The Basic Evaluation of Urinary Incontinence

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.

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

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

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

Hypermobile Urethra

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

Urge Incontinence

UI Symptoms Do Not Equate to Underlying Conditions Adapted from: Weidner AC, et al. Am J Obstet Gynecol. 2001;184(2):  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]) 12% 33% 4% 51% Stress Urge Mixed Other Symptoms Underlying Condition

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

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

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

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.

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

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

Evaluation of Urinary Incontinence 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?)

Transient Causes of Urinary Incontinence (DIAPPERS) DeliriumInfection Atrophic vaginitis PharmacologicPsychologicalEndocrine Restricted mobility Stool Impaction

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

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

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

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 * output greater than 4,000 cc/24 hours * more than 8 voids per day or 2 per night * more than 8 voids per day or 2 per night (Wyman, Obstet Gynecol,1998) (Wyman, Obstet Gynecol,1998)

Time Amount Voided Activity Leakage* (0-3 scale) Urge Present (yes/no) Fluid Intake Amount/Type 6:50 AM 425 mL Getting up/breakfast 0Yes 16 oz. coffee 6 oz. orange juice 7: mL Leaving for work 0Slight… 8: mL At work 0Yes 8 oz. coffee 9:10…Cough2Yes… 9: mL Working0Yes 10 oz. water 12:25 PM 275 mL Working/at lunch 0Yes 8 oz. water 2: mL Bending1Yes 4 oz. water 5: mL Leaving work 0Yes… 6: mL Exercise class 2Slight 12 oz. water 7:45…Dinner0No 4 oz. wine, 8 oz. water 8: mL At home 0Yes 4 oz. water 10: mL Getting ready for bed 0Yes… Urine Voiding Diary *Leakage: 0=no leakage; 1=drops; 2=wet underwear or light pad; 3=soaked pad or clothing.

Urinalysis BacteriuriaHematuriaPyuriaGlycosuriaProteinuria

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

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) (Galloway,1983) Any neurological abnormalities should receive further evaluation

Other Basic Tests Cotton swab test –Demonstrates urethral hypermobility

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

Other Basic Tests Postvoid residual

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

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) ( International Continence Society,2003)

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) (Miklos,1995)

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) (Weidner 2001) (Most consider a negative stress test an indication for further testing) (Most consider a negative stress test an indication for further testing)

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

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 % of patients in his study.

Simple Cystometry

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

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)

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

Empty Supine Test The test is performed by having the patient perform a Valsalva’s maneuver while in the supine position with cc fluid in the bladder. Any leakage is considered a positive test 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

Filling Cystometry First sensation cc First urge to void cc Max capacity cc Compliance -- resting pressure < 8cm No uninhibited pressure rises > 15 cm Any abnormalities are indication for further testing

Summary A thorough, thoughtful evaluation to include a history, physical, voiding diary, and simple urodynamics will enable the physician to understand the pathophysiology of a patient’s symptoms sufficiently to formulate a reasonable course of therapy in most cases. However, the clinician must recognize the findings which will require further evaluation to include multi channel urodynamic testing.