Diagnostic Evaluation Of Urinary Incontinence In Women

Main Category: Urology / Nephrology
Also Included In: Women's Health / Gynecology
Article Date: 07 Aug 2008 - 3:00 PDT

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UroToday.com - The incontinent patient is evaluated in order to make a presumptive diagnosis so that treatment can be offered. The evaluation begins with a history and a physical examination. The history focuses on the description of the patient's incontinence.

Although the history may define the patient's problem it may be misleading. Urge incontinence may be triggered by activities such as coughing so that by history the patient would seem to have stress incontinence. A patient who only complains of urge may also have stress incontinence. Mixed incontinence is very common with at least 65% of patients with stress incontinence having associated urgency or urge incontinence. It may be impossible to determine by history alone which is the more significant problem. Assessing the patient's bother and determining their expectations of treatment may further guide how aggressive one needs to be both with the evaluation and the presentation of treatment options.

The important parts of the physical exam are an examination of the abdomen and pelvis including a provocative stress test. If the test is done supine and there is no leakage it should be repeated standing, as this will increase the patient's abdominal pressure. A urinalysis and a post-void residual (PVR) should be performed in all incontinent patients.

Incontinence questionnaires, voiding diaries, and pad weight tests can provide more objective data than the history alone. Upper tract imaging is indicated in the patient with a history of hematuria and in patients with suspected hydroureteronephrosis. Other imaging may be useful to further evaluate other suspected pelvic pathology. Urodynamics are performed to determine if the incontinence is due to bladder or urethral dysfunction or both, to assess if the patient has a storage or emptying problem and lastly in an effort to identify patients whose upper tracts are at risk due to high bladder storage pressures.

The most common abnormality of bladder function is detrusor over activity that causes urge incontinence. Detrusor over activity is defined as the inability to suppress involuntary detrusor contractions during filling.1 A cystometrogram may fail to demonstrate any detrusor over activity in a patient who has urge incontinence by history. Any patients with symptoms of urge incontinence by history should be presumed to have urge incontinence. The purpose of urodynamics is not to diagnose detrusor over activity but to examine compliance, to diagnose stress incontinence, to rule out obstruction as a cause of either overflow or urge incontinence and to insure that the patient has a reasonable, safe, bladder capacity.

The diagnosis of stress incontinence is best made with measurement of the abdominal pressure required to induce urinary loss, the Valsalva or abdominal leak point pressure and, or fluoroscopy. Stress incontinence is diagnosed if there is urethral loss of urine associated with an elevation of abdominal pressure. Valsalva leak point pressure (VLPP) is used to diagnose stress incontinence since it is abdominal pressure that is the expulsive force in stress incontinence. Measurement of the VLPP allows for quantification of the degree of urethral dysfunction. A normal urethra will not leak at any pressure. A mobile urethra will leak at high abdominal pressures (>120 cm H2O) and a poorly functioning intrinsic sphincter will leak at low pressures (<60 cm H2O).2 The majority of patients with a ALPP of <90 cm H2O have intrinsic sphincter dysfunction.

A pressure flow test is indicated in the patient in whom obstruction is suspected. Such patients would include the patient who has had a prior procedure for stress incontinence, the patient with a large post void residual or the patient with significant prolapse and obstructive or irritative symptoms. No universally accepted definition of bladder outlet obstruction in women exists. Usually bladder outlet obstruction is defined as high pressure-low flow. However since some women normally void with very low detrusor pressures it is difficult to define a high detrusor pressure in women. In patients with emptying problems or suspected neurogenic dysfunction an EMG may be indicated. Cystoscopy is indicated in the work up of some incontinent patients.

The evaluation of the incontinent patient consists of a history, a physical, urinalysis and a postvoid residual. Optional evaluative tests consist of a variety of urodynamic tests, imaging studies and cystoscopy.

References:
1. International Continence Society Committee on Standardization of Terminology of lower urinary tract function. Neurourol. Urodyn., 7; 1988, 403.
2. McGuire, E.J., Fitzpatrick, C.C., Wan, I., Bloom, D., Sanvordenker, J., Ritchey M., and Gormley, E.A., J Urol, Clinical assessment of urethral sphincter function. 150: 1993, 1452.

Presented by: E. Ann Gormley, MD, FACS, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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