evaluation of the incontinent woman assoc. prof. gazi yildirim, m.d. yeditepe university, medical...
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EVALUATION OF THE INCONTINENT WOMAN
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty Dept of Ob&Gyn
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• To define– incontinence
• To learn– Risk factors for incontinence– Diagnosis of the type of incontinence
• To manage – An incontinent woman
Objectives
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DefinitionDefinition
• Urinary incontinence is the inability to control urination which results in unintended urinary flow or leakage
• Urinary incontinence is the inability to control urination which results in unintended urinary flow or leakage
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Classification of UIClassification of UI
• 6 major subtypes of urinary incontinence:
– Stress
– Urge (“overactive bladder”)
– Mixed
– Overflow
– Functional
– Other (deformity/lack of continuity)
• 6 major subtypes of urinary incontinence:
– Stress
– Urge (“overactive bladder”)
– Mixed
– Overflow
– Functional
– Other (deformity/lack of continuity)
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Stress incontinenceStress incontinence
• Signs & Symptoms: – urine leakage triggered by coughing,
sneezing, laughing, lifting, exercising, straining
– usually worse standing than supine– small to moderate volumes of urine– infrequent nocturnal leakage– little post-void residual
• Signs & Symptoms: – urine leakage triggered by coughing,
sneezing, laughing, lifting, exercising, straining
– usually worse standing than supine– small to moderate volumes of urine– infrequent nocturnal leakage– little post-void residual
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Stress incontinenceStress incontinence
• Causes: – urethral hypermobility due to pelvic floor laxity
– aging– difficult or multiple vaginal deliveries– hysterectomy – other perineal injury (e.g. radiation)
– intrinsic urethral sphincter deficiency – autonomic neuropathy– inadequate estrogen levels – partial denervation
• Causes: – urethral hypermobility due to pelvic floor laxity
– aging– difficult or multiple vaginal deliveries– hysterectomy – other perineal injury (e.g. radiation)
– intrinsic urethral sphincter deficiency – autonomic neuropathy– inadequate estrogen levels – partial denervation
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Stress incontinenceStress incontinence
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Urge incontinence (overactive bladder, detrusor instability)
Urge incontinence (overactive bladder, detrusor instability)
• Symptoms: – Frequent abrupt, intense urge to urinate that cannot
be voluntarily suppressed– moderate to large volumes of urine– nocturnal wetting– perineal sensation intact
• Symptoms: – Frequent abrupt, intense urge to urinate that cannot
be voluntarily suppressed– moderate to large volumes of urine– nocturnal wetting– perineal sensation intact
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Urge incontinence (overactive bladder, detrusor instabiliy)
Urge incontinence (overactive bladder, detrusor instabiliy)
• Cause: – Inappropriate contraction of detrusor muscle during
bladder filling– idiopathic– related to aging (unclear mechanism)– decreased cortical inhibition (CVA, Parkinson’s disease,
Alzheimer’s disease, brain tumor)– bladder irritation (UTI, bladder CA, stones)
• Cause: – Inappropriate contraction of detrusor muscle during
bladder filling– idiopathic– related to aging (unclear mechanism)– decreased cortical inhibition (CVA, Parkinson’s disease,
Alzheimer’s disease, brain tumor)– bladder irritation (UTI, bladder CA, stones)
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Urge incontinence (overactive bladder)Urge incontinence (overactive bladder)
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Mixed IncontinenceMixed Incontinence
• Refers to patients with both stress incontinence and urge incontinence.
• Helpful to identify the most bothersome symptom and treat accordingly
• Refers to patients with both stress incontinence and urge incontinence.
• Helpful to identify the most bothersome symptom and treat accordingly
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Overflow incontinenceOverflow incontinence
• Signs & Symptoms: – Frequent voiding/dribbling (worse after fluid load or diuretic)– small volumes– without warning– slow or weak flow– incomplete bladder emptying– feel need to strain– nocturnal wetting
• Bladder hypotonic/flaccid and palpably distended • Large post-void residual (PVR)
• Signs & Symptoms: – Frequent voiding/dribbling (worse after fluid load or diuretic)– small volumes– without warning– slow or weak flow– incomplete bladder emptying– feel need to strain– nocturnal wetting
• Bladder hypotonic/flaccid and palpably distended • Large post-void residual (PVR)
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Overflow incontinenceOverflow incontinence
• Causes:– long-standing outlet obstruction
– detrusor chronically overstretched– detrusor insufficiency
– lower motor neuron damage due to peripheral neuropathy or sacral cord injury
– impaired sensation – peripheral neuropathy, Vit B12 deficiency, SCI
– medications that reduce detrusor tone – anticholinergics, antidepressants, antipsychotics, anti-
Parkinsonians, narcotics, Ca-channel blockers, vincristine
• Causes:– long-standing outlet obstruction
– detrusor chronically overstretched– detrusor insufficiency
– lower motor neuron damage due to peripheral neuropathy or sacral cord injury
– impaired sensation – peripheral neuropathy, Vit B12 deficiency, SCI
– medications that reduce detrusor tone – anticholinergics, antidepressants, antipsychotics, anti-
Parkinsonians, narcotics, Ca-channel blockers, vincristine
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Overflow incontinenceOverflow incontinence
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Functional IncontinenceFunctional Incontinence
• Inability to void independently due to impairment of physical and/or cognitive function
– disabling illness, bedridden– frontal lobe dysfunction, lack of awareness– deliberate incontinence (rare)
• Patient may have other types of incontinence that are amenable to treatment
• Pure functional incontinence should be a diagnosis of exclusion
• Inability to void independently due to impairment of physical and/or cognitive function
– disabling illness, bedridden– frontal lobe dysfunction, lack of awareness– deliberate incontinence (rare)
• Patient may have other types of incontinence that are amenable to treatment
• Pure functional incontinence should be a diagnosis of exclusion
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Deformity or Lack of ContinuityDeformity or Lack of Continuity
• Causes:– Vesicovaginal or ureterovaginal fistula, often
as complication of hysterectomy or other pelvic surgery
– Ectopic ureters– Diverticulae
• Causes:– Vesicovaginal or ureterovaginal fistula, often
as complication of hysterectomy or other pelvic surgery
– Ectopic ureters– Diverticulae
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Pharmacologic Causes
• sedatives
• loop diuretics
• alcohol
• caffeine
• cholinergics (donepezil)
awareness, detrusor activity Func & O UI
• Diuresis overwhelms bladder capacity Urge & O UI
• Polyuria, awareness Urge & Functional UI
• Polyuria, detrusor activity Urge
• detrusor activity Urge Culligan PJ Urinary Incontinence in women
Evaluation and Management AFP 12-1-01
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HistoryHistory
• Identify contributing medical factors – DM– CVA– Lumbar disc disease– Chronic lung disease– fecal impaction– cognitive impairment
• Identify contributing medical factors – DM– CVA– Lumbar disc disease– Chronic lung disease– fecal impaction– cognitive impairment
• OB/Gyn Hx– gravity/parity– # of vaginal, instrument
assisted and C/S deliveries– interval between deliveries– previous hysterectomy,
vaginal and/or bladder surg– pelvic RT– trauma– estrogen status
• OB/Gyn Hx– gravity/parity– # of vaginal, instrument
assisted and C/S deliveries– interval between deliveries– previous hysterectomy,
vaginal and/or bladder surg– pelvic RT– trauma– estrogen status
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Bladder DiaryBladder Diary
• 24-48 hours
• Requires literacy and significant amount of time and work by patient
• see sample in handout
• 24-48 hours
• Requires literacy and significant amount of time and work by patient
• see sample in handout
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Physical ExamPhysical Exam
• If screen (+) for UI:
• Have pt void as normally and completely as possible immediately before exam
• Record volume voided
• Determine PVR within 10 minutes by catheterization (send urine for UA & Cx)
• PVR > 100ml considered abnormal
• If screen (+) for UI:
• Have pt void as normally and completely as possible immediately before exam
• Record volume voided
• Determine PVR within 10 minutes by catheterization (send urine for UA & Cx)
• PVR > 100ml considered abnormal
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Physical Examination
• General examination
• Neck examination (cervical spondylosis)
– should investigate limitations in cervical lateral rotation and lateral flexion,
– interosseous muscle wasting, – Babinski reflex +
interruption of inhibitory tracts to the detrusor
detrusor overactivity
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Physical Examination
• Back examination – may reveal dimpling or a
hair tuft at the spinal cord base, suggestive of occult dysraphism
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Physical Examination
• Cardiovascular examination should look for evidence of volume overload.
• Abdomen should be palpated for masses, tenderness, and bladder distention.
• Extremities should be examined for joint mobility and function.
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Physical Examination
• Genital examination – Inspection of the vaginal mucosa
(atrophy, narrowing of the introitus by posterior synechia, vault stenosis, and inflammation)
– A bimanual examination (masses or tenderness)
– Pelvic floor muscle strength
• Rectal examination – Masses and fecal impaction
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Pelvic-floor muscle assessment International Continence Society
1—no response, cannot perceive
2—weak squeeze, felt as a flick
3—moderate squeeze, felt all around finger
4—strong squeeze, full fingers compressed
Messelink EJ et al Neurourol Urodynam 2005;24:374–80
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Physical Examination
• Neurologic examination – Sacral root integrity
• perineal sensation, • tone of the anal sphincter• the bulbocavernosus reflex
– Cognitive status,– Motor strength and tone,– Peripheral sensation for
peripheral neuropathy
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Q-tip test
Sensitivity Specifity
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Postvoid Residual Measurement
• Rules out urinary retention• Poor test-retest reliability (limited
use)• PVR < 100 cc normal
> 200 cc abnormally
100-200 cc borderline → further investigation
1. Catheter or cystoscope2. Radiography
excretion urography, micturition cystography
3. USG4. Radioisotopes
d1Xd2Xd3X0.7
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Pad Tests
• The most useful objective urine loss test in clinical practice
• Normal range: < 2 g of urine/h2-10gr Mild10-50gr Moderate> 50gr Severe
• Pad tests are not recommended in the routine assessment of women with UI
RCOG 2006
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Urodynamic testingUrodynamic testing
• PVR: simple test for overflow incontinence• Cystometry: dx of complicated mixed conditions
– Normal: sense filling between 100-200ml
– non-urgent desire to void at 250-350ml– detrusor contraction at 400-550ml
• Uroflowmetry: info on outflow obstruction• Cystoscopy: detects structural abnormalities,
inflammation, masses• IVP: detects structural abnormalities, urethral narrowing,
incomplete bladder emptying
• PVR: simple test for overflow incontinence• Cystometry: dx of complicated mixed conditions
– Normal: sense filling between 100-200ml
– non-urgent desire to void at 250-350ml– detrusor contraction at 400-550ml
• Uroflowmetry: info on outflow obstruction• Cystoscopy: detects structural abnormalities,
inflammation, masses• IVP: detects structural abnormalities, urethral narrowing,
incomplete bladder emptying
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Endoscopy
• provide unique anatomical information with a simple, minimally invasive approach
• adjunct to multichannel urodynamics in women with possible ISD, urethral diverticula, urogenital fistulae, foreign bodies or urothelial lesions
• Cystoscopy is not recommended in the initial assessment of women with UI alone
RCOG 2006
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Treatment:
Non-surgical Fluid management Reduce caffeine, alcohol, and smoking Bladder retraining Pelvic floor exercises Pessaries Continence devices
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Treatment:
Non-surgical Hormone replacement therapy Medication to help strengthen the urethra Medication to help relax the bladder
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Non-surgical Treatment:
Fluid management
Avoid caffeine and alcohol Avoid drinking a lot of fluids in the evening
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Non-surgical Treatment:
Bladder retraining Regular voiding by the clock Gradual increase in time between voids Double voiding
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Non-surgical Treatment:
Physiotherapy Pelvic floor exercises Vaginal cones Devices for reinforcement
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Non-surgical Treatment:
Pessaries Support devices to correct the prolapse Pessaries to hold up the bladder
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Non-surgical Treatment:
Hormone replacement Systemic Local Vaginal cream Vaginal estrogen ring
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Anticholinergic Drugs (Urge UI)
• Oxybutynin• Tolterodine• Trospium• Darifenacin• Variety of preparations: Immediate Release;
Extended Release; Transdermal• Outcomes same; Try different agent if one
doesn’t work***** ALL these drugs suppress the detrusor contractility and MAY CAUSE
URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO PRESCRIBING!!!
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Urethral Hypermobility Internal Sfyncteric Deficiency
Burch colposuspension Tension-free slings
Periurethral injections
Surgery in urodynamic stress incontinence
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Anti-inkontinans Operasyonlar
• Burch kolposuspansiyon– Burch+Paravajinal Defekt Onarımı
• Mid uretral sling– Retropubik (TVT)– Transobturator (TOT)
• Periuretral enjeksiyonlar
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Burch Sutures areas
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Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage
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Obturator Kanal
Üretra
Mesane
Retropubik Midüretral Sling
Minimal İnvaziv Midüretral Sling OperasyonlarıRetropubik Yöntem
Obturator Damar ve sinirlerİnferior epigastrik
damarlar
Eksternal iliakDamarlar
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Retropubik (TVT)
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Outside-in (TOT)(Dıştan içe)
Transobturator yöntemde teknik
İnside-out (TVT-O)(İçten dışa)
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Transobtrator