Urinary incontinence

Dr. Shameem R. ALaasam

Investigations
Midstream urine specimen

Urinary infection can produce a variety of urinary symptoms, including

incontinence.
Urinary diary

• A urinary diary is a simple record of the patient’s fluid intake and output .
• Episodes of urgency and leakage and precipitating events are also
recorded.
• There is no recommended period for diary keeping; a suggested practice
is 3–5 consecutive days.
• These diaries are more accurate than patient recall and provide an
assessment of functional bladder capacity.
• In addition to altering fluid intake, urinary diaries can be utilized to
monitor conservative treatment, e.g. bladder re-education, electrical
stimulation and drug therapy.
Urinary diary (W, wet episode).
Pad test
• Pad tests are used to verify and quantify urine loss.
• pad test takes 1 hour.
• The patient wears a pre-weighed sanitary towel, drinks 500 mL of
water and rests for 15 minutes.
• After a series of defined manoeuvres, the pad is reweighed; a urine
loss of more than 1 g is considered significant.
stress test
• A stress test is performed by filling the bladder with up to 300 mL of
normal saline or sterile water through a catheter.
• The patient is asked to cough, and the clinician observes to verify the
loss of urine.
• This can be done standing or in the lithotomy position.
• If urine leakage is witnessed by the clinician, the patient is then said
to have genuine stress incontinence.
postvoid residual
• A postvoid residual (PVR) is obtained by catheterization of the bladder
after voiding.
• This specimen can then be used to rule out urinary retention and
infection.
• An alternative is to measure the postvoid residual with an ultrasound
bladder scanner.
• The upper limits of a normal postvoid residual have been reported as
50 to 100 mL.
cotton swab test
• The purpose of the cotton swab test is to diagnose a hypermobile
urethra associated with stress incontinence.
• The clinician inserts a lubricated cotton swab into the urethra to the
angle of the urethrovesical junction . When the patient strains as if
urinating, the urethrovesical junction descends and the cotton swab
moves upward.
• The change in cotton swab angle is normally less than 30 degrees ,
and a value of greater than 30 degrees is consistent with a
hypermobile urethra
Uroflowmetry
• Uroflowmetry is the measurement of urine flow rate , it is a simple,
non-invasive procedure that can be performed in the outpatient
department . It provides an objective measurement of voiding
function and the patient can void in privacy.
• Although uroflowmetry is performed as part of a general urodynamic
assessment, the main indications are complaints of hesitancy or
difficulty voiding in patients with neuropathy or a past history of
urinary retention. It is also indicated prior to bladder neck or radical
pelvic cancer surgery to exclude voiding problems that may
deteriorate afterwards.
• The normal flow curve is bell shaped.
• A flow rate <15 mL/second on more than one occasion is considered
abnormal in females.
• The voided volume should be >150 mL, as flow rates with smaller volumes
are not reliable.
• A low peak flow rate and a prolonged voiding time suggest a voiding disorder.
• Straining can give abnormal flow patterns with interrupted flow.
• Uroflowmetry alone cannot diagnose the cause of impaired voiding;
simultaneous measurement of voiding pressure allows a more detailed
assessment.
Normal uroflowmetry.
Cystometry

• Cystometry involves the measurement of the pressure–volume

relationship of the bladder.
• It is still considered the most fundamental investigation.
• It involves simultaneous abdominal pressure recording in addition to
intravesical pressure monitoring during bladder filling and voiding.
• Electronic subtraction of abdominal from intravesical pressure
enables determination of the detrusor pressure
The following are parameters of normal bladder function:
• Residual urine of <50 mL.
• First desire to void between 150 and 200 mL.
• Capacity between 400 and 600 mL.
• Detrusor pressure rise of <15 cmH2 O during filling and standing.
• Absence of systolic detrusor contractions.
• No leakage on coughing.
• A voiding detrusor pressure rise of <70 cmH2 O with a peak flow rate
of >15 mL/second for a 2 volume >150 mL.
• Detrusor overactivity is diagnosed when spontaneous or provoked
detrusor contractions occur which the patient cannot suppress.
• Systolic detrusor overactivity is shown by phasic contractions,
whereas low compliance detrusor instability is diagnosed when the
pressure rise during filling is >15 cmH2O and does not settle when
filling ceases.
• Urodynamic stress incontinence is diagnosed if leakage occurs as a
result of coughing in the absence of a rise in detrusor pressure.
Videocystourethrography

• If a radio-opaque filling medium is used

during cystometry, the lower urinary tract
can be visualized by x-ray screening with
an image intensifier
• During voiding, vesicoureteric reflux,
trabeculation and bladder and urethral
diverticulae can be noted
Intravenous urography

• This investigation provides little information about the lower urinary tract, but
is indicated in cases of haematuria, neuropathic bladder and suspected
ureterovaginal fistula.

Ultrasound
Ultrasound is becoming more widely used in urogynaecology. Post-micturition
urine residual estimation can be performed without the need for urethral
catheterization and the associated risk of infection.
This is useful in the investigation of patients with voiding difficulties, either
idiopathic or following postoperative catheter removal.
Urethral cysts and diverticula can also be examined using this technique.
Magnetic resonance imaging

• Magnetic resonance imaging (MRI) produces accurate anatomical

pictures of the pelvic floor and lower urinary tract and has been used
to demarcate compartmental prolapse.
Cystourethroscopy

Cystourethroscopy establishes the presence of disease in the urethra or

bladder. There are few indications in women with incontinence:
• Reduced bladder capacity.
• Short history (less than two years) of urgency and frequency.
• Suspected urethrovaginal or vesicovaginal fistula.
• Haematuria or abnormal cytology.
• Persistent urinary tract infection.
Urethral pressure profilometry

• Urethral pressure profiles can be obtained using a catheter tip dual

sensor microtransducer.
Treatment

Simple measures, such as exclusion of urinary tract

infection, restriction of fluid intake, modifying
medication (e.g. diuretics) and treating chronic cough
and constipation, play an important role in the
management of most types of urinary incontinence.
Urodynamic stress incontinence

Prevention
• Shortening the second stage of delivery and reducing traumatic
delivery may result in fewer women developing stress incontinence.
• The benefits of hormone replacement therapy have not been
substantiated.
• The role of pelvic floor exercises either before or during pregnancy
needs to be evaluated.
• Treatment of stress incontinence includes a multifaceted approach
including lifestyle and behavioral modification , medical and surgical
management.
• Lifestyle and behavioral modifications include
weight loss, caffeine restriction, fluid management, bladder training,
pelvic floor muscle exercises (Kegel exercises), and physical therapy
(biofeedback, magnetic therapy, and electrical stimulation).
Pelvic floor muscle exercises (Kegel exercises) result in an increase in
resting and active muscle tone and thereby increase urethral closing
pressure. These can be done with or without biofeedback and/or electrical
stimulation.
• Medical therapy for the treatment of stress incontinence is limited and no mediations
are FDA approved for this purpose.
• Alpha-adrenergic agonists (midodrine, pseudo- ephedrine),
• beta-adrenergic receptor antagonists and agonists (clenbuterol, propranolol),
• tricyclic antidepressants (imipramine), and
• serotonergic/noradrenergic reuptake inhibitors (duloxetine) have been tried, but
limited data exists for their use.
• The side effects from these various medications must be weighed against the benefit.
• The use of systemic estrogen to treat stress incontinence has been controversial, and
in recent publications, it has not been shown to improve the symptoms and may
worsen or lead to the development of stress incontinence in some women.
• Incontinence pessaries and other intravaginal devices are used to
physically elevate and support the urethra, which restores normal
anatomic relationships. As a result, increases in intra-abdominal
pressures are transmitted equally to the bladder and urethra and
continence is maintained.
• Surgery is frequently the treatment of choice for stress incontinence.
Several approaches have been employed with roughly equal success.
These include
the abdominal retropubic urethropexies (Burch procedures), In Burch
colposuspension, the perivesical tissue is anchored to Cooper’s
ligament (iliopectinate ligament) on the lateral pelvic wall.
 bladder neck slings,
 tension-free midurethral slings (tension-free vaginal tape TVT,
transobturator tape TOT).
• The colposuspension operation used to be considered the gold
standard operation for stress incontinence associated with the highest
success rates in the hands of most surgeons.
• The success rate is over 95 per cent at one year, falling to 78 per cent
at 15-year follow up.
• However, since the introduction of the tension-free vaginal tape (TVT)
and subsequent modifications the popularity of the colposuspension
has waned.
• Disadvantages of surgery include the risks of an invasive procedure
and the risk of failure with resumption of symptoms over time.
Diagram showing colposuspension. Tension-free vaginal tape
• Patients with intrinsic sphincter deficiency
may benefit from periurethral or
transurethral placement of bulking
agents to improve sphincter tone
• it is less invasive and is performed as
an office or day-case procedure ,For the elderly
or frail patient with a scarred, narrowed vagina

Periurethral injection of collagen around the bladder neck.

Detrusor overactivity and voiding difficulty

• The treatment of urge incontinence will depend on the etiology of

disease. In cases where an underlying etiology is identified, it should
be treated appropriately. Idiopathic urgency incontinence, the most
common type, is managed with a combination of lifestyle and
behavior modifications, medication, and sometimes surgery.
• Lifestyle and behavioral modifications include weight loss, caffeine
restriction, fluid management, bladder training, pelvic floor muscle
exercises (Kegel exercises), and physical therapy (biofeedback,
magnetic therapy, and electrical stimulation).
• The most common medications used to treat urgency incontinence
are anticholinergic drugs with antimuscarinic effects such as
oxybutynin 2.5 mg twice daily or tolterodine 2 mg twice daily, can be
equally as effective.
• Newer anticholinergic drugs include solifenacin, fesoterodine and
darifenacin and these are used regularly as first- and second-line
agents for the mangement of DOA.
• Imipramine is often used for enuresis and desmopressin (an
antidiuretic hormone analogue) is useful for nocturia.
• Anticholinergic drugs act by increasing bladder capacity and
decreasing urgency resulting in decreased incidences of incontinence
and decreased voids overall.
• The effect may take up to 4 weeks, and therefore, premature
discontinuation and dose changes should be avoided before this time.
• Side effects of anticholinergic drugs include dry mouth, blurred near
vision, tachycardia, drowsiness, decreased cognitive function and
constipation.
• They are contraindicated in patients with gastric retention and angle
closure glaucoma.
• Surgical treatments for urgency incontinence include
• sacral and peripheral neuromodulation,
• bladder injections (Botulinum toxin),
• and augmentation cystoplasty(required in patients with severe
refractory urgency incontinence).
OVERFLOW INCONTINENCE

Treatment strategy in overflow incontinence is geared toward

• relieving urinary retention,
• increasing bladder contractility,
• and decreasing urethral obstruction.
• Medical management of overflow incontinence includes the use of
various agents to reduce urethral closing pressure (prazosin,
terazosin, phenoxy- benzamine) and striated muscle relaxants
(diazepam, dantrolene) to reduce bladder outlet resistance.
• Cholinergic agents (bethanechol) are used to increase bladder
contractility.
• Intermittent self-catheterization may also be used in overflow
incontinence to avoid chronic urinary retention and infection.
• Patients with overflow incontinence due to bladder outlet
obstruction caused by a continence procedure benefit from surgical
correction of the obstruction.
• Postoperative over- distension of the bladder is typically temporary
and may be managed by continuous bladder drainage for 24 to 48
hours.
thanks