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EVALUATION OF THE IN C ONTINENT WOMAN

This article provides an evaluation of urinary incontinence in women, including definitions, risk factors, diagnosis, and management. It covers various types of urinary incontinence, such as stress, urge, mixed, overflow, functional, and other types.

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EVALUATION OF THE IN C ONTINENT WOMAN

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  1. EVALUATION OF THE INCONTINENT WOMAN Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn

  2. Objectives • To define • incontinence • Tolearn • Risk factorsforincontinence • Diagnosis of thetype of incontinence • Tomanage • An incontinentwoman

  3. Definition • Urinary incontinence is the inability to control urination which results in unintended urinary flow or leakage

  4. Classification of UI • 6 major subtypes of urinary incontinence: • Stress • Urge (“overactive bladder”) • Mixed • Overflow • Functional • Other (deformity/lack of continuity)

  5. Stress 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

  6. Stress 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

  7. Stress incontinence

  8. 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

  9. 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)

  10. Urge incontinence (overactive bladder)

  11. Mixed Incontinence • Refers to patients with both stress incontinence and urge incontinence. • Helpful to identify the most bothersome symptom and treat accordingly

  12. Overflow 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)

  13. Overflow 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

  14. Overflow incontinence

  15. Functional 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

  16. Deformity or Lack of Continuity • Causes: • Vesicovaginal or ureterovaginal fistula, often as complication of hysterectomy or other pelvic surgery • Ectopic ureters • Diverticulae

  17. 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 Pharmacologic Causes

  18. 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 History

  19. Bladder Diary • 24-48 hours • Requires literacy and significant amount of time and work by patient • see sample in handout

  20. Physical 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

  21. 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

  22. Physical Examination • Back examination • may reveal dimpling or a hair tuft at the spinal cord base, suggestive of occult dysraphism

  23. 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.

  24. 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

  25. 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

  26. 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

  27. Q-tip test Sensitivity Specifity

  28. 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 d1Xd2Xd3X0.7 1. Catheter or cystoscope 2. Radiography excretion urography, micturition cystography 3. USG 4. Radioisotopes

  29. Pad Tests • The most useful objective urine loss test in clinical practice • Normal range: < 2 g of urine/h 2-10gr Mild 10-50gr Moderate > 50gr Severe • Pad tests are not recommended in the routine assessment of women with UI RCOG 2006

  30. Urodynamic 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

  31. 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

  32. Treatment: Non-surgical • Fluid management • Reduce caffeine, alcohol, and smoking • Bladder retraining • Pelvic floor exercises • Pessaries • Continence devices

  33. Treatment: Non-surgical • Hormone replacement therapy • Medication to help strengthen the urethra • Medication to help relax the bladder

  34. Non-surgical Treatment: Fluid management • Avoid caffeine and alcohol • Avoid drinking a lot of fluids in the evening

  35. Non-surgical Treatment: Bladder retraining • Regular voiding by the clock • Gradual increase in time between voids • Double voiding

  36. Non-surgical Treatment: Physiotherapy • Pelvic floor exercises • Vaginal cones • Devices for reinforcement

  37. Non-surgical Treatment: Pessaries • Support devices to correct the prolapse • Pessaries to hold up the bladder

  38. Non-surgical Treatment: Hormone replacement • Systemic • Local • Vaginal cream • Vaginal estrogen ring

  39. 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!!!

  40. Surgery in urodynamic stress incontinence Urethral Hypermobility Internal SfynctericDeficiency Burch colposuspension Periurethral injections Tension-free slings

  41. Anti-inkontinans Operasyonlar • Burch kolposuspansiyon • Burch+Paravajinal Defekt Onarımı • Mid uretral sling • Retropubik (TVT) • Transobturator (TOT) • Periuretral enjeksiyonlar

  42. Burch Sutures areas

  43. Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage

  44. Retropubik Midüretral Sling Eksternal iliak Damarlar Mesane Obturator Damar ve sinirler İnferior epigastrik damarlar Obturator Kanal Üretra Minimal İnvaziv Midüretral Sling Operasyonları Retropubik Yöntem

  45. Retropubik (TVT)

  46. Transobturator yöntemde teknik Outside-in (TOT) (Dıştan içe) İnside-out (TVT-O) (İçten dışa)

  47. Transobtrator

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