared to multichannel cystometry.
- Method: the bladder is filled with normal saline, 50ml increments (By gravity),
using a catheter attached to syringe with the piston removed.
A rise in the fluid level by > 15 ml associated with urgency or leakage is suggestive of
detrusor instability. (In the absence of ? in intra abdominal pressure)
Multi-channel Urethrocystometry
Advantage: measures bladder, urethral and abdominal pressures
The bladder is filled at a standard rate of saline (50-100ml/min) and the
patient’s sensations are recorded and correlated with the subtracted detrusor
pressure.
Normal values are:
Residue urine <50ml
First desire to void 150-250ml
Cystometric capacity 400-600ml
Max-detrusor pressure <15cm H2O
Max-detrusor pressure during voiding <70cm H2O
Ultrasonography
- Bladder neck mobility can be visualized by vaginal, rectal and perineal
ultrasonography.
- To visualize the bladder neck during rest, coughing and valsalva maneuver.
- Hyper mobility is defined as a bladder neck descent >1cm during valsalva.
Step by Step Evaluation
Stepwise evaluation helps the treating physician to formulate a presumptive diagnosis
and initiate treatment starting from simple, less expensive and less invasive method to
more complex, expensive and invasive methods.
Step I
- Patient history and P/E
- U/A including culture
- Post-void residual urine
- Urinary diary
Step II
- Perineal pad test
- Q-tip test
- Bead-chair cyst urethrography
- Ultrasound-vaginal/perineal
- Simple single channel cystometry (electronic/non electronic)
Step III
Complex multi channel uro-dynamics
Some indications for Step III evaluation
2 Complicated History
3 Inconclusive studies from step II
4 Before surgical treatment for stress incontinence
5 Urge incontinence not responsive to therapy
6 Previous surgery for stress incontinence
7 After pelvic radiation and radical pelvic surgery
8 Those with neurologic disorder
References
1 Acta Obstet Gynecol Scand. 1998; 77: 361-371.
2 Clinical Urogynecology. 1993
3 Int J Gynecol Obstet 1996 52 : 75-86.
4 Novak’s Gyneclogy 12th ed., 1996 pp. 619-657.
5 Obstetrics and Gynecol clin of North America 1998 Vol. 25. No. 4
6 Te Linde’s Operative Gynecology. 8th ed. 1997. pp. 1087-1206.
