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Section II: Topics in Gynecology
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Overflow incontinence: leakage associated with significant urinary retention which exceeds the storage capacity of the bladder (usually associated with neurogenic conditions) What type of incontinence do the following symptoms suggest Leakage when coughing/sneezing/ laughing/exercising: stress incontinence Leakage associated with a strong desire to void: urge incontinence Many voids per day: urge or overflow incontinence or possible infection Continual dripping with shifting positions: overflow incontinence or sphincter impairment Nocturia or incontinence associated with intercourse: urge incontinence Painful urination: obstruction, infection, or urge incontinence What are the known risk factors for urinary incontinence What age-related changes contribute to the development of urinary incontinence Childbearing; advanced age; obesity; family history; chronic cough; ascites; pelvic masses 1 The prevalence of detrusor overactivity increases with age 2 Total bladder capacity diminishes 3 Urinary flow rate decreases 4 Postvoiding residual increases 5 The urethral mucosal epithelium becomes atrophic secondary to low estrogen levels No, however the prevalence and severity of incontinence increases with age Thus, patients should be queried regarding the presence of these symptoms Infection should be ruled out when there is any sudden change or onset of incontinence symptoms
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What are the pertinent factors to ask about when taking a history Review of symptoms: how often leakage occurs, what provokes urine loss, how much urine is leaked, what
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6: Urogynecology
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makes the problem better/worse, any prior treatment that has been tried General medical history: systemic illnesses (such as diabetes, vascular insufficiency, chronic pulmonary disease, or any neurologic condition) Past surgical history Current medications What types of medications can sometimes cause urinary incontinence Benzodiazepines; -agonists (OTC cold medications); -antagonists (antihypertensives); calcium channel blockers; ACE inhibitors (by increasing cough); alcohol General examination: look for signs of other medical problems as well as for alertness/functional status Pelvic examination: look for signs of atrophy, infection, fistulae, diverticulum, pelvic organ prolapse Urinalysis: routine urinalysis and culture, urine cytology (in women over 50 with urinary tract irritation or hematuria) Labs: metabolic panel (renal function, glucose, calcium), vitamin B12 (in the elderly), glucose Measurement of postvoid residual urine (especially in high-risk patients) Give out a frequency/volume bladder diary for the patient to record her symptoms What are normal values for the following Daily urine output: Average void volume: Functional bladder capacity: Voids per day: Is routine urodynamic testing indicated in the evaluation of urinary incontinence 1500 2500 mL 250 mL 400 600 mL 7 8 times No While it is the gold standard, it is not always necessary to make the diagnosis It should be considered if empiric therapy has failed or prior to any surgical intervention
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Section II: Topics in Gynecology
Describe the following urodynamic tests:
Multichannel urodynamic testing: produces a biophysical profile of the patient s bladder and urethra Used for patients with mixed incontinence, prior bladder surgeries, or suspected intrinsic sphincter deficiency Cystometry: measures the pressurevolume relationship of the bladder Filling cystometry measures bladder pressure during filling; fluid is infused while pressure is continually monitored The point of urgency, point of leakage, and total capacity are recorded Voiding cystometry (also known as pressure-flow study) measures the urine flow rate and correlates it with the detrusor pressure Urethral pressure profile: measures urethral closure and sphincteric integrity
During a bladder filling test, what type of incontinence does a woman have if: She feels urinary urgency and involuntary voiding upon filling Urge incontinence
She leaks small amounts upon coughing Stress incontinence
STRESS INCONTINENCE
What are the typical symptoms of stress incontinence Leakage of a small amount of urine with any activity that increases intraabdominal pressure (coughing, sneezing, laughing, etc) 20 30% of women complain of stress incontinence It is the most common type of urinary incontinence in younger women and the second most common cause of incontinence in older women With weakening of the pelvic muscles and endofascia, urethral support is impaired With rising intra-abdominal pressure (because of sneezing, coughing, or exercise), the intravesicular pressure rises higher
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