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Women's Health Foundation is a non-profit 501(c)(3) educational and support organization for females with health problems. Read the article Causes
and Types of Urinary Incontinence
Physical examination The physical examination is a basic evaluation required for all incontinent patients. It includes:
Additional tests Estimation of PVR volume This test is recommended for all patients with UI either by catheterization or by pelvic ultrasound, in general, a PVR less than 50 mL is considered adequate bladder emptying and over 200 mL is considered inadequate emptying. Provocative stress testing If stress UI is suspected, provocative stress testing (direct visualization) can be performed by having the individual relax and then cough vigorously while the examiner observes for urine loss from the urethra. Optimally, these tests should be done when the patient's bladder is full. They can be done in the standing or lithotomy position. If an instantaneous leakage occurs with cough, then stress UI is likely; if leakage is delayed or persists after the cough, detrusor overactivity should be suspected. Urinalysis This is a basic test required for UI to detect associated or contributing conditions such as hematuria (suggestive of infection, cancer, or stone), pyuria, and bacteriuria, as well as glycosuria and proteinuria. Dipstick (enzymatic) testing of urine is an acceptable screening technique of urinalysis. Microscopic evaluation of the urinary sediment may also be used during the initial assessment. A specimen may be sent for culture. Supplementary assessments Use of a voiding record (diary) These written records may be used to determine the frequency, timing, amount of voiding, and other factors associated with UI. These records can be kept by the patient or a caregiver for a few days prior to the basic evaluation. Such a record may provide clues as to the underlying cause of UI and can serve as a baseline to gauge severity and treatment. Evaluation of environmental and social factors With frail or functionally impaired individuals, especially the elderly, environmental and social factors must be considered. Environmental factors include access to toilets or toilet substitutes. Social factors include living arrangements, social contacts, or caregiver involvement. Observation of voiding This is done to detect signs of hesitancy or straining and slow or interrupted stream and is especially useful if urethral obstruction or a bladder emptying problem is suspected. Determining the ability to interrupt the urinary stream is also useful if pelvic muscle exercises will be prescribed. Blood tests Tests should be done for blood urea nitrogen (BUN) and creatinine levels in patients suspected of having obstruction or noncompliant bladders and in those with urinary retention. However, normal BUN and creatinine levels do not rule out hydronephrosis. Patients with polyuria in the absence of diuretic agents should be evaluated for excess intake, hyperglycemia, and hypercalcemia if indicated. Urine cytology Urine cytology should be done to screen for malignancy in patients with hematuria or the recent onset of irritative voiding symptoms in the absence of UTI. If UI persists after the transient causes are identified and managed, further evaluation may be helpful before therapy is initiated. Patients who may not need such testing are those with simple stress UI, those with urge UI with low PVR volume and no complicating features. Patients requiring further evaluation include those who meet one of the following criteria:
Specialized Tests Numerous specialized diagnostic tests are available, and the evaluation must be tailored to the question to be answered. Specialized tests include the following:
Urodynamic tests Urodynamic evaluations have increasingly become an important part of the evaluation of voiding dysfunctions. Urodynamics gives an accurate evaluation of voiding problems, allowing for a clearer diagnosis. This leads to appropriate treatment or management of the patients voiding dysfunction.These tests are designed to determine the anatomic and functional status of the urinary bladder and urethra. Uroflowmetry measures the urine flow rate visually, electronically, or with the use of a disposable unit. An electronically generated flow curve is considered helpful in identifying abnormal voiding patterns. Cystometry is a test of detrusor function. Depending on the technique used, cystometry can assess bladder sensation, capacity, and compliance, and it can determine the presence and magnitude of both voluntary and involuntary detrusor contractions. It is important to reproduce the patient's symptoms at the time of cystometry, since involuntary detrusor contractions may be observed in asymptomatic patients. On the other hand, cystometry may be falsely negative in a patient with a genuinely overactive bladder because of psychological inhibition of reflex activity or lack of measurable increase of detrusor pressure, which may be dissipated by poor urethral resistance and therefore must be examined closely. Simple cystometry is performed by filling the bladder via a urethral catheter to capacity or until an involuntary detrusor contraction occurs. A filling cystometrogram (CMG) with simultaneous measurement of intra-abdominal pressure is a more accurate technique, since it will differentiate an involuntary detrusor contraction from an increase of intra-abdominal pressure. A voiding CMG or pressure flow study can measure detrusor contractility and detect outlet obstruction if the patient is able to void. Another use of a filling CMG is to determine leak point pressure in patients with stress UI; intravesical pressure is measured at the moment of fluid leakage during straining or Valsalva maneuver. Urethral pressure profilometry (UPP) UPP measures resting and dynamic pressures in the urethra. Videourodynamics is a technique that combines the various urodynamic tests with simultaneous fluoroscopy. It is helpful in sorting out causes of complex incontinence problems and can identify detrusor overactivity, detrusor sphincter dyssynergia, intrinsic urethral defects, outlet obstruction, and detrusor contractility problems including DHIC. Electromyography (EMG) of the striated urethral sphincter measures the integrity and function of its innervation. Both needle and surface EMG, in conjunction with CMG, are helpful in diagnosing detrusor sphincter dyssynergia. Endoscopic test Cystourethroscopy. This procedure may help in identifying bladder lesions and foreign bodies, as well as urethral diverticula, fistula, strictures, or ISD. Imaging tests Upper tract imaging is not a routine test to evaluate UI. Ultrasound of the kidneys and/or bladder can help identify dilation of the upper urinary tract and renal pathology, especially in patients with urinary retention, abnormal renal function, or poorly compliant bladders. Excretory urography or other imaging modalities are indicated for patients with hematuria or for further evaluation of upper tract obstruction or other pathology identified by ultrasound . Lower tract imaging with and without voiding is helpful in examining the anatomy of the urinary bladder and urethra. The voiding component can identify a urethral diverticulum, obstruction, and vesicoureteral reflux. Treatment of Urinary Incontinence The three major categories of treatment are:
As a general rule, the least invasive and least dangerous procedure that is appropriate for the patient should be the first choice. For many forms of UI, behavioral techniques meet these criteria. However, an informed patient's preference must be respected. Behavioral Techniques Behavioral techniques include:
Additional techniques that may be used in conjunction with these behavioral methods include:
All behavioral techniques involve educating the patient and providing positive reinforcement for effort and progress. These techniques should be offered to cooperative individuals who wish to avoid dependence on protective garments, external devices, medications, and/or more invasive procedures. Behavioral techniques have no reported side effects and do not limit future options. Behavioral techniques can increase patient understanding of lower urinary tract function and the environmental factors affecting symptoms. These techniques can improve control of detrusor and pelvic muscle function. If motivated, most people treated with behavioral techniques show improvement ranging from complete dryness to important reductions of wetness. Improved bladder control can even occur in the cognitively impaired individual. Behavioral techniques can be used in combination with other therapies for UI. Bladder Training Bladder training (also termed bladder retraining) has many variations but generally consists of three primary components:
The education program usually combines a written, visual, and verbal instruction package that addresses the physiology and pathophysiology of the lower urinary tract. The voiding schedule incorporates a progressively increased interval between mandatory voidings with concomitant distraction or relaxation techniques. The person is taught to delay voiding consciously. If the patient is unable to delay voiding between schedules, one approach is to adjust this schedule and start the timing from the last void. Another option is to keep the prearranged schedule and disregard the unscheduled void between schedules. Positive reinforcement is provided. A bladder retraining program requires the participant to resist or inhibit the sensation of urgency, to postpone voiding, and to urinate according to a timetable rather than according to the urge to void. This form of training has been used to manage UI due to bladder instability. Habit Training Habit training or timed voiding is scheduled toileting on a planned basis. The goal is to keep the person dry by telling them to void at regular intervals. Attempts are made to match the voiding intervals to the person's natural voiding schedule. Unlike bladder retraining, there is no systematic effort to motivate the patient to delay voiding and resist urge. Prompted Voiding Prompted voiding has been shown to be effective in dependent or cognitively impaired nursing home incontinent. As a supplement to habit training, prompted voiding attempts to teach the incontinent person to discriminate their incontinence status and to request toileting assistance from caregivers. There are three major elements to prompted voiding: Monitoring. The person is checked by caregivers on a regular basis and asked to report verbally if wet or dry. Prompting. The person is asked (prompted) to try to use the toilet. Praising. The person is praised for maintaining continence and for attempting to toilet. Pelvic Muscle Exercises Pelvic muscle exercises, also called Kegel exercises, improve urethral resistance through active exercise of the pubococcygeus muscle. The exercises strengthen the voluntary periurethral and pelvic muscles. The contraction exerts a closing force on the urethra and increases muscle support to the pelvic visceral structures. The first step in pelvic muscle re-education is to establish better awareness of pelvic muscle function. These exercises can be performed by drawing in the perivaginal muscles and anal sphincter as if to control urination or defecation but without contracting abdominal, buttock, or inner thigh Emphasis is placed on sustaining contractions for a period of up to 10 seconds followed by an equal period of relaxation These exercises should be performed about 30-80 times a day for at least 6 weeks and may need to be continued indefinitely. Biofeedback of performance is useful in teaching pelvic muscle exercise because it reinforces the patient's ability to discriminate muscle contraction. Vaginal Cones The use of vaginal cones may serve as an adjunct to pelvic muscle training in women. The patient receives a set of cones that are of identical shape and volume but of increasing weight. As part of a structured exercise program, women insert the weighted cone intravaginally with the tapered portion resting on the superior surface of the perineal muscle and attempt to retain it by contracting the pelvic muscles for up to 15 minutes. This is done twice daily. The sustained contraction required to retain the cone increases the strength of the pelvic muscles, and the weight of the cone is assumed to provide heightened proprioceptive feedback to desired pelvic muscle contraction. Biofeedback Biofeedback uses electronic or mechanical instruments to relay information to patients about their physiologic activity. It aims to alter bladder dysfunction by teaching people to change physiologic responses that mediate bladder control. Display of this information, through auditory or visual displays, forms the core of biofeedback procedures. Measures used for biofeedback include EMG and manometric indices of pelvic and abdominal muscle activity and manometric measures of detrusor activity. Pharmacologic Treatment of Incontinence Drugs for Incontinence due to Detrusor Overactivity: Urge Incontinence There is little consensus regarding the correlation between symptomatic and urodynamic response of detrusor overactivity to medication. In general, all active medications used to treat storage disorders increase bladder capacity and, to a lesser degree, residual urine. Propantheline Anticholinergic agents block contraction of the normal bladder and probably the unstable bladder as well. The prototype of anticholinergic agents used for urologic conditions is propantheline. Although its central nervous system side effects are less marked, no agent better approximates atropine's effect on the bladder in vitro. Moreover, propantheline is inexpensive and has been widely used over time. All anticholinergic drugs are contraindicated in patients with narrow-angle but not wide-angle glaucoma. Recommended dose is 15-30 mg taken orally three times/day. Oxybutynin Oxybutynin has both anticholinergic and direct smooth muscle relaxant properties. The recommended dose is 2.5-5 mg taken orally three to four times/day. Calcium channel blocking agents Influx of extracellular calcium is important for detrusor muscle contraction and can be blocked by calcium channel antagonists. No controlled studies could be found for nifedipine, diltiazem, or verapamil. Terodiline In vitro, terodiline has both anticholinergic and calcium channel blocking activity. Recent reports of its association with serious ventricular arrhythmia have resulted in its temporary withdrawal from the European market and may prevent its Food and Drug Administration approval. Tricyclic agents Although tricyclic agents are widely used. In older patients, these agents also have been associated with an increased risk of falling and hip fracture. Imipramine and doxepin are recommended. The usual oral doses are 10-25 mg initially administered one to three times/d, but less frequent administration is usually possible because of the drug's long half-life; the daily total dose is usually 25-100 mg. Flavoxate Flavoxate is a tertiary amine that has been demonstrated in vitro to have smooth muscle relaxant properties. Flavoxate is widely used for incontinence. Dicyclomine hydrochloride Dicyclomine is an anticholinergic agent with smooth muscle relaxant properties. Clinical experience suggests that it is as effective as other anticholinergic agents in controlling detrusor overactivity. It is therefore recommended as an alternative to other acceptable anticholinergic agents. The dose is 10-20 mg taken orally three times daily. Other drugs of possible benefit Other drugs used for detrusor overactivity include nonsteroidal anti- inflammatory drugs, a beta- adrenergic agonist (terbutaline), a spinal synaptic inhibitor (baclofen), a quaternary ammonium antimuscarinic agent (fentonium bromide), and procaine hematoporphyrin. Limited studies and clinical experience with these agents suggest that further studies must be done before they can be recommended for general use. Drugs for Incontinence due to Urethral Sphincter Insufficiency: Stress Incontinence The effectiveness of pharmacologic therapy for UI due to urethral sphincter insufficiency (stress UI) is based on the high concentration of alpha-adrenergic receptors in the bladder neck, bladder base, and proximal urethra. Sympathomimetic drugs with alpha-adrenergic agonist activity presumably cause muscle contraction in these areas and thereby increase bladder outlet resistance. Pharmacotherapeutic strategies designed to increase bladder outlet resistance include the use of drugs with direct alpha-adrenergic agonist activity, estrogen supplementation for both direct effect on urethral mucosal and periurethral tissues and enhancement of alpha-adrenergic response, and beta-adrenergic blocking drugs which might allow unopposed stimulation of alpha receptor-mediated contractile muscle responses. Alpha-adrenergic agonist drugs Phenylpropanolamine Phenylpropanolamine in sustained release form is the major alpha- adrenergic agonist drug studied in women with stress incontinence. Side effects from adrenergic agonist drugs include anxiety, insomnia, agitation, respiratory difficulty, headache, sweating, hypertension, and cardiac arrhythmias, all of which may occur more commonly in elderly patients. The risk of PPA use in hypertensive women and its efficacy in women taking antihypertensive drugs have not been determined. Phenylpropanolamine should be used with caution in patients with hypertension, hyperthyroidism, cardiac arrhythmias, and angina. The recommended dose for PPA is 25-75 mg in sustained release form, administered orally, twice daily. Estrogen therapy Because the vagina and urethra are of similar embryologic origin, estrogen supplementation in postmenopausal women may restore urethral mucosal coaptation and increase vascularity, tone, and the alpha- adrenergic responsiveness of urethral muscle, which in turn may increase bladder outlet resistance and decrease stress incontinence. Evidence suggests that estrogen therapy by oral or vaginal administration may benefit some patients with stress UI but may be more beneficial in ameliorating the symptoms of urge UI. Other beneficial effects of long-term estrogen may include decreased risk of stroke, ischemic heart disease, and osteoporosis. Estrogen replacement should be given with a progestin when the uterus is present to avoid unopposed estrogen stimulation of the endometrium, particularly if prolonged therapy is anticipated. It is contraindicated in patients with known or suspected cancer of the breast, cervix, or uterus, as well as in patients with active thrombophlebitis or thromboembolic disorders. Surgical Treatment of Urinary Incontinence Surgical treatment of UI should be performed only after a precise, focused assessment, which requires a comprehensive clinical evaluation including estimation of surgical risk, an objective confirmation of the diagnosis and its severity, a correlation of anatomic and physiologic findings with the surgical plan, and an estimation of the impact of the proposed surgery on the patient's quality of life. Female Incontinence due to Urethral Hypermobility and Intrinsic Sphincter Deficiency The surgical objective in cases of hypermobility is to restore the sphincter unit to an appropriate retropubic position without obstruction, whereas the goal of surgery for ISD is to increase urethral coaptation and resistance. Although many operations result in both reposition and compression of the proximal urethra, a primarily repositional procedure is less likely to succeed for a patient with ISD than for a patient with only hypermobility. Procedures for hypermobility After complete evaluation, the proper surgical procedure is selected according to certain general principles. If the primary pathophysiologic defect appears to be urethral hypermobility or displacement, three main types of procedures are used:
Retropubic and needle suspension procedures produce a superior result to that of the anterior repair in "curing" UI and, therefore, are the two preferred techniques for the surgical treatment of urethral hypermobility. The option selected depends on the surgeon's training and expertise and on the presence of concurrent pathology that would require correction by a vaginal or abdominal approach. If ISD is present, the surgical procedure should be one with compressive effects: sling (abdominal or vaginal approach), periurethral bulking injection, or artificial sphincter. The choice must be individualized for each patient. Women who have severely damaged urethras require special procedures such as urethral or bladder neck reconstruction, urethral substitution, continent vesicotomy, or urinary diversion. Anterior vaginal repair The anterior vaginal repair category of treatments includes several modifications of the original Kelly plication. They all include some degree of dissection of the anterior vaginal wall from the overlying bladder base and urethra and plication of the pubocervical fascia. Retropubic suspension The category of retropubic suspension procedures also includes several different techniques performed through a low abdominal incision (retropubic approach). They all have in common elevation of the lower urinary tract (particularly the urethrovesical junction) within the retropubic space. They differ according to which structures are used to achieve the elevation. For the Marshall-Marchetti-Krantz procedure, the periurethral tissue is approximated to the symphysis pubis. For the Burch colposuspension, the vaginal wall lateral to the urethra and bladder neck is elevated toward Cooper's ligament. The paravaginal repair involves reapproximating the endopelvic fascia to the obturator shelf. Total "cure" rates average 78 percent, with additional improvement of 5 percent. Complication rates average 18 percent. Needle bladder neck suspension The third type of anatomic correction employs needle suspension of the bladder neck. Variations of this procedure are all performed through a vaginal approach, and most utilize small suprapubic skin incisions. Anchoring tissues adjacent to the urethra and bladder neck are held by suspending sutures. Complications included UTI, urinary retention longer than 3 weeks' duration, obstructive symptoms, suture abscess, wound infection or vaginal granuloma, vesicocutaneous fistula, hematoma, sepsis, new onset of symptomatic detrusor instability, and prolonged suprapubic pain. Procedures for intrinsic sphincter deficiency Surgical procedures for management of ISD include:
Sling procedures The various sling procedures all involve the placement of a sling, made of either autologous or heterologous material, under the urethrovesical junction and anchoring it to retropubic and/or abdominal structures. The operation can be performed through an abdominal approach, a vaginal approach, or a combined abdominal and vaginal approach. Artificial sphincter The artificial sphincter has also been used for females with ISD. Complications included fluid leak, loose cuff, erosion or atrophy of cuff site, tubing kink, and infection. Periurethral injections Periurethral bulking injections also have been described in the section about male urethral abnormalities. In women, these injections are easily performed under local anesthesia. Other Measures and Supportive Devices Other measures and supportive devices used in the management of UI include:
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