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

2. Objectives To define To learn To manage incontinence
Risk factors for incontinence
Diagnosis of the type of incontinence
To manage
An incontinent woman

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
pelvic floor weakness usually attributed to nerve, muscle and/or connective tissue damage assoc with vag delivery, but many other causes

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. 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

18. History Identify contributing medical factors OB/Gyn Hx gravity/parityDM
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

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 Rectal 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
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 ml
non-urgent desire to void at ml
detrusor contraction at ml
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 Sfyncteric Deficiency
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. Minimal İnvaziv Midüretral Sling Operasyonları
Retropubik Yöntem
Retropubik Midüretral Sling
Obturator
Damar ve sinirler
İnferior epigastrik
damarlar
Eksternal iliak
Damarlar
Obturator Kanal
Üretra
Mesane

45. Retropubik (TVT)

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

47. Transobtrator